Prevention and Treatment of Osteoporosis
Who should be screened for osteoporosis?
- Women or men of any age with fractures after minimal trauma
- All women over age 65
- All men over 75
- Younger women and men with major risk factors
What are the major risk factors for osteoporosis?
- Low body weight (BMI <23)
- Family history of osteoporosis
- Significant history of smoking or alcohol excess
- Premature menopause in women
- Testosterone deficiency in men
- Chronic glucocorticoid use
What are the major risk factors for fractures?
- Prior fractures with minimal trauma, including asymptomatic vertebral fractures
- Low bone mineral density
- History of falls or impaired physical function
- Impaired cognition
How should patients be screened for osteoporosis?
- Bone mineral densitometry of hip, with or without lumbar spine measurement
- Use the lowest T-score to determine need for treatment (T-score provides a comparison to healthy young adults; negative scores reflect low bone mineral density)
What should be done to prevent osteoporosis?
- Weight bearing exercise
- Calcium (1,000 - 1,500 mg/day) & Vitamin D (400 - 800 IU/day)
- Adequate calcium & vitamin D is essential for other therapies to be effective. Calcium is best taken in divided doses, with meals
- Stop smoking
- Avoid excess alcohol
- Maintain a healthy body weight
- Avoid thyroid hormone excess
When is drug treatment needed?
- In addition to basic recommendations for prevention of osteoporosis, treatment is recommended for T scores < - 2.5
- Consider treatment, if T-score is < -2 and other risk factors are present, or if there is documented bone loss over time
- All patients on chronic glucocorticoids need drug treatment
- Fosamax (Alendronate) (70 mg/week)
- Actonel (Risedronate) (35 mg/week)
- Additional potential benefits: none
- Potential risks: esophageal ulcers
- Side effects: GI distress, arthralgias/myalgias
- Estrogen or Estrogen/Progestin Therapy
- Appropriate if primary indication is relief of vasomotor symptoms
- Additional potential benefits: treatment of vasomotor symptoms and genitourinary atrophy
- Potential risks: breast cancer, gallbladder disease, venous thrombosis, cardiovascular disease, stroke
- Side effects: vaginal bleeding, breast tenderness
- Evista (Raloxifene) (60 mg/day)
- Additional potential benefits: reduced risk of breast cancer, LDL
- Potential risks: venous thromboembolic events
- Side effects: vasomotor symptoms, leg cramps
- Forteo (Teriparatide) (20 mcg/day by injection)
- Additional potential benefits: none unless high risk of fracture
- Potential risks: osteosarcoma after long-term use in rodents
- Side effects: hypercalcemia, leg cramps
How can fractures be prevented in patients at increased risk? Fall prevention strategies:
- Safety devices in home (e.g., non-skid rugs, night lights, tub or shower bars, stair banisters)
- Balance, strength, gait and weight-bearing exercises
- Proper footwear
- Optimize vision
- Minimize sedative and psychotropic drug use
- Consider devices (e.g., canes, walkers, hip protectors)
How should patients be followed?
- Assess compliance with recommended calcium and vitamin D intake, exercise program, and prescribed medications
- Monitor bone mineral density every 2 years (or annually if osteoporosis is severe) until stable, then less frequently
When should patients be referred to a specialist?
- Lack of response to conventional treatment, especially evidence of continued bone loss
- New fracture on therapy
- Inability to tolerate oral medications
- Unexplained Z-score of < - 2, to rule out secondary causes of osteoporosis (Z-score provides comparison to age-matched adults)