AUGUST 15, 2012 F L O R I D A A C A D E M Y O F F A M I L Y P H Y S I C I A N S A REVIEW

DEFINITIONOsteoporosis is characterized by the loss of bone density over time as a consequence of an unbalance between

osteoclastic (bone removal) and osteoblastic (bone replacement) activity1,2. The World Health Organization defines osteoporosis as a

Body Mass Density (BMD) at the hip or spine that is less than or equal to 2.5 standard deviations below the young

normal mean reference population.1,3

EPIDEMIOLOGYThe National Osteoporosis Foundation1 has estimated that more

than 10 million Americans have osteoporosis. Moreover, 1 out of 2 white women will experience an

osteoporosis-related fracture. And 1 in 5 men will experience an osteoporosis-related fracture. Reducing this morbidity (and mortality) is vitally

important in family medicine.

The Definition and Epidemiology

SCREENING DIAGNOSIS TREATMENT

OSTEOPOROSISA B R I E F S U M M A R Y O F S C R E E N I N G , D I A G N O S I S , A N D T R E AT M E N T R E C O M M E N D AT I O N S

by Gema Hernández-Santiago, MD and Jennifer Keehbauch, MD

WHO TO SCREEN FOR

OSTEOPOROSIS?Screening recommendations vary slightly depending on the organization:

USPSTFThe United States Preventative Services

Task Force4 (USPSTF) recommends screening women:

‣ Aged 65 years or older

‣ Younger women whose fracture risk is

equal to or greater than that of a 65-year-old white woman (i.e. a FRAX score > 9.3%).

The World Health Organization (WHO) has developed a tool to evaluate the fracture risk of patients called The FRAX

(Fracture Risk Assessment Tool).5 After entering that patient’s risk factors, the tool outputs a 10-year probability of a major osteoporotic fracture. This tool is free and

can be accessed on-line at http://www.shef.ac.uk/FRAX/. The tool utilizes clinical data such as age, body mass index

(BMI), family history, and tobacco and alcohol use. A Dual-energy x-ray absorptiometry (DXA) measurement is

not necessary to assess risk.

The USPSTF recommends screening younger women whose fracture risk is equal to or greater than a 65 year-old white woman (FRAX score > 9.3%)

ACPMAmerican College of Preventive Medicine6 (ACPM) recommends screening:

‣ All women age ≥65 (LOE1a)

‣Women aged 50-65 if they have at least one major or two minor risk

factors (see table on next page)

JOSEPHINE

IS A 82 YEAR OLD FEMALE WHO HAS BEEN REMARKABLY HEALTHY. SHE IS ON NO MEDICATIONS AND SHE DOES NOT SMOKE OR DRINK.

PLAN: FRAX SCORE DOES NOT NEED TO BE CALCULATED SINCE PATIENT IS ≥ 65. PROCEED WITH SCREENING.

VICTORIA

IS A 55 YEAR OLD FEMALE WHO HAS BEEN HEALTHY. HER MOM RECENTLY HAD A HIP FRACTURE AND SHE IS WONDERING IF SHE SHOULD BE SCREENED FOR OSTEOPOROSIS. SHE IS HEALTHY AND HAS NO PRIOR HISTORY OF FRACTURES. SHE DOES NOT SMOKE OR DRINK. WEIGHT IS 155 POUNDS. HEIGHT IS 66 INCHES.

PLAN: FRAX SCORE IS 10% WHICH IS > 9.3%. PROCEED WITH SCREENING.

ANNETTE

IS A 46 YEAR OLD FEMALE WITH HISTORY OF RHEUMATOID ARTHRITIS CURRENTLY TREATED WITH LOW DOSE PREDNISONE. SHE DOES NOT SMOKE OR DRINK. SHE HAS NEVER HAD A VERTEBRAL OR HIP FRACTURE, BUT HER MOTHER HAD A HIP FRACTURE LAST YEAR. HEIGHT IS 66 INCHES. WEIGHT IS 145 POUNDS.

PLAN: FRAX SCORE IS 12% WHICH IS > 9.3%. PROCEED WITH SCREENING.

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The diagnosis of osteoporosis is established by measurement of BMD, in addition to a detailed history and

physical examination.1

Dual-energy x-ray absorptiometry (DXA) measurements of the hip and spine are the preferred method to

establish or confirm a diagnosis of osteoporosis. The WHO has established the following definitions

based on BMD measurement at the spine, hip or forearm by DXA devices:

‣Normal: BMD is within 1 SD of a

“young normal” adult (T-score at -1.0 and above).

‣ Low bone mass (“osteopenia”):

BMD is between 1.0 and 2.5 SD below that of a “young normal” adult (T-score between -1.0 and -2.5).

‣Osteoporosis: BMD is 2.5 SD or more below that of a “young normal” adult (T-score at or below

-2.5).

When should we use the Z-Score?In assessing and following certain populations, the T-score should not be used alone:

‣ Premenopausal women

‣ Men less than 50 years of age

‣ Children

The International Society for Clinical Densitometry (ISCD) recommends that instead of T-scores, ethnic or race

adjusted Z-scores should be used, with Z-scores of -2.0 or lower defined as either “low bone mineral density for chronological age” or “below the

expected range for age” and those above -2.0 being “within the expected range for age.”

DIAGNOSING OSTEOPOROSISINTERPRETING

DXA SC AN RESULTS:

NORMAL

OSTEOPENIA

OSTEOPOROSIS

DXA Measurements of the hip and spine are the preferred method to establish or confirm the diagnosis of osteoporosis.

T-SCORE ≥ -1.0

T-SCORE between -1.0 to -2.5

T-SCORE ≤ -2.5

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Major Risk Factors

‣Fragility/compression fracture

‣Family history of osteoporotic

fracture

‣Glucocorticoid therapy > 3

months

‣Malabsorption syndrome

‣Primary hyperparathyroidism

‣Fall risk

‣Hypogonadism

‣Early menopause (< age 45)

Minor Risk Factors

‣Rheumatoid arthritis

‣Past history of hyperthyroidism

‣Anticonvulsant therapy

‣Low dietary calcium intake

‣Smoker or excessive alcohol

‣Excessive caffeine

‣Weight < 127 lbs or >10% loss

‣Chronic heparin therapy

The choice of therapy should be based on the patient's clinical situation and the tradeoffs between benefits and harms.4

Patients that should be considered for pharmacological treatment include postmenopausal women and men age 50 and older presenting with:

‣ A hip or vertebral fracture

‣ T-score ≤ -2.5 at the femoral neck

or spine after appropriate evaluation to exclude secondary causes

‣ Osteopenia (T-score between -1.0 and -2.5 at the femoral neck or spine) and a 10-year probability of a

hip fracture ≥ 3% or a 10-year probability of a major osteoporosis-

related fracture ≥ 20% based on

the FRAX score. 1

General Recommendations for Prevention of Fractures1

‣Women older than age 50 should consume at least 1,200 mg per day of elemental calcium and of 800 to

1,000 international units (IU) of vitamin D per day.

‣ Recommend regular weight-bearing and muscle-strengthening exercise to

reduce the risk of falls and fractures.

‣ Fall prevention: checking and correcting vision and hearing,

evaluating any neurological problems, reviewing prescription medications for side effects that may

THE TREATMENT OF OSTEOPOROSIS

Medication Indication Route Fracture type

Cost per month

Fosamax (Alendronate)

Prevention Treatment

Oral weekly

Hip, vertebral, and non-vertebral

$9-10

Actonel/Atelvia

(Risdronate)

Prevention Treatment

Oralweekly or monthly

Hip, vertebral, and non-vertebral

$119 to 126

Boniva (Ibandronate)

Prevention Treatment

Oral monthly Vertebral $100

Boniva (Ibandronate) Treatment IV q 3

months No data $162

Reclast (Zoledronic

Acid)

Prevention Treatment IV q year

Hip, vertebral, and non-vertebral

$104

Miacalcin (Calcitonin) Treatment Nasal Vertebral $126

Forteo (Teriparatide) Treatment Subcut. daily Vertebral and

non- vertebral $675

Prolia (Denosumab) Treatment Subcut. q 6

months Vertebral and non- vertebral $137

affect balance and providing a checklist for improving safety at home.

‣ Avoid tobacco smoking

‣ Recognize and treat patients with excessive alcohol intake

Prevention and Treatment of Steroid-Induced Osteoporosis7,8

‣ Bisphosphonate therapy should be considered in all patients on

steroid therapy (prednisone ≥7.5

mg) for longer than 3 months

‣ Consider treatment in high risk

patients on prednisone ≥ 5 mg daily

Monitoring Treatment1

Measurements for monitoring patients should be performed every two years. DXA scan is the “gold standard” for

serial assessment of BMD.

How Long to Treat with Bisphosphonates

Consider stopping bisphosphonates after 3 to 5 years for most patients. Continue in patients at high risk for

fracture. Recheck BMD every 2-3 years after discontinuing therapy and restart medications if BMD drops

significantly10

PHARMACOLOGICAL TREATMENT OPTIONS

Sources: AFP 2009; 79(3) 193-200; Denosumab N Engl J Med 2009;361:756-65.

Consider medications for osteopenia if 10-year probability of hip fracture ≥ 3% or a 10-year probability of a major osteoporosis-related fracture ≥ 20%

1. National Osteoporosis Foundation. “Clinician’s Guide to Prevention and Treatment of Osteoporosis.”

Washington, DC: National Osteoporosis Foundation; 2010.

2. US National Library of Medicine. “Osteoporosis”. 8 Nov 2010. Web. 4

Apr. 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001400/

3. World Health Organization. “WHO Scientific group on the assessment of osteoporosis at primary health

care level. Summary Meeting Report. Brussels, Belgium 5-7 May 2004.” Genova, World Health Organization. 2007

4. USPSTF Screening for Osteoporosis Recommendation Statement. Accessed July 7, 2012. http://

www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm

5. World Health Organization. “Fracture Risk Assessment Tool”. Accessed July 2012. http://www.shef.ac.uk/FRAX/

6. Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive

practice. Am J Prev Med 2009 Apr;36(4):366-75

7. Prescriber's Letter 2011; 18(3):

270309

8. American College of Rheumatology 2010 Recommendations for the Prevention and Treatment of

Glucocorticoid-Induced Osteoporosis http:// mail3.rheumatology.org/practice/

clinical/guidelines/ACR_2010

9. Sweet MG et al. Diagnosis and Treatment of Osteoporosis. AFP 2009; 79(3) 193-200

10. Cummings SR et al. Denosumab for the prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med

2009;361:756-65.

11. Prescriber's Letter 2011; 18(11):271122

References

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Edited and designed by David Koo, MDFlorida Hospital Family Medicine Residency

Winter Park, Florida