Osteoporosis – At A Glance

Osteoporosis is a condition which weakens the bones, making them more fragile and increasing the risk of fracture.
This can be considered as one of the most renowned diseases among elderly population and this term can be frequently heard among their community.

Causes / Risk Factors Of Osteoporosis

Non Modifiable 

  • History
    • Past history of fracture as an adult
    • Fracture in first degree relative
  • Female sex
  • Advancing age
  • Dementia

Potentially Modifiable

  • Smoking and alcohol
  • Low body weight < 57.6 kg
  • Early menopause / Premenopausal amenorrhoea 
  • Dietary deficiency (Low calcium intake)
  • Sedentary life style 
  • Recurrent falls 

Diseases That Predispose Osteoporosis

  • Endocrine diseases
    • Hyperthyroidism 
    • Hyperparathyroidism  
    • Cushing’s syndrome / Steroid therapy 
    • Diabetes mellitus
    • Growth hormone deficiency
    • Hypogonadism (Turner’s syndrome)
  • Haematological diseases
    • Multiple myeloma
    • Lymphoma
  • Gastrointestinal diseases
    • Malabsorption syndrome 
    • Liver diseases
    • Gastrectomy 
  • Rheumatoid arthritis
  • Chronic renal failure

Clinical Presentation

Mostly these patients present following a fracture, till then they remain undiagnosed. 
Osteoporosis is a chronic disease which develops gradually, frequently following osteopenia. 

Common sites of fracture

  • Wrist fractures
  • Hip fractures
  • Vertebral fractures
    • 2/3rd of vertebral fractures are asymptomatic 

Therefore, the most common presentation among these patients is pain following a fracture. 

On examination

  • Kyphosis
  • Exaggerated cervical lordosis
  • Loss of lumber lordosis

Investigations

  • To assess risk factors
    • Complete blood count
    • Liver function tests
    • Thyroid function tests 
    • 25-Hydroxy Vitamin D Test (To look for vitamin D deficiency)
    • Serum testosterone
      • Males with osteoporosis without significant risk factors should always be check for testosterone levels 
  • Dual energy X-Ray absorptiometry (DEXA) scan – Confirmatory
    • Measures the bone mineral density (BMD)
    • BMD of the wrist is assessed by this scan
    • Standard deviation is calculated at the end of the test and expressed as the T score
    • Results are interpreted as below
      • T-score of > –1 ⇒ Normal
      • T-score of –1 to –2.5 SD ⇒ Osteopenia
      • T-score of < –2.5 SD ⇒ Osteoporosis

Osteopenia

Loss of bone mineral density which can be accountable as osteoporosis is termed as osteopenia. 

Treatment

Aim is to prevent further osteoporotic fractures and to strengthen the weakened bones.

  • First line therapy – Oral bisphosphonates (Alendronate / Risedronate)
    • Dosage of alendronate – 70mg, once a week
    • 25% will develop GI problems (Severe gastric erosions)
    • Precautions to follow while taking alendronate
      • Should be taken in the morning in an empty stomach
      • With plenty of water
      • Should not eat or drink anything for at least 30 mins 
      • Should remain seated or standing for at least 30 mins 
  • Second line therapy – Ibandronate / Raloxifene
    • Ibandronate is given once monthly
    • Raloxifene
      • It is a selective oestrogen receptor modulator (SERM)
      • Raloxifene is recommended for patients who cannot tolerate bisphosphonates 
      • Reduces the risk of breast cancer as well
  • Other drugs used in osteoporosis
    • Strontium ranelate (Not a routine drug) 
    • Teriparatide
      • It is the recombinant form of PTH
      • Can be used in patients with high risk of fracture or with failed bisphosphonate therapy
  • Vitamin D and Calcium supplementation 
  • Life style modifications
    • Regular exercises to strengthen the bones
    • Healthy balanced diet
    • Avoid smoking and alcohol

Risk Assessment For Fracture

In osteoporosis, 10 year risk of fracture is calculated by using Fracture risk assessment tool | FRAX® 

This tool can be used to obtain the percentage risk of a fracture within 10 years time and helps to categorize patients according to their severity. 

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