| Osteoporosis |
| Normal Bone Osteoporotic Bone |
| Osteoporosis is a silent, progressive disease characterized by decreased bone density and increased bone fragility, with a consequent susceptibility to fracture. |
| In the United States, over 28 million people are at high risk of developing osteoporosis. Up to 1.5 million fractures a year are attributable to osteoporosis. |
| Health care expenditures related to osteoporosis are over $14 billion per year. |
| Women are at the greatest risk. One third of Caucasian women over the age of 50 have osteoporosis, yet nearly 80% remain undiagnosed. After menopause, a woman's risk of suffering an osteoporotic spine or femur fracture is 30% or three times that of a man's. |
| Osteoporosis is a complex, multi-factorial disease that may progress silently for decades. There may be no symptoms until fractures occur. Bone loss is the major risk factor that can be modified in mid-life to reduce fracture risk. Bone loss can be reduced by treatment, but it is difficult to restore the microarchitecture of the skeleton once bone has been lost. Early detection and intervention are crucial. |
| Osteoporosis used to be considered an inevitable consequence of aging. Today, with new techniques for early detection and ever-increasing treatment options, osteoporosis management can and should be a part of your practice. |
| Diagnosis, Assessment, Monitoring |
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| Bone densitometry is an essential tool in osteoporosis management. Densitometry assists physicians in diagnosis, fracture risk assessment, and monitoring response to therapy. |
| Physicians utilize bone densitometry to categorize patients as normal, osteopenic, or osteoporotlc following the World Health Organization (WHO) classifications. The patient's T-score (comparison to the young adult reference) is the critical variable in diagnosis. Typically, both femurs and the spine are assessed, with the diagnosis made using the lowest T-score. Patient examination, in addition to the T-score, is key to diagnosing osteoporosis. |
| Bone mineral density (BMD) is the strongest tool to predict fracture risk, which increases exponentially as BMD decreases. Femur BMD is recognized as the strongest predictor of femur fracture risk, which has the highest morbidity, mortality and cost of all osteoporotic fractures. A decrease of 1 standard deviation (SD) in femur BMD corresponds to approximately a 3X increase in femur fracture risk. In comparison, a 1 SD decrease in spine BMD corresponds to a 2X increase in spine fracture risk. |
| Monitoring Changes in BMD |
| Patients may return for bone density tests every 1-3 years, depending on their expected rate of loss and their clinical situation. Bone Density may increase over time as a response to therapy, or it may decrease with disease progression or poor response to therapy. Precision (reproducibility) of the BMD measurements is the key factor in detecting changes in patient BMD over time. |
| Osteopenia on routine x-ray, and thus, need for confirmation of the subjective suspicion of low bone mass |
| When assistance is needed in making a decision regarding HRT or other nonhormonal therapy |
| Glucocorticoid therapy or Cushings syndrome |
| Primary hyperparathyroidism, to assist with decisions regarding surgical intervention |
| Premature menopause or prolonged periods of amenorrhea. Anorexia nervosa, bulimia, and female athletes. |
| After organ transplantation |
| Maternal history of fracture |
| Prolonged immobilization |
| Renal failure to monitor the effects of excess parathyroid hormone |
| Liver disease |
| Excess thyroid hormone production or administration |
| Malabsorption syndromes |
| Height loss greater than 4 cm |
| Weight loss greater than 5 kg |
| Rheumatoid arthritis, even without glucocorticoid therapy |
| All postmenopausal women under 65 who have one or more additional risk factors for osteoporotic fracture (besides menopause) |
| All women aged 65 and older regardless of additional risk factors |
| Postmenopausal women who present with fractures (to confirm diagnosis and determine disease activity) |
| Women who are considering therapy for osteoporosis, if BMD testing would facilitate the decision |
| Women who have been on hormone replacement therapy for prolonged periods |
| Defining Osteoporosis by BMD |
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| The World Health Organization (WHO) has established the following definitions based on bone density measurement at any skeletal site in white women: |
| Normal: T-score above -1 (BMD is within 1 SD of a young normal adult) |
| Osteopenia: T-score between -1 and -2.5 (BMD is between 1 and 2.5 SD below that of a young normal adult) |
| Osteoporosis: T.score at or below -2.5 (BMD is 2.5 SD or more below that of a young normal adult. Women in this group with one or more fractures are deemed to have severe or established osteoporosis.) |
| Diseases |
| Acmmegaly |
| Adrenal atrophy and Addison's disease |
| Amyloidosis |
| Ankylosing spondylitis |
| Chronic obstructive pulmonary disease |
| Congenital porphyria |
| Cushing?s syndrome |
| Endometriosis |
| Epidermolysis bullosa |
| Gastrectomy |
| Gonadal insufficiency (primary and secondary) |
| Hemochromatosis |
| Hemophilia |
| Hyperparathyroidism |
| Hypophosphatasia |
| Idiopathic scoliosis |
| Insulin-dependent diabetes mellitus |
| Lymphoma and leukemia |
| Malabsorption syndromes |
| Mastocytosis |
| Multiple myeloma |
| Multiple sclerosis |
| Nutritional disorders |
| Osteogenesis imperfecta |
| Parenteral nutrition |
| Pernicious anemia |
| Rheumatoid arthritis |
| Sarcoidosis |
| Severe liver disease, especially primary biliary cirrhosis |
| Thalassemia |
| Thyrotoxicosis |
| Tumor secretion of parathyroid hormone-related peptide |
| Drugs |
| Aluminum Excessive thyroxine Heparin Anticonvulsants Glucocorticosteroids and Lithium Cigarette smoking adrenocorticotropin Tamoxifen Cytotoxic drugs Gonadotropin-releasing (premenopausal use) Excessive alcohol hormone agonists |
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| Diagnosis of Osteoporosis Fracture Assessment Indications for Bone Densitometry Who Should be Tested Diseases and Drugs with Increased Risk for Osteoporosis |
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