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Prevention and treatment of osteoporosis
The National Osteoporosis Foundation released new 2013 guidelines for the treatment and management of osteoporosis for postmenopausal women and men over the age of 50 years.
Osteoporosis definition
Osteoporosis is defined by a bone mineral density (BMD) measurement (T score) less than or equal to 2.5 standard deviations (SD) below the mean for a young adult reference population, or the occurrence of a hip or vertebral fracture without preceding major trauma. Osteopenia is established by BMD testing showing a T score between 1.0-2.5 SD below a young adult reference population.
Assess patient’s risk for fracture
All postmenopausal women and men above age 50 years should be evaluated for risk of osteoporosis in order to determine the need for BMD testing and/or vertebral imaging. In addition, all patients should be evaluated for their risk of falling, since the majority of osteoporosis-related fractures occur because of a fall.
The WHO FRAX tool, may be used in order to calculate the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (clinical vertebral, hip, forearm or proximal humerus fracture). Risk of fracture can be calculated either with or without availability of BMD. The 10-year probability of fracture can be used to determine the need for pharmacologic treatment.
Diagnosis
Bone mineral density testing
Dual-energy x-ray absorptiometry (DXA) imaging of the hip and spine can diagnose or confirm osteoporosis. Testing should be considered in:
• Women aged 65 years and older and men 70 years of age and older, regardless of clinical risk factors.
• Patients of either sex who are aged between 50-69 years with clinical risk factors.
• Patients with a fracture after age 50 years.
• And patients with conditions (for example, rheumatoid arthritis) or on medications (for example, glucocorticoids) associated with low bone mass or bone loss.
Vertebral imaging
A single vertebral fracture increases the risk of subsequent vertebral and hip fractures, is consistent with the diagnosis of osteoporosis, and is an indication for pharmacologic treatment regardless of BMD. New to these guidelines is a recommendation for a proactive screening effort for vertebral fractures using lateral thoracic and lumbar spine x-ray or by lateral vertebral fracture assessment (VFA). Indications for vertebral imaging are:
• Women aged 65 years and older and men aged 70 years and older if T score is –1.5 or below.
• Women aged 70 years and men age 80 years and older.
• Postmenopausal women and men aged 50 years and older with a low trauma fracture.
• And/or postmenopausal women and men aged 50-69 years if there is height loss of 1.5 inches or more or ongoing long-term glucocorticoid treatment.
Markers of bone turnover
Biochemical markers of bone turnover are divided into two types:
• Markers of bone remodeling – serum C-telopeptide (CTx) and urinary N-telopeptide (NTx)
• Formation markers-serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and aminoterminal propeptide of type 1 procollagen (P1NP)]
Markers should be collected as fasting morning specimens and may be helpful in predicting risk of fracture and extend of fracture risk reduction when repeated after 3-6 months of pharmacologic therapy.
General recommendations
Vitamin D and calcium: A diet rich in vitamin D and calcium is an inexpensive way to prevent bone mineral density loss. Fruits, vegetables, low-fat dairy, and sunlight are great sources. If dietary supplementation is required, men aged 50-70 years should consume 1,000 mg of calcium/day and women over 51 years old should have 1,200 mg of calcium daily. Both men and women over 50 years should have 800-1,000 IU of vitamin D daily.
Treat vitamin D deficiencies: Supplementation should be adequate to achieve serum levels of 30ng/mL (75nmol/L).
Decreased alcohol use, smoking cessation, exercise, and fall prevention: Smoking cessation should be strongly advised. Moderate alcohol intake does not adversely affect bone and may be associated with lower fracture risk, though consuming more than three drinks daily may have an adverse effect on bone health and increases the risk of falling. Weight-bearing and muscle-strengthening exercise improves bone health and decreases the risk of falls. Home assessment for fall prevention for the elderly may decrease the risk of fracture.
Pharmacologic treatments
Treatment should be considered in postmenopausal women and men over 50 years with a hip or vertebral fracture; T score less than or equal to –2.5 at femoral neck, total hip or lumbar spine; low bone mass (T score between –1.0 and –2.5) and a 10-year probability of hip fracture greater than or equal to 3% or 10 year probability of major osteoporosis-related fracture greater than or equal to 20%. The antifracture benefits of medications have been studied primarily in postmenopausal women with osteoporosis. Pharmacologic therapy should not be considered life-long and that treatment decisions should be individualized. After 3-5 years of treatment a comprehensive risk assessment should be performed.
The bottom line
Identify risk factors for osteoporosis in postmenopausal women and men over the age of 50 years. Bone mineral density screening is an important part of fracture prevention, and vertebral imaging should now be considered as a part of osteoporosis screening. Pharmacologic treatment can be considered when a nontraumatic fracture is apparent; if the T score is less than or equal to –2.5; or for individuals with an elevated 10-year fracture risk based on WHO model.
• Source: Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Charles is a second year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
The National Osteoporosis Foundation released new 2013 guidelines for the treatment and management of osteoporosis for postmenopausal women and men over the age of 50 years.
Osteoporosis definition
Osteoporosis is defined by a bone mineral density (BMD) measurement (T score) less than or equal to 2.5 standard deviations (SD) below the mean for a young adult reference population, or the occurrence of a hip or vertebral fracture without preceding major trauma. Osteopenia is established by BMD testing showing a T score between 1.0-2.5 SD below a young adult reference population.
Assess patient’s risk for fracture
All postmenopausal women and men above age 50 years should be evaluated for risk of osteoporosis in order to determine the need for BMD testing and/or vertebral imaging. In addition, all patients should be evaluated for their risk of falling, since the majority of osteoporosis-related fractures occur because of a fall.
The WHO FRAX tool, may be used in order to calculate the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (clinical vertebral, hip, forearm or proximal humerus fracture). Risk of fracture can be calculated either with or without availability of BMD. The 10-year probability of fracture can be used to determine the need for pharmacologic treatment.
Diagnosis
Bone mineral density testing
Dual-energy x-ray absorptiometry (DXA) imaging of the hip and spine can diagnose or confirm osteoporosis. Testing should be considered in:
• Women aged 65 years and older and men 70 years of age and older, regardless of clinical risk factors.
• Patients of either sex who are aged between 50-69 years with clinical risk factors.
• Patients with a fracture after age 50 years.
• And patients with conditions (for example, rheumatoid arthritis) or on medications (for example, glucocorticoids) associated with low bone mass or bone loss.
Vertebral imaging
A single vertebral fracture increases the risk of subsequent vertebral and hip fractures, is consistent with the diagnosis of osteoporosis, and is an indication for pharmacologic treatment regardless of BMD. New to these guidelines is a recommendation for a proactive screening effort for vertebral fractures using lateral thoracic and lumbar spine x-ray or by lateral vertebral fracture assessment (VFA). Indications for vertebral imaging are:
• Women aged 65 years and older and men aged 70 years and older if T score is –1.5 or below.
• Women aged 70 years and men age 80 years and older.
• Postmenopausal women and men aged 50 years and older with a low trauma fracture.
• And/or postmenopausal women and men aged 50-69 years if there is height loss of 1.5 inches or more or ongoing long-term glucocorticoid treatment.
Markers of bone turnover
Biochemical markers of bone turnover are divided into two types:
• Markers of bone remodeling – serum C-telopeptide (CTx) and urinary N-telopeptide (NTx)
• Formation markers-serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and aminoterminal propeptide of type 1 procollagen (P1NP)]
Markers should be collected as fasting morning specimens and may be helpful in predicting risk of fracture and extend of fracture risk reduction when repeated after 3-6 months of pharmacologic therapy.
General recommendations
Vitamin D and calcium: A diet rich in vitamin D and calcium is an inexpensive way to prevent bone mineral density loss. Fruits, vegetables, low-fat dairy, and sunlight are great sources. If dietary supplementation is required, men aged 50-70 years should consume 1,000 mg of calcium/day and women over 51 years old should have 1,200 mg of calcium daily. Both men and women over 50 years should have 800-1,000 IU of vitamin D daily.
Treat vitamin D deficiencies: Supplementation should be adequate to achieve serum levels of 30ng/mL (75nmol/L).
Decreased alcohol use, smoking cessation, exercise, and fall prevention: Smoking cessation should be strongly advised. Moderate alcohol intake does not adversely affect bone and may be associated with lower fracture risk, though consuming more than three drinks daily may have an adverse effect on bone health and increases the risk of falling. Weight-bearing and muscle-strengthening exercise improves bone health and decreases the risk of falls. Home assessment for fall prevention for the elderly may decrease the risk of fracture.
Pharmacologic treatments
Treatment should be considered in postmenopausal women and men over 50 years with a hip or vertebral fracture; T score less than or equal to –2.5 at femoral neck, total hip or lumbar spine; low bone mass (T score between –1.0 and –2.5) and a 10-year probability of hip fracture greater than or equal to 3% or 10 year probability of major osteoporosis-related fracture greater than or equal to 20%. The antifracture benefits of medications have been studied primarily in postmenopausal women with osteoporosis. Pharmacologic therapy should not be considered life-long and that treatment decisions should be individualized. After 3-5 years of treatment a comprehensive risk assessment should be performed.
The bottom line
Identify risk factors for osteoporosis in postmenopausal women and men over the age of 50 years. Bone mineral density screening is an important part of fracture prevention, and vertebral imaging should now be considered as a part of osteoporosis screening. Pharmacologic treatment can be considered when a nontraumatic fracture is apparent; if the T score is less than or equal to –2.5; or for individuals with an elevated 10-year fracture risk based on WHO model.
• Source: Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Charles is a second year resident in the Family Medicine Residency Program at Abington Memorial Hospital.
The National Osteoporosis Foundation released new 2013 guidelines for the treatment and management of osteoporosis for postmenopausal women and men over the age of 50 years.
Osteoporosis definition
Osteoporosis is defined by a bone mineral density (BMD) measurement (T score) less than or equal to 2.5 standard deviations (SD) below the mean for a young adult reference population, or the occurrence of a hip or vertebral fracture without preceding major trauma. Osteopenia is established by BMD testing showing a T score between 1.0-2.5 SD below a young adult reference population.
Assess patient’s risk for fracture
All postmenopausal women and men above age 50 years should be evaluated for risk of osteoporosis in order to determine the need for BMD testing and/or vertebral imaging. In addition, all patients should be evaluated for their risk of falling, since the majority of osteoporosis-related fractures occur because of a fall.
The WHO FRAX tool, may be used in order to calculate the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (clinical vertebral, hip, forearm or proximal humerus fracture). Risk of fracture can be calculated either with or without availability of BMD. The 10-year probability of fracture can be used to determine the need for pharmacologic treatment.
Diagnosis
Bone mineral density testing
Dual-energy x-ray absorptiometry (DXA) imaging of the hip and spine can diagnose or confirm osteoporosis. Testing should be considered in:
• Women aged 65 years and older and men 70 years of age and older, regardless of clinical risk factors.
• Patients of either sex who are aged between 50-69 years with clinical risk factors.
• Patients with a fracture after age 50 years.
• And patients with conditions (for example, rheumatoid arthritis) or on medications (for example, glucocorticoids) associated with low bone mass or bone loss.
Vertebral imaging
A single vertebral fracture increases the risk of subsequent vertebral and hip fractures, is consistent with the diagnosis of osteoporosis, and is an indication for pharmacologic treatment regardless of BMD. New to these guidelines is a recommendation for a proactive screening effort for vertebral fractures using lateral thoracic and lumbar spine x-ray or by lateral vertebral fracture assessment (VFA). Indications for vertebral imaging are:
• Women aged 65 years and older and men aged 70 years and older if T score is –1.5 or below.
• Women aged 70 years and men age 80 years and older.
• Postmenopausal women and men aged 50 years and older with a low trauma fracture.
• And/or postmenopausal women and men aged 50-69 years if there is height loss of 1.5 inches or more or ongoing long-term glucocorticoid treatment.
Markers of bone turnover
Biochemical markers of bone turnover are divided into two types:
• Markers of bone remodeling – serum C-telopeptide (CTx) and urinary N-telopeptide (NTx)
• Formation markers-serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and aminoterminal propeptide of type 1 procollagen (P1NP)]
Markers should be collected as fasting morning specimens and may be helpful in predicting risk of fracture and extend of fracture risk reduction when repeated after 3-6 months of pharmacologic therapy.
General recommendations
Vitamin D and calcium: A diet rich in vitamin D and calcium is an inexpensive way to prevent bone mineral density loss. Fruits, vegetables, low-fat dairy, and sunlight are great sources. If dietary supplementation is required, men aged 50-70 years should consume 1,000 mg of calcium/day and women over 51 years old should have 1,200 mg of calcium daily. Both men and women over 50 years should have 800-1,000 IU of vitamin D daily.
Treat vitamin D deficiencies: Supplementation should be adequate to achieve serum levels of 30ng/mL (75nmol/L).
Decreased alcohol use, smoking cessation, exercise, and fall prevention: Smoking cessation should be strongly advised. Moderate alcohol intake does not adversely affect bone and may be associated with lower fracture risk, though consuming more than three drinks daily may have an adverse effect on bone health and increases the risk of falling. Weight-bearing and muscle-strengthening exercise improves bone health and decreases the risk of falls. Home assessment for fall prevention for the elderly may decrease the risk of fracture.
Pharmacologic treatments
Treatment should be considered in postmenopausal women and men over 50 years with a hip or vertebral fracture; T score less than or equal to –2.5 at femoral neck, total hip or lumbar spine; low bone mass (T score between –1.0 and –2.5) and a 10-year probability of hip fracture greater than or equal to 3% or 10 year probability of major osteoporosis-related fracture greater than or equal to 20%. The antifracture benefits of medications have been studied primarily in postmenopausal women with osteoporosis. Pharmacologic therapy should not be considered life-long and that treatment decisions should be individualized. After 3-5 years of treatment a comprehensive risk assessment should be performed.
The bottom line
Identify risk factors for osteoporosis in postmenopausal women and men over the age of 50 years. Bone mineral density screening is an important part of fracture prevention, and vertebral imaging should now be considered as a part of osteoporosis screening. Pharmacologic treatment can be considered when a nontraumatic fracture is apparent; if the T score is less than or equal to –2.5; or for individuals with an elevated 10-year fracture risk based on WHO model.
• Source: Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Charles is a second year resident in the Family Medicine Residency Program at Abington Memorial Hospital.