62Osteoporosis

Publication Details

According to the National Osteoporosis Foundation, more than 25 million Americans have osteoporosis, and each year more than 1.3 million fractures occur as a result. Osteoporosis is the most common metabolic bone disorder, and the risk for osteoporosis and osteoporosis-related fractures increases with advancing age. As the population of the United States ages, osteoporosis becomes an increasing public health concern.

About 70% of fractures in persons aged 45 or older are related to osteoporosis. The earliest and most predominant fractures involve the lower thoracic and lumbar vertebrae. These are often asymptomatic and may be diagnosed through spinal x-rays obtained for other reasons. These fractures produce loss of height and the development of a "dowager's hump," a distortion of the spine. As these fractures progress, they produce compression of the abdominal cavity, resulting in difficulties eating and digesting. After age 65, fractures of the hip and of the arm produce greater morbidity and are associated with pain, disability, and decreased functional ability. In the first year following a hip fracture, a patient's expected survival decreases 15% to 20%. The economic impact of osteoporosis is also high. In 1995, an estimated $13.8 billion was spent in the United States for osteoporosis-related medical, nursing home, and social costs. These numbers are expected to increase over the next 20 years.

Important risk factors for osteoporosis are female gender, low dietary intakes of calcium during adolescence, age, and early menopause. Women of Caucasian or Asian ancestry and those whose mothers have had osteoporosis are at greatest risk. Dietary intake of calcium during childhood and adolescence is a determinant of adult peak bone mass. Peak bone mass is achieved in the third decade, after which bone loss begins. In women, bone loss is accelerated by menopause, particularly premature menopause induced by oophorectomy. Low body weight, excessive alcohol intake, and sedentary life style have been associated with osteoporosis as well. Parity, lactation history, caffeine intake, and smoking have been suggested in the past as possible risk factors but are poor predictors of bone mass.

The main techniques available for screening for osteoporosis include single photon absorption (SPA), dual photon absorption (DPA), dual energy x-ray absorption (DXA), and quantitative computed tomography (QCT). DXA is currently the favored method because of its ease of use, good precision, relatively low procedure time (5 to 10 minutes), and very low radiation dose. Like the SPA and DPA, however, it cannot discriminate between cortical bone and trabecular bone; QCT must be used to accomplish this. DXA measures bone mineral content (g/cm) or areal density (g/cm2) and may be used over the total body or for a specific area. Most experts agree that DXA is a safe, accurate, and precise modality for measuring bone density. Ultrasound technology for assessing bone density is under development and may be of use in the future.

DXA can identify at risk persons who can most benefit from interventions; however, because the rate of postmenopausal bone loss varies among women, bone mass at menopause correlates only moderately with bone mass 10 to 20 years later when most fractures occur. Also, no consensus exists regarding what interventions are indicated for patients with any particular level of bone density.

See chapter 47 for information on hormone replacement therapy. See Chapter 56 for information on nutrition counseling and Chapter 57 for information on physical activity counseling.

Recommendations of Major Authorities (Includes Screening)

  • American Academy of Family Physicians --
  • All patients should be counseled about the importance of adequate calcium intake, regular weight-bearing exercise, smoking cessation, and moderate alcohol use. Patients at risk and those diagnosed with osteoporosis should be advised of treatment options. Bone densitometry cannot be recommended for routine use at this time. Bone mineral densitometry may be useful for high-risk patients, to monitor therapy, and for patients who are unable to come to a decision about hormone replacement therapy.
  • American College of Obstetricians and Gynecologists --
  • All women should be counseled on diet and exercise as part of routine preventive visits. Women over 40 should be counseled on use of hormone replacement therapy. Women 65 and over should be counseled on fall prevention.
  • American College of Physicians --
  • Routine screening of all postmenopausal women by bone densitometry for osteoporosis is not recommended. Bone density measurements may be indicated in specific clinical situations where the decision to treat must be based on knowledge of bone mass and related to risk of fracture.
  • Canadian Task Force on Periodic Health Examination --
  • Does not recommend routine radiologic screening for osteoporosis. Bone density measurements may be useful to guide treatment in selected postmenopausal women considering hormone replacement therapy. The CTFPHE recommends counseling all peri-menopausal women regarding the benefits and risks of estrogen replacement therapy; however, there is insufficient evidence to recommend for or against the inclusion or exclusion of counseling premenopausal and postmenopausal women to engage in regular weight-bearing exercise to reduce osteoporosis risk.
  • National Osteoporosis Foundation --
  • Recommends a comprehensive program to prevent osteoporosis in women and men of all ages that includes adequate calcium and vitamin D intake, weight-bearing exercises, a healthy lifestyle with no smoking and limited alcohol consumption, and medication when appropriate. A bone mineral density (BMD) test is the only way to detect bone loss before a fracture occurs. A BMD test is indicated when risk factors are present and a decision must be made regarding osteoporosis medications to reduce fracture risk.
  • National Institutes of Health --
  • A 1984 consensus conference on osteoporosis recommended that estrogen therapy after menopause should be considered in high-risk women who have no medical contraindications and who are willing to adhere to a program of careful follow-up.
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine screening for osteoporosis with bone densitometry in postmenopausal women. Recommendations against routine screening may be made on other grounds. All postmenopausal women should be counseled about hormone prophylaxis and advised of the importance of smoking cessation, regular exercise and adequate calcium intake. For those high-risk women who would consider estrogen only to prevent osteoporosis, screening may be appropriate to assist treatment decisions.
  • World Health Organization --
  • Bone density measurements may be useful to guide treatment in selected postmenopausal women considering hormone replacement therapy.

Basics of Osteoporosis Counseling

The most effective management for osteoporosis is the prevention of osteoporosis through counseling about dietary and behavioral practices to maximize the peak bone mass achieved by the third decade and to slow the rate of bone loss after that period.

1.

Counsel all patients about consuming adequate amounts of calcium and vitamin D (chapter 56). Also advise patients to avoid smoking and excessive alcohol intake.

2.

Counsel all patients to exercise (chapter 57). Weight bearing activities such as walking and stair climbing promote achievement of peak bone mass and delay bone loss. Once fractures have occurred, the patient should limit exercise to tolerable walking and avoid lifting and vigorous muscle straining.

3.

Advise perimenopausal women of the probable risks and benefits of hormone replacement therapy (HRT) (chapter 47).

4.

For all older persons, assess the risk of falls and provide appropriate counseling to implement precautionary measures such as removal of throw rugs and installation of hand rails next to stairs and in the bathroom (chapter 55).

5.

Evaluate for the presence of clinical risk factors (Table 62.1) to identify individuals who may profit from more precise evaluation of bone mineral content as a procedure for selection and monitoring of specific therapy.

6.

Discuss with patients the drugs currently approved by the FDA for the prevention of osteoporosis (HRT and alendronate [Fosamax]) and for the treatment of osteoporosis (estrogen replacement therapy, alendronate, and calcitonin). The protective effects of all therapies appear to be lost soon after discontinuation of treatment.

Table 62.1 Risk Factors for Hip Fractures.

Table

Table 62.1 Risk Factors for Hip Fractures.

Hormone Replacement Therapy (HRT):

Recent studies have shown that women who start HRT late after menopause receive the same protective effect against risk of subsequent fractures as those who start treatment during or immediately after menopause. Counsel each patient about the risks and benefits of hormone replacement therapy (chapter 47).

Alendronate:

This third-generation amino-bisphosphonate that acts as an osteoclast inhibitor, has been approved for the prevention and treatment of osteoporosis. Initial studies have shown that alendronate not only arrests further loss of bone mineral content, but in many cases leads to an actual increase in bone mineral density. Alendronate treatment is also associated with decreases in fractures in people with low bone mass density who have already had a spine fracture. Other bisphosphonate agents are currently under review, and these agents may increase treatment options for patients.

Calcitonin:

Calcitonin, a hormone that helps control bone remodeling, is administered by injection (subcutaneously or intramuscularly) or by nasal spray. Side effects include flushing, rash, nausea, dizziness, and faintness. Calcitonin does not offer the other benefits of estrogen (control of hot flashes, lowering of cholesterol, protection against coronary heart disease), and its efficacy in fracture prevention has not been proven. Its effectiveness has been demonstrated only in women with established osteoporosis who are more than 5 years postmenopausal.

Patient Resources

  • Osteoporosis in Women: Keeping Your Bones Healthy and Strong. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City MO 64114-2797; (800)944-0000.
  • Preventing Osteoporosis (ACOG Patient Education Pamphlet AP048). American College of Obstetricians and Gynecologists. 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • National Osteoporosis Foundation, Osteoporosis and Related Bone Disorders National Resource Center, 1150 17th St, NW, Suite 500, Washington, DC 20036; (800)624-BONE.

Provider Resources

  • National Osteoporosis Foundation, Osteoporosis and Related Bone Disorders National Resource Center, 1150 17th St, NW, Suite 500, Washington, DC 20036; (800)624-BONE.

Selected References

  1. Alexeera L, Burkhardt P, Christiansen C, et al. Assessment of Fracture Risk and Application of Screening for Postmenopausal Osteoporosis . World Health Organization. Technical Report Series 843. Geneva: World Health Organization, 1994.
  2. American Academy of Family Physicians. Diagnosis and Management of Osteoporosis. Kansas City, Mo: American Academy of Family Physicians; 1996.
  3. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, MO: American Academy of Family Physicians; 1997.
  4. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  5. American College of Obstetricians and Gynecologists. Osteoporosis . ACOG Technical Bulletin #167. Washington, DC: American College of Obstetricians and Gynecologists; 1992.
  6. American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann Intern Med . 1992; 117:1038–1041. [PubMed: 1443972]
  7. Black DM, Cummings SR, Karpf DB et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. . 1996; 348:1535–41. [PubMed: 8950879]
  8. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fractures in white women. N Engl J Med . 1995; 332(12):767–773. [PubMed: 7862179]
  9. Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care . Ottawa, Canada: Canadian Communication Group; 1994:602-631.
  10. Canadian Task Force on the Periodic Health Examination. Physical Activity Counselling. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 47.
  11. Canadian Task Force on the Periodic Health Examination. Prevention of Osteoporotic fractures in women by estrogen-replacement therapy. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 52.
  12. Melton LJ, Eddy DM, Johnston CC. Screening for osteoporosis. Ann Intern Med . 1990; 112:516–528. [PubMed: 2180356]
  13. National Institutes of Health. Consensus conference: osteoporosis. JAMA . 1984; 252:799–802. [PubMed: 6748181]
  14. Ray NF, Chan JK, Thamer M, Melton LJ. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone and Mineral Research. 12(1)1997;24-35.
  15. US Preventive Services Task Force. Guide to Clinical Preventive Services .2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 25.