Osteoporosis and Fractures Are
Common, and Becoming More So
• About 10 million Americans age >50 years have
osteoporosis1
• Almost 34 million more have osteopenia1
• In 2005, >2 million osteoporotic fractures were
sustained, costing an estimated $17 billion2
• As the population continues to age, the incidence and
prevalence will increase1
– By 2020, 1 in 2 Americans older than age 50 years will have, or
be at risk of, developing osteoporosis of the hip1
– By 2025, the number of fractures is expected to increase to
>3 million at an estimated cost of $25.3 billion every year2
1. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General.
Rockville, MD: 2004. 2. Burge R, et al. J Bone Miner Res. 2007;22:465-475.
Osteoporotic Fractures Are Associated
with Increased Mortality
With permission from Bluic D, et al. JAMA. 2009;301:513-521.
“Red Flags” that Warrant Further
Assessment
• Prior low-trauma fracture as an adult
• Family history of osteoporosis, especially parental
history of hip fracture
• Weight loss of >1%/year in the elderly
• Treatment with drugs that adversely affect bone
metabolism
• Disease or conditions linked to secondary osteoporosis
• Unusual cessation of menstrual periods
• Anorexia nervosa (marked weight reduction)
• Athletic amenorrhea syndrome related to intense
physical activity
US Department of Health and Human Services. Bone Health and Osteoporosis:A Report of the Surgeon General.
Rockville, MD: 2004.
Selected Secondary Causes
of Osteoporosis in Adults
Endocrine Disease
or Metabolic Causes
Hypogonadism
Cushing’s syndrome
Hyperthyroidism
Hyperparathyroidism
Anorexia nervosa
Nutritional
Conditions
Malabsorption
syndromes (eg,
celiac disease)
Chronic cholestatic
liver disease
Heparin
Porphyria
Vitamin D
deficiency
Acromegaly
Medroxyprogesterone
Excess thyroid
hormone
Gastric operations
Diabetes mellitus,
type 1
Glucocorticoids
Malnutrition
Hyperprolactinemia
Hypophosphatasia
Drugs
Calcium deficiency
Alcoholism
Hypercalciuria
Antiepileptics
Gonadotropinreleasing hormone
analog agonists
Disorders of
Collagen
Metabolism
Other
Osteogenesis
imperfecta
Chronic obstructive
pulmonary disease
Homocystinuria
Rheumatoid arthritis
Ehlers-Danlos
syndrome
Myeloma, leukemia,
lymphoma
Marfan syndrome
Immobilization
Renal tubular acidosis
Organ
transplantation
Aromatase inhibitors
Mastocytosis
Thiazolidinedione
drugs
Thalassemia
Selective serotonin
reuptake inhibitors
Proton pump
inhibitors
AACE Osteoporosis Guidelines. Endocr Pract. 2003;9:544-564. With permission from the American Association of Clinical
Endocrinologists.
Who Should Have BMD Screening?
The National Osteoporosis Foundation recommends BMD screening for:
• Women age ≥65 years and men age ≥75 years, regardless of risk
factors
• Younger postmenopausal women, women in the menopausal
transition, and men age 50–70 years if they have risk factors
associated with increased fracture risk
• Adults with a previous fracture after age 50
• Anyone at risk for secondary osteoporosis
• Anyone receiving osteoporosis treatment, to monitor treatment effect
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation.
Washington, DC: National Osteoporosis Foundation; 2002:1-55.
Osteoporosis Defined Based on DXA
Measurement of BMD
Normal
BMD within 1 SD of young normal adult
(T-score ≥-1.0)
Osteopenia
(low bone mass)
BMD 1.1–2.49 SD below young normal adult
(T-score -1.1 to -2.49)
Osteoporosis
BMD ≥2.5 SD below young normal adult
(T-score ≤-2.5)
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our
Nation. 2002:1-55.
FRAX—Fracture Risk Assessment Tool
www.shef.ac.uk/FRAX
•
•
Estimates absolute 10-year risk of a hip fracture or major osteoporotic fracture (ie,
vertebral, hip, forearm, humerus)1
Incorporates clinical risk factors for fracture2,3
–
–
–
–
–
–
–
–
–
–
•
•
Age
Gender
Previous fragility fracture after age 50 years
History of glucocorticoid use
Parental history of hip fracture
Rheumatoid arthritis
Secondary osteoporosis
Current smoker
Alcohol consumption >3 drinks per day
Body mass index
More sensitive than bone mineral density alone in identifying those
at high risk of fracture2
Pertains only to previously untreated patients1
1. National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our
Nation. 2002:1-55. 2. American College of Rheumatology Hotline summary of FRAX. March 18, 2008. 3. FRAX. WHO
Fracture Risk Assessment Tool. 2008. www.shef.ac.uk/FRAX. Accessed April 21, 2009.
Primary Prevention for All Patients
• Well-balanced nutrition
– Calcium = at least 1200 mg/day
– Vitamin D = 800 to 1000 mg/day
• Active, healthy lifestyle
– Regular weight-bearing and muscle-strengthening exercise
 Improves agility, posture, and balance
 May provide modest increases in bone density
– Avoid or stop cigarette smoking
– Avoid or stop excessive alcohol consumption (>3 drinks/day)
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our
Nation. 2002:1-55.
Fall Prevention Strategies
• Falls frequently cause fractures; preventing falls
helps prevent fractures
• Address risk factors for falls
– Environmental factors: low lighting, obstacles in the
walking path, lack of assist devices in the bathroom
– Medical factors: poor vision, previous fall, orthostatic
hypotension, medications that may affect balance or
cause sedation
• Consider muscle strengthening and balance
retraining
US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General.
Rockville, MD: 2004.
Pharmacologic Therapy
in Primary Prevention
Antiresorptive Agent
MOA: reduce bone loss
• Bisphosphonates
– Alendronate
Anabolic Agents
MOA: build bone
• Parathyroid hormone
– Teriparatide
– Ibandronate
– Risedronate
– Zoledronate
• Estrogen
• Raloxifene
• Calcitonin
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our
Nation. 2002:1-55.
Monitoring Patients on Pharmacotherapy
• Assess adherence to therapy and lifestyle modifications
• Continue to evaluate and address risk factors for falls
• Measure bone mineral density every 2 years in patients
on pharmacotherapy
– Monitoring with DXA should be in accordance with medical
necessity, expected response, and in consideration of local
regulatory requirements
– Use consistent DXA instrument, facility, and personnel
for repeat monitoring
• Consider measurement of biochemical markers of bone
turnover in patients whose bone density has decreased
despite treatment compliance; evaluate for other
secondary causes of bone loss
National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our
Nation. 2002:1-55.