Treatment should begin by addressing potentially modifiable risk factors such as excess alcohol consumption , tobacco use , nutrition , and physical activity levels .
Diagnosis
A bone mineral density ( BMD ) test is used to diagnose Osteoporosis ( see Table A ).
• The result of this test is reported as a T-score . The World Health Organization ( WHO ) established a classification of BMD according to the standard deviation difference between a patient ’ s BMD and that of a young adult reference population ( T-score ).
• A dual energy x-ray absorptiometry ( DXA ) gives an accurate estimate of bone mineral density .
Evaluation
The goal of the evaluation is to rule out secondary causes of low bone mass , such as hyperparathyroidism and to detect treatable causes or contributing factors of osteoporosis .
Postmenopausal women with a low BMD ( T-score below -2.5 ) and / or a fragility fracture should have the following tests :
• Biochemistry profile ( calcium , phosphorus , albumin , total protein , creatinine , liver enzymes , electrolytes )
• 25-hydroxyvitamin D
• Complete blood count
• Thyroid-stimulating hormone
Additional evaluation for women with abnormalities on the initial laboratory testing includes :
• Women with anemia and / or low vitamin D levels should be tested for celiac disease
• Serum PTH should be measured in patients with hypercalcemia , hypercalciuria , history of renal stones , or osteopenia
• Urinary cortisol excretion should be measured if Cushing ’ s syndrome is suspected and in patients with unexplained osteoporosis and vertebral fracture .
Treatment
Lifestyle modifications should be encouraged for all adults with low bone mass ( osteopenia and osteoporosis ). These include :
• Dietary calcium intake of 1000 to 1200 mg daily
• Vitamin D3 intake of 800 to 1000 IU for ages 50 and over
• Regular weight-bearing exercise
• Smoking cessation
• Achievement of healthy weight ( BMI 20.0 - 24.9 )
• Moderation of alcohol consumption
Drug therapy is recommended for :
• History of fragility fracture of hip or spine
• BMD values consistent with osteoporosis ( see Table B ).
Treatment continued …
Medications
• First-line treatments to consider are bisphosphonates * ( alendronate , risedronate , ibandronate , zoledronic acid ) and denosumab .
• Selective estrogen receptor modulators ( SERMs ), such as raloxifene and tamoxifen , have been shown benefit for vertebral fractures , should not be used in menstruating women as they block estrogen action on the bone , leading to further bone loss .
• Parathyroid hormone ( teriparatide ) is often reserved for patients with severe osteoporosis with duration of therapy limited to 2 years .
* Bisphosphonates Warning : In bisphosphonate use rare complications can occur , such as osteonecrosis of the jaw ( ONJ ) or atypical femur fractures . Risk factors for developing ONJ include cancer and anticancer therapy , invasive dental procedures ( dental extractions , dental implants ), poorly fitting dentures , glucocorticoids , smoking , diabetes and preexisting dental disease . Patients who are being treated with bisphosphonates for osteoporosis and develop ONJ , bisphosphonates should be discontinued . Other rare complication is atypical femur fractures which evolve over time , patient typically experience onset of symptoms such as dull or aching pain in the groin or thigh . Patients who are being treated with bisphosphonates and experience an atypical fractures or stress reaction on radiographs , bisphosphonates should be discontinued and should be prescribed adequate calcium and vitamin D supplements . These patients may require orthopedic intervention depending upon the radiographs and degree of pain .
Follow Up
• An appropriate point to repeat a DXA is after one to two years of treatment and every two years thereafter .
• A repeat DXA is performed to check if the patient is responding to treatment . If DXA results are normal , continue medication .
• If there is no improvement , consider adjusting the patient ’ s medication .
• For untreated postmenopausal women , repeat DXA testing is not useful until two to five years have passed and reinforce osteoporosis prevention .
� Consider a “ bisphosphonate holiday ” after 5 years of stability in moderate-risk patients and after 6-10 years in high-risk patients .
� Consider drug holiday for zoledronic acid after 3 annual doses .
Table A : Indications for BMD Testing Consider BMD testing in the following individuals : Women who are age 65 or older and men who are age 70 and older , regardless of clinical risk factors . Younger postmenopausal women , women in the menopausal transition , and men who are age 50 to 69 with clinical risk factors for fracture . Adults who have a fracture after the age of 50 .
Adults with a condition ( e . g ., rheumatoid arthritis ) or take a medication ( e . g ., glucocorticoids in a daily dose greater than or equal to 5 mg prednisone or equivalent of three months or more ) associated with low bone mass or bone loss .
Monitor osteoporosis treatment effects
Osteoporosis - 2