Osteopenia and Osteoporosis
Vitamin D deficiency
25-hydroxyvitamin D level < 20 nmol/L
Osteopenia and Osteoporosis: treatment
Calcium intake: Postmenopausal women who are getting adequate calcium from dietary intake alone (approximately 1200 mg daily) do not need to take calcium supplements. Women with inadequate dairy intake should take supplemental elemental calcium (generally 500 to 1000 mg/day) with a total consumption of 1200 mg/day. Vitamin D intake: Women should also ingest a total of 800 international units of vitamin D daily. Higher doses are required if they have malabsorption or rapid metabolism of vitamin D due to concomitant anticonvulsant drug therapy. Vitamin D levels must be monitored. Intakes of calcium in excess of 1,200 to 1,500 mg per day have limited potential for benefit and may increase the risk of developing kidney stones or cardiovascular disease Several controlled clinical trials of calcium, mostly plus vitamin D, have confirmed reductions in clinical fractures, including fractures of the hip (~20-30% risk reduction).
Osteopenia and Osteoporosis: Diagnostics
Dual x-ray absorptiometry (DEXA) Highly accurate x-ray technique that has become the standard for measuring bone density Although it can be used for measurement in any skeletal site, clinical determinations usually are made of the lumbar spine and hip
Diagnosis of Osteoporosis
Fragility fracture, particularly at the spine, hip, wrist, humerus, rib, and pelvis OR T-score ≤-2.5 standard deviations (SD) at any site based upon bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DXA)
Risk Assessment: Osteopenia and Osteoporosis Medications
Glucocorticoids (≥5 mg/d prednisone or equivalent for ≥3 months) Gonadotropin-releasing hormone antagonists and agonists Lithium Methotrexate Proton pump inhibitors Thyroid hormones (in excess)
Vitamin D :
Goal: maintain a serum 25(OH)D concentration above 30 ng/mL Treat with 50,000 international units (units) of vitamin D2 or D3 orally once per week for six to eight weeks, and then 800 units of vitamin D3 daily thereafter if labs show improvement. The above recommendations are largely in agreement with Endocrine Society practice guidelines on the treatment of vitamin D deficiency In adults with vitamin D deficiency, however, the Endocrine Society guidelines suggest a maintenance dose of vitamin D2or D3 (1500 to 2000 international units daily) to maintain a serum 25(OH)D concentration above 30 ng/mL (75 nmol/L).
Who should be considered for pharmacologic treatment?
History of a hip or vertebral fracture T-score less than or equal to -2.5 at the femoral neck or spine (after ruling out correctable secondary causes) Low bone mass (T-score between -1.0 and -2.5 at the femoral neck or spine) and a 10 year probability of hip fracture greater than or equal to 3% or a 10 year probability of a major osteoporosis-related fracture greater than or equal to 20% based on the US adapted WHO algorithm.
Osteopenia and Osteoporosis: diagnostics
Indication for Bone Mineral Density ( BMD ) testing Women age 65 and older and men age 70 and older, regardless of clinical risk factors Younger postmenopausal women, women in the menopausal transition and men age 50-69 with clinical risk factors for fracture Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids in a daily dose ≥5 mg prednisone or equivalent for ≥3 months) associated with low bone mass or bone loss Anyone being treated for osteoporosis, to monitor treatment effect
Treatment Bisphosphonates
Most patients prefer the convenience of the once-weekly regimen. alendronate :5 mg/day or 35 mg/week: used for prevention 10 mg/day or 70 mg/week: used for treatment of established osteoporosis Approved for treatment of men with osteoporosis and men and women with osteoporosis taking glucocorticoids Available as a generic Reduces spine and hip fractures by about 50% over 3 years in patients with a prior vertebral fracture Reduces vertebral fractures by about 48% over 3 years in patients without a prior vertebral fracture Risedronate: 5 mg/day or 35 mg/week approved for prevention and treatment Approved to treat osteoporosis in men as well as in men and women with osteoporosis taking glucocorticoids. Reduces the incidence of vertebral fractures by about 41-49 percent and non-vertebral fractures by about 36 percent over three years
Osteopenia and Osteoporosis: treatment
Non-pharmacologic Therapy (prevention and treatment) Calcium Vitamin D Fall prevention Weight bearing exercises
Osteopenia and Osteoporosis
Osteoporosis is a common condition in the elderly; women are at particularly high risk. In the United States, 8 million women and 2 million men have osteoporosis The annual incidence of osteoporosis-related fractures is at least 2 million; almost half of them are vertebral fractures, followed in frequency by hip and wrist fractures Hip fractures are associated with significant morbidity (thromboembolism) and a 20-50% risk of mortality overall
Osteopenia and Osteoporosis Clinical Presentation
Patients are asymptomatic or will present to you after a fracture occurs. Prevention is key. Patient with a vertebral fracture may present with an area of focal bone pain in the spine without a trauma or fall history. Focal tenderness upon palpation of the vertebral spine and kyphosis or acute angulation of the spine may be present. Lateral thoracic and lumbar spine radiographs are the standard tool for assessment of vertebral fractures. MRI and CT can be performed as well.
Osteopenia and Osteoporosis Etiology
Risk factors, certain medications and diseases have been associated with increased risk of osteoporosis or fragility fracture. Risk Factors Diet with Low Ca , low Vit D, and/or high caffeine intake Lack of Physical Activity Family History Gender (F > M 3:1) Ethnicity - Higher risk in Asians and Caucasians Post menopausal - lack of estrogen After age 30-45 the resorption and formation processes become imbalanced, and resorption exceeds formation. it becomes exaggerated in women after menopause. Excessive bone loss can be due to an increase in osteoclastic activity and/or a decrease in osteoblastic activity.
Osteopenia and Osteoporosis: diagnostics
The Fracture Risk Assessment Tool (FRAX website) estimates the 10-year probability of hip fracture and major osteoporotic fracture for an untreated patient (40 to 90 years of age) using femoral neck BMD (g/cm2) and easily obtainable clinical risk factors for fracture
Osteopenia and Osteoporosis: diagnostics BMD measurement
The radiograph tube generates photon beams of two different energy levels, thus the term "dual-energy." DXA measures bone mineral content (BMC, in grams) and bone area (BA, in square centimeters), then calculates BMD in g/cm2 by dividing BMC by BA. Osteophyte formations, compression fractures, previous spine surgery and aortic calcification or examples of conditions that can falsely elevate BMD readings DXA every 2 years (per Medicare coverage) Can occasionally do more often with appropriately demonstrated need.
Osteopenia:
is characterized as low bone mass with dual-energy x-ray absorptiometry (DXA) measurements with T-score that is 1 to 2.5 SD below the young-adult mean . These patients are at increased risk for osteoporosis
Osteoporosis:
is characterized by low bone mass, microarchitectural disruption, and increased skeletal fragility. T-score ≤2.5 standard deviations (SD) at any site based upon bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DXA) or Fragility fracture, particularly at the spine, hip, wrist, humerus, rib, and pelvis.
Vitamin D insufficiency
serum 25-hydroxyvitamin D between 21-29 nmol/L