Osteoporosis

The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. (B) The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures. (C) Women from 45 years of age and men from 50 years of age should be have their risk factors for osteoporosis and fracture assessed (C). Screening bone mineral densitometry should only be conducted in patients over 45 years of age who sustain a low trauma fracture or in postmenopausal women with suspected vertebral fracture or major risk factors (A for women, C for men). Women 45years of age and over who should be assessed for risk factors of osteoporosis and should have preventive advice every 12 months (A) Women over 45 years of age who sustain a low trauma fracture or in postmenopausal period with suspected vertebral fracture or major risk factors should be screened at presentation and every 2 years (B) Canadian Task Force recommended Using history of previous fractures for prediction of osteoporotic fractures (B) Using SCORE or ORAI to predict low BMD (A) Screening by using BMD to predict fractures (B) British Columbia 2007 BMD measurement – It is not recommended as a screening procedure for women under age 65 or as part of a routine evaluation around menopause. Indications for BMD measurement using DXA – BMD measurement should only be performed when (1) Results are likely to alter patient care, and (2) Patients have at least one major or two minor risk factors for osteoporosis

Epidemiology

• Postmenopausal osteoporosis affects many people. Although white women are most often affected, women of all races and all ethnic origins are susceptible to osteoporosis and fracture.

Major Risk Factors

• Age ≥ 65 years
• Low trauma vertebral    compression fracture
• Low trauma fracture over age of 40
• Family history of osteoporotic fracture (especially maternal  hip fracture)
• Current systemic glucocorticoid therapy of > 3 months duration
• Malabsorption syndrome
• Primary hyperparathyroidism
• Hypogonadism
• Early menopause (before age of 45)

Minor Risk Factors 

• Past history of clinical hyperparathyroidism
• Chronic anticonvulsant therapy
• Low dietary calcium intake
• Smoking
• Excessive alcohol intake
• Excessive caffeine intake (e.g.>4 cups coffee/day)
• Weight < 57 kg
• Short term weight loss > 10 kg from weight at age 25
• Chronic heparin therapy
• Rheumatoid arthritis

Risk factors (particularly for men)

• Hypogonadism, glucocorticoid use, excess alcohol, multiple myeloma, thyroxine excess and primary hyperparathyroidism

Primary Preventive Measures

• Provide risk factors modification;
• General diet high in calcium (1000 – 1500 mg/day) (approximately 3 cups daily of dairy products) and vitamin D
• Adequate levels of physical activity
• Smoking cessation
• Limited alcohol and caffeine intake
• counsel patients for fall prevention
• Offer calcium and vitamin D supplements for those with poor diet and limited sun exposure.

Secondary prevention of recurrent fragility fractures

• In postmenopausal women with osteoporosis but no prevalent  fractures Alendronate can be used (A)  and Residronate (B)for secondary prevention of nonvertebral fractures,
• While either Alendronate or Residronate can be used for secondary prevention of hip and nonvertebral fractures (B)

• Tertiary prevention of recurrent fragility fractures

• In postmenopausal women with osteoporosis and prevalent fractures Alendronate (A) and Residronate, Raloxifine, Etidronate or oral Pamidronate can be used (B)for tertiary prevention of vertebral fractures,
• While Alendronate can be used for tertiary  prevention of hip fractures and Residronate for tertiary prevention of hip and nonvertebral fractures (B)
• Parathyroid hormone can be used for tertiary prevention of both vertebral and nonvertebral fractures (B)

Created by: Dr Farouq Al-Zurba