Diagnosis and Treatment of Osteoporosis

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SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Prevention of fractures and treatment of osteoporosis Older persons at risk of falls should consider exercise, physical therapy, home hazard B 26, 27 assessment, and withdrawal of psychotropic medication to decrease fall risk. Daily vitamin D supplementation (at least 700 to 800 IU), with or without calcium, should be B 15, 31 used to decrease fracture risk in persons 60 years and older. Bisphosphonates should be used to prevent osteoporotic fractures (see Table 5 for specific A 14, 16, 17, 21, 33, 34 indications). Raloxifene (Evista) can be used to prevent vertebral fractures in postmenopausal women with A 22, 33, 34 osteoporosis, especially if at high risk of breast cancer. Calcitonin (Miacalcin) can be used to prevent recurrent vertebral fractures in postmenopausal B 23, 34 women. Teriparatide (Forteo) can be used to prevent vertebral and nonvertebral fractures in A 24, 34 postmenopausal women with prior vertebral fractures. Screening The following populations should be screened for osteoporosis: All women 65 years and older A 2, 3 Selected postmenopausal women and men 50 to 69 years of age with risk factors for fracture C 2, 13 All men 70 years and older C 2, 13 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort. Force (USPSTF) guideline, based on a systematic review of the evidence, recommends screening DEXA in all women 65 years and older, as well as in women 60 to 64 years of age who have increased fracture risk. The USPSTF states that the evidence is insufficient to recommend for or against screening in postmenopausal women younger than 60 years. 3 The National Osteoporosis Foundation (NOF), which receives substantial support from the pharmaceutical industry, developed a guideline using an expert panel that recommends screening in women 65 years and older, men 70 years and older, adults with a fracture, and selected postmenopausal women and men with clinical risk factors for fracture (Table 1 2,3 ). 2 Table 1. Selected Factors Associated with Fracture or Low Bone Mineral Density in Postmenopausal Women Increasing age Low body weight (< 127 lb [58 kg]) Personal history of fracture Family history of osteoporotic fracture Not using hormone therapy White or Asian race Information from references 2 and 3. Excessive alcohol (> 2 drinks per day), caffeine, and tobacco use History of falls Low level of physical activity Low calcium or vitamin D intake Use of certain medications or presence of certain medical conditions (Table 2) It is reasonable to clinically assess age and risk factors when deciding which women to screen. Validated clinical rules, such as the Simple Calculated Osteoporosis Risk Estimation (SCORE) tool, may be considered as well. The SCORE tool is a six-item instrument with a sensitivity of 91 percent and a specificity of 40 percent. It is used to predict which women may benefit from DEXA screening. 8 This calculator may be found at http://osteoed.org/tools.php. The USPSTF found that, for women 55 to 59 years of age, the number needed to screen (NNS) over five years was more than 4,000 to prevent one hip fracture and 1,300 to prevent one vertebral fracture. The NNS to prevent one hip fracture over five years declines with age, to 1,856 for women 60 to 64 years of age, 731 for women 65 to 69 years of age, and 143 for women 75 to 79 years of age. 9 Diagnosis Osteoporosis is diagnosed clinically or radiographically. Osteoporosis may present with low-impact fractures (occurring from a fall at or below standing height) or fragility fractures (occurring spontaneously). 7 Osteoporosis is most commonly diagnosed with a T-score of −2.5 or below as determined by central DEXA scan of the total hip, femoral neck, or lumbar spine. 2,3,6 Quantitative computed tomography can be 194 American Family Physician www.aafp.org/afp Volume 79, Number 3 ◆ February 1, 2009
Table 2. Causes of Secondary Osteoporosis Cause Examples Cause Examples Chronic medical and systemic diseases Endocrine and metabolic disorders Amyloidosis Ankylosing spondylitis Chronic obstructive pulmonary disease Human immunodeficiency virus or acquired immunodeficiency syndrome Inflammatory bowel diseases Liver disease (severe) Multiple myeloma Renal insufficiency or renal failure Rheumatoid arthritis Systemic lupus erythematosus Athletic amenorrhea Cushing syndrome Diabetes mellitus, type 1 Hemochromatosis Hyperadrenocorticism Hyperparathyroidism (primary) Hyperthyroidism Hypogonadism (primary and secondary) Hypophosphatasia Medication Nutrition Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) Drugs causing hypogonadism (e.g., parenteral progesterone, methotrexate, gonadotropinreleasing hormone agonists) Glucocorticoids Heparin (long-term) Immunosuppressants (e.g., cyclosporine [Sandimmune], tacrolimus [Prograf]) Lithium Thyroid hormone excess Alcohol (> 2 drinks per day) Anorexia nervosa Celiac disease Gastric bypass or gastrectomy Vitamin D deficiency Information from references 1, 2, 6, and 7. used to assess BMD, but is limited by radiation exposure and cost. Quantitative calcaneal ultrasonography and peripheral DEXA, which measures BMD in the heel, finger, and forearm, are more portable and less costly than central DEXA and can effectively predict fracture risk. Their results, however, do not correlate well enough with central DEXA to be used diagnostically, and they have not been shown to be useful in monitoring treatment over time. 10 Biochemical markers of bone turnover in the serum or urine are not currently recommended for diagnosis. 6,11 Evaluating for Suspected Secondary Osteoporosis The number of postmenopausal women with osteoporosis from a secondary cause is unknown, but thought to be low. A careful history and physical examination may identify common causes of secondary osteoporosis. If clinical evaluation does not raise suspicion of a secondary cause, there is currently little evidence to warrant additional testing in postmenopausal women. 12 In contrast, approximately 50 percent of pre- and perimenopausal women with osteoporosis have an associated underlying cause. 12 There are no evidence-based guidelines to direct the evaluation of a suspected secondary cause of osteoporosis. 11,12 In pre- and perimenopausal women, a basic laboratory evaluation should be considered if there is no clear etiology evident by history and physical examination (Table 3 7 ). Screening and Diagnosis of Osteoporosis in Men In the United States, one in eight men will have an osteoporotic fracture in his lifetime, accounting for 30 percent of hip fractures and 18 percent of the total annual cost of osteoporosis. 1,4 Men have nearly twice the mortality from hip fractures compared with women. 1,4,13 Because data on the screening, diagnosis, and treatment of osteoporosis in men are limited, most published recommendations are based on expert opinion. 7,12 The NOF and the International Society for Clinical Densitometry recommend screening all men 70 years and older and men 50 to 69 years of age with risk factors (the USPSTF guidelines do not address screening in men). 2,13 Based on a recent systematic review, the American College of Physicians also recommends that older men be periodically assessed for risk of osteoporosis and have DEXA performed if at increased risk. 14 The validity of using a T-score of −2.5 or below as the diagnostic criterion for osteoporosis in men is unclear, but this is a commonly used standard. 12,13 Approximately 50 percent of men with osteoporosis have a secondary cause and warrant additional evaluation, along with a careful history and physical examination. 7,12 In addition to treating any underlying cause, interventions February 1, 2009 ◆ Volume 79, Number 3 www.aafp.org/afp American Family Physician 195
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Diagnosis and Treatment of Osteoporosis

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