Osteoporosis
Original Editors - Alli Castagno & Christy Kaiser from Bellarmine University's Pathophysiology of Complex Patient Problems project.
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Definition/Description[edit | edit source]
Osteoporosis is a disease characterized by decrease in bone mass and damage to bone structure. Bone frailty leads to an increase risk for fractures. Bone tissue is constantly being absorbed and replaces througout ones life span. Bone mass decreases when the rate of absorbtion increases the rate or production; typically occurring with advanced age. Peak bone mass is met at the average age of 20. Those who develope less bone mass prior to this time, have a high chance of developing osteoporosis. There are two types of osteoporosis; primary and secondary. Primary osteoporosis is unrelated to other diseases or conditions, and is the more common of the two. It is most common in post menopause women or older men, but can occur at any ages. Secondary osteoporosis occurs as a side effect of medication or secondary to another condition or disease. A common precursor to osteoporosis is osteopenia, which is a condition of a mild decrease in bone mass. T-scores are often used to classify individuals as osteoporotic. According to the World Health Organization, a normal bone mineral density score is -1.0 or higher, -1.0 to -2.5 for osteopenia, and -2.5 or lower for osteoporosis.
Prevalence[edit | edit source]
Osteoporosis is the most prevalent bone disease in the world. According to the National Osteoporosis Foundation, about 10 million Americans currently have osteoporosis, while about 34 million are at risk for the disease. It is estimated that one in two women over the age of 50 and one in four men will break a bone because of osteoporosis. It is projected that by 2020, half of Americans over the age of 50 will have osteoporosis or low bone density.
Characteristics/Clinical Presentation[edit | edit source]
Osteoporosis is often referred to as a silent disease because there are no early clinical signs or symptoms. Frequently, no symptoms are present until bone loss is advanced enough to result in a fracture. Common locations of fracture include; proximal femur, vertebrae, hip, pelvis, proximal humerus, distal radius, and tibia. Proximal femur and vertebrae are the two most common sites. Therefore, a constant mild to severe back pain may be a concern, when there is no history of injury or falls. Hip fractures are usually not detected until a fall has occurred. Because of the lack of early symptoms, those at risk are highly suggested to get routine bone scans. Many individuals will develop secondary orthopedic problems related to associated postural changes, fractures, and a general decrease in physical conditioning. A common presentation of an individual with osteoporosis may be a Caucasian female, 65 years or older, with a thin body type.
Clinical Signs and Symptoms
Back pain: Episodic, acute low thoracic/high lumbar pain
Compression fracture of the spine
Bone fractures
Decrease in height
Kyphosis
Dowager’s hump
Decreased activity tolerance
Early satiety
Associated Co-morbidities[edit | edit source]
As many diseases increase an individuals risk of osteoporosis, they also may be seen as comorbidities.
Eating disorders
Cancer and cancer treatment
Chronic renal failure
Osteogenesis imperfect
Rheumatic diseases
Chronic pulmonary disease
Cushing’s Disease
Male hypogonadism
Hypothyroidism
Hyperparathyroidism
Type 2 Diabetes Mellitus
Gastrointestinal Disease Hepatic disease
The following comorbidities should may increase the risk of fracture:
Inflammatory bowel or joing disease Breast or prostat cancer Diabetes Celiac diseases Moderate Renal Failure Depression
Medications[edit | edit source]
| Class and Drug | Brand Name | Form | Frequency | Side Effects |
| Biphosphonates | ||||
| Alendronate | Generic Alendronate and Fosamax | Oral (tablet) | Daily/Weekly |
Side effects for all biphosphonates may include bone, joint, or muscle pain. Side effects of the oral tablets may include nausea, difficulty swallowing, heartburn, irritation of the esophagus, and gastric ulcer. Side effects that can occur shortly after receiving an IV biphosphonate include flu-like symptoms, fever, headache, and pain in muscles or joints. |
| Alendronate | Fosamax Plus D (with 2,800 IU or 5,600 IU of Vitamin D3) | Oral (tablet) | Weekly | |
| Ibandronate | Boniva | Oral (tablet) | Monthly | |
| Ibandronate | Boniva | Intravenous (IV) injection | Four times per year | |
| Risedronate | Actonel | Oral (tablet) | Daily/Weekly/Twice Monthly/Monthly | |
| Risedronate | Actonel with Calcium | Oral (tablet) | Weekly | |
| Zoledronic Acid | Reclast | Intravenous (IV) infusion | One time per year/Once every two years | |
| Calcitonin | ||||
| Calcitonin | Fortical | Nasal spray | Daily | Runny nose, headache, back pain, and nosebleed (epistaxis) |
| Calcitonin | Miacalcin | Nasal spray | Daily | |
| Calcitonin | Miacalcin | Injection | Varies | May cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea, and a skin rash. |
| Estrogen | ||||
| Estrogen | Multiple brands | Oral (tablet) | Daily | Increased risk of endometrial and breast cancer, vaginal bleeding, breast tenderness, gallbladder disease, stroke, venous blood clot, cognitive decline. |
| Estrogen | Multiple brands | Transdermal (skin patch) | Twice Weekly/Weekly | |
| Estrogen Agonists/Antagonists also called Selective Estrogen Receptor Modulators (SERMs) | ||||
| Raloxifene | Evista | Oral (tablet) | Daily | Hot flashes, leg cramps, and deep vein thrombosis (blood clots) |
| Parathyroid Hormone | ||||
| Teriparatide | Forteo | Injection | Daily | Leg cramps and dizziness |
| RANK Ligand (RANKL) Inhibitor | ||||
| Denosumab | Prolia | Injection | Every 6 Months | May lower calcium levels in the blood. May also increase the risk of injection and skin rashes. |
Antiresorptive medications, such as biphosphonates, calcitonin, denosumab, estrogen, and estrogen agonists/antagonists, work to prevent more bone loss and reduce the risk of fractures.
Anabolic drugs, such as Teriparatide (a parathyroid hormone), work to increase the rate of bone formation and reduce the risk of fractures.
Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
In order to make a diagnosis of osteoporosis there are series of diagnostic tests and lab tests that your doctor may perform after taking a thorough patient history and performing an examination.
Bone Density Test
The most common test used is a bone density test, which is the only test that can detect osteoporosis before a fracture occurs. There are two types of bone density tests: Central DXA and Screening Tests. Central DXA uses a dual energy absorptiometry machine to test the bone density of the hip and spine. If testing can’t be done to the hip and spine then it is recommended to test the radius of the forearm. Central DXA is the preferred method because it measures bone density at the hip and spine where bone loss occurs most rapidly.
Screening Tests, also called peripheral tests, measure bone density in the lower arm, wrist, finger, or heel. These are useful when Central DXA testing is not possible. Screening tests cannot accurately diagnose osteoporosis or measure how well medication is working.
Bone density test results are reported using T-scores. T-scores are relative to how much higher or lower your bone density is compared to that of a healthy 30 year old adult.
| Category |
T-score |
| Normal |
-1.0 or above |
| Osteopenia (low bone mass) |
-1.0 to -2.5 |
| Osteoporosis |
-2.5 or less |
| Severe Osteoporosis |
-2.5 or less with one or more fragility fractures |
Laboratory Tests
- Blood Calcium levels
- 24-hour urine calcium measurement
- Thyroid function tests
- Parathyroid hormone levels
- Testosterone levels in men
- 25-hydroxyvitamin D test to determine whether the body has enough vitamin D
- Biochemical marker tests, such as NTX and CTX
Some of these tests can help to identify if you have any other medical conditions that could contribute to osteoporosis, which would be called secondary osteoporosis. Biochemical marker tests can help estimate how fast you are losing or making bone.
Etiology/Causes[edit | edit source]
Bone tissue is constantly being absorbed and replaces throughout ones life span. Bone mass decreases when the rate of absorption increases the rate or production; typically occurring with advanced age. Peak bone mass is met at the average age of 20. Those who develop less bone mass prior to this time, have a high chance of developing osteoporosis. *MC
Primary osteoporosis has no known definite cause, but there are many contributing factors associated with the disorder. These include prolonged negative calcium balance, impaired gonadal and adrenal function, estrogen deficiency, or sedentary lifestyle. Postmenopausal osteoporosis is associated with increased bone loss due to decrease production of estrogen. Women commonly lose 1% per year after peak bone density has been met, for up to 8 years post menopause. Senile osteoporosis is an age-related bone loss that often accompanies advanced aging.
Secondary osteoporosis is caused by prolonged use of medications or secondary to another disease or condition which inhibits the absorption of calcium or impedes the body's ability to produce bone.
Low calcium intake or absorption can greatly increase one's risk for developing osteoporosis.*MC Life long calcium intake is crucial in building up bone stock prior to peak levels of bone mass, as well as maintain bone mass after the age of 20. Excessive alcohol consumption can decrease the body's ability to absorb calcium.
Bone produces in response to the load applied to it. Physical active individuals typically have higher bone density, then those who have a sedentary lifestyle.
Hormone levels, either too little or too much, can impede on the body's ability to produce and maintain adequate bone mass. Dysfunction with sex glands, thyroid, parathyroid, or adrenal glands is often associated with osteoporosis. *MC
Risk Factors
Age 50 years and older
Female gender
Caucasian and Asian *MC
Menopause (especially early or surgically induced)
Family history of osteoporosis or fragility fractures
Northern European ancestry
Long periods of inactivity or immobilization
Depression
Alcohol (>3 drinks/day)
Tobacco
Caffeine (>4 cups/ day)
Amenorrhea (abnormal absence of menses)
Thin body build *MC
Associated Diseases & Disorders:
Endocrine Disorders:
Hypothyroidism
Hyperparathyroidism
Type 2 Diabetes Mellitus
Cushing’s Disease
Male hypogonadism (testosterone deficiency) Malabsorption syndrome:
Gastrointestinal disease; gastric surgery
Hepatic disease
Medication-related:Organ transplant
Chronic pulmonary disease
Rheumatic diseases, including juvenile rheumatoid arthritis
Other:
Chronic renal failure
Osteogenesis imperfect
Cancer and cancer treatment; skeletal metastases
Eating disorders
Spinal cord injury
Cerebrovascular accident or stroke
Acid-balance imbalance (metabolic acidosis)
Depression (men > women)
Medication (>6 months)
Corticosteroids/steroids
Immunosuppressants
Heparin; Coumadin
Nonthiazide diuretics
Methotrexate
Chemotherapy
Antacids (containing aluminum)
Laxatives
Anticonvulsants
Some antibiotics
Buffered aspirin
Thyroid hormone
Lithium
Depo-provera (contraceptive)
Diet & Nutrition
Calcium and magnesium deficiency
Vitamin D deficiency
Vitamin C deficiency (helps with calcium absorption)
High ratio of animal to vegetable protein intake
High-fat diet (reduces calcium absorption in the gut)
Excess sugar (depletes phosphorus)
Eating disorders or repeated crash dieting
Systemic Involvement[edit | edit source]
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Medical Management (current best evidence)[edit | edit source]
According to Kurt Kennel, M.D., an endocrinology specialist from the Mayo Clinic, the most common medications used to manage osteoporosis are biphosphonates, such as Fosamax, Boniva, Actonel, Atelvia, Reclast, and Zometa. It is also a common practice to use hormones, like estrogen, to help treat and prevent osteoporosis. Some women do not elect to use these hormones due to the increased risk of heart attacks and certain types of cancers. The choice of which drug is right for you is generally based on preference, convenience, and adhering to dosing schedule.
The length of time that a medicine should be used is variable. Most current research shows that biphosphonate medications should be taken up to 5 years for it to be safe and effective. There haven't been enough long-term studies to prove the efficiency of the medications after 5 years of treatment. One thing is known that if you have been taking biphosphonate drugs you can still have positive effects after you stop taking the medications due to building up the medicine in your bone. Due to this effect of the medications, some doctors have patients take a break from the medications after 5 years if they believe they are at a low-risk for fractures.
Medical management helps reduce the risk of fractures but does not eliminate it. If you experience a fracture while taking medications to help treat your osteoporosis you may need to switch to a more aggressive bone-building therapy, such Forteo which is a parathyroid hormone, or a new osteoporosis drug like Prolia or Xgeva. These drugs produce similar or better results than biphosphonates but just work in a different way.
Medical management isn't the only way to treat osteoporosis. It is also important to include daily exercise, good nutrition (including the adequate amount of calcium and vitamin D), quit smoking, and limit your alcohol intake.
Physical Therapy Management (current best evidence)[edit | edit source]
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Alternative/Holistic Management (current best evidence)[edit | edit source]
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