Osteoporosis is associated with significant morbidity and mortality, especially if it results in a hip fracture. Within the year following hip fracture, 12% to 20% of patients die, more than 30% have permanent disabilities, and more than 50% can never live independently again.1 Ten million Americans have osteoporosis, and an additional 18 million with osteopenia are at risk.2 Because risk increases with age and the number of Americans older than 65 years is expected to double by 2050, we must do more to prevent this debilitating disease. The accompanying patient education handout discusses prevention strategies.
Screening
Dual-energy x-ray absorptiometry (DEXA) of the hip and spine is the preferred screening test. It is highly specific and sensitive for predicting hip fracture and for diagnosing osteoporosis or osteopenia.1,3 Other methods are not s reliable.4 Table 1 shows a listing of the DEXA screening recommendations of various organizations.1-7
Risk actors for osteoporosis
The most significant risk factors are female gender, advancing age, estrogen deficiency, and white race. Others include inadequate intake of calcium and vitamin D, family history of osteoporosis, smoking, low body weight or low body mass index, prior fracture, physical inactivity, excessive alcohol or caffeine intake, and frequent falls.
Medical risks for secondary osteoporosis
Factors leading to increased risk of developing secondary osteoporosis (SOP) include genetic disorders, endocrinopathy, GI disease, nutritional deficiency, hematologic conditions, connective tissue disease, other chronic medical conditions, or medication that interferes with the intake, absorption, metabolism, utilization, and excretion of calcium and vitamin D.
Any medical condition or treatment that produces emaciation, significant weight loss, physical inactivity, incoordination, unsteadiness, or estrogen or gonadal deficiency or that affects bone architecture and/or collagen metabolism increases risk for SOP. The more common medical conditions include pre-mature ovarian failure, hyperprolactinemia, hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing's disease, malabsorption syndromes, rheumatoid arthritis, chronic obstructive pulmonary disease, and alcoholism. Less common causes include AIDS, type I diabetes, acromegaly, osteogenesis imperfecta, certain forms of homocystinuria, Ehler-Danlos syndrome, Marfan syndrome, osteomalacia, Paget's disease, multiple myeloma, lymphoma, other malignancies, porphyria, thalassemia, hemochromatosis, pernicious anemia, end-stage renal disease, chronic hepatic diseases, congestive heart failure, organ transplantation, anorexia nervosa, and gastric bypass surgery.1,2,8
Medication risks
The most commonly implicated medications are glucocorticosteroids. Others include excessive thyroid replacement, phenytoin, phenobarbital, loop diuretics, depot medroxyprogesterone acetate, gonadotropin-releasing hormone agonists, and possibly heparin.1
The bottom line
Osteoporosis will become a leading cause of morbidity and mortality unless we establish appropriate programs for its prevention, screening, diagnosis, and treatment. Clinicians should recommend universal screening to all postmenopausal women, those with one or more risk factors, and all persons at risk for SOP. However, as with any other kind of medical screening, the patient should undergo testing only if the findings will lead to or influence a treatment regimen. JAAPA
REFERENCES
1. Hodgson SF, Watts NB, Bilezikian JP, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract. 2003;9(6):544-564.
2. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement. March 27-29, 2000;17(1):1-36.
3. US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med. 2002;137:526-528.
4. Neff MJ; American College of Obstetricians and Gynecologists. ACOG releases guidelines for clinical management of osteoporosis. Am Fam Physician. 2004;69(6):1558-1560.
5. Genant HK, Cooper C, Poor G, et al. Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporosis Int. 1999; 10(4):259-264.
6. National Osteoporosis Foundation. Physician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2003.
7. A decision tree for the use of estrogen replacement therapy or hormone replacement therapy in postmenopausal women: consensus opinion of the North American Menopause Society. Menopause. 2000;7(2):76-86.
8. Campion JM, Maricic MJ. Osteoporosis in men. Am Fam Physician. 2003;67(7): 1521-1526.
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