_______________________________________________________ Osteoporosis: Diagnosis and Management
To effectively prevent, diagnose, and treat this disease, physicians and other healthcare providers should understand the epidemiology, physiology, and management of osteoporosis. The following case study will be referenced throughout the text to illustrate the challenges of treating patients with osteoporosis. An Asian woman, Patient D, is 64 years of age with a history of type 2 diabetes, asthma, hypertension, and degenerative joint disease. She presents to a general medicine clinic with persistent lower back pain. The patient reports that for the last few months, she has been experiencing aching pain in the lower lumbar area. It is worse with exertion. The pain is fairly localized, without radiation. She does not experience any tingling, numbness, or weakness. There is no history of trauma. On exam, blood pressure is 135/75 mm Hg, heart rate 72 beats per minute, respirations 18 breaths per minute, temperature 99 degrees Fahrenheit, height 59 inches (150 cm), and weight 99 lbs (45 kg). The patient does exhibit some tenderness to palpation in the lower lumbar area. She notes that she tries to remain active, walking about 2 to 3 miles, three or four days a week; she is also a devoted gardener. She is concerned enough about this pain that she believes she needs an x-ray. She also reluctantly remarks that she is not sure if she is exaggerating, but she feels she might be “shrinking.” She recently tried on a pair of pants she purchased several years ago, and now they appear to be too long. She wants to know if this is possible. One of her sisters recently told her that she was diagnosed with “brittle bones.” She asks you what this means and if she should be concerned. DEFINITIONS The definition of osteoporosis has evolved over the past few decades. Osteoporosis has been described colloquially as “thin bones” or “brittle bones,” and at one time, the diagnosis of osteoporosis relied on the occurrence of a low-trauma fracture. The most widely accepted medical definition was proposed in 1991 and reaffirmed in 1993 at consensus development conferences supported by the National Institute of Arthritis and Musculoskeletal Disease of the National Institutes of Health and the BHOF. At those conferences, osteoporosis was defined as [15; 16]: A systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. In 1994, a World Health Organization (WHO) working group determined a level of bone mineral density (BMD) that would be clinically applicable and consistent with the new definition [17]. This was due to a desire to seek a more quantitative, rather than qualitative, definition. Additionally, this group published a set of standards to define the patient with osteopenia. Osteopenia had been loosely defined as low bone mass or decreased calcification of bone without the clinically increased risk of fracture. However, there is a wide spectrum of bone quality and strength. Frequently, osteopenia is a precursor of osteoporosis.
INTRODUCTION Osteoporosis has increasingly become a major health problem. The Bone Health and Osteoporosis Foundation (BHOF) (formerly the National Osteoporosis Foundation) has estimated that 10 million Americans have osteoporosis and 44 million have low bone mass, or osteopenia, which places them at risk for osteoporosis [1; 2]. Approximately 1 in 2 women and 1 in 4 men 50 years of age and older will have an osteoporosis-related fracture in their lifetime [3]. Osteoporosis is the most common type of metabolic bone disease. It results either from the body’s inability to form new bone or from an increased resorption of formed bone. Essentially, when there is an imbalance between osteoblastic and osteoclastic activity, skeletal problems arise. Risk factors, such as advanced age, family history, race, estrogen deficiency, tobacco use, steroid use, low calcium intake, physical inactivity, and low body weight, contribute to this condition [4]. Several diagnostic techniques have improved the ability to diagnose osteoporosis, most notably dual-energy x-ray absorptiometry (DXA), which is considered the gold standard for diagnosing osteopenia or osteoporosis [5]. Ultrasound, radionuclide absorptiometry, quantitative computed tomography (CT), and magnetic resonance imaging (MRI) also have been used to assess risk of fracture [6]. In the United States, current diagnostic criteria are based solely on quantitative CT hip and DXA spine or hip T-score measurements [7; 8]. Along with these diagnostic techniques, biochemical markers, such as hydroxyproline and collagen cross links, may be used to identify patients at risk [5; 9]. Several screening guidelines have been published indicating the preferred techniques and indications. Treatment of osteoporosis remains controversial. The focus of management has been on slowing or stopping bone loss or creating new bone. Because of the significant disability, morbidity, mortality, and costs associated with osteoporosis- related fractures, the American College of Physicians recommends that treatment be aimed at fracture prevention [10]. First-line therapy remains diet supplementation and regular weight-bearing and muscle-strengthening exercises, both of which should be started before 30 years of age [11; 12]. Numerous medications, either antiresorptives or bone formation agents (anabolics), exist with different patient indications, adverse events, and contraindications. Additionally, several high-profile studies have impacted the treatment and prevention of osteoporosis. Specifically, the Heart and Estrogen/Progestin Replacement Study (HERS) and the Women’s Health Initiative (WHI) have indicated some potential dangers (e.g., increased risk of breast cancer, heart attack, stroke, blood clots in the legs and lungs) associated with estrogen replacement, which until recently had been one of the mainstays of treatment [13; 14].
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