###Definitions

- Osteoporosis = a Bone Mineral Density T-score -2.5

- (i.e. BMD is 2.5 or more SDs below the peak bone mass for young adults)
- Fragility Fracture = fracture occurring spontaneously or following minor traum
a (e.g. fall from standing height or less)
###Screening
- Assess pts 50 (or menopausal ) on Hx & PEx for fracture RFs
- If presence of any Fracture RFs listed below: get DEXA
- Calculate fracture risk w/ FRAX tool (w/o BMD)
- Screen pts 65 w/ a DEXA scan
- Conditions that justify DEXA screening at any age:
- 1) Premature menopause (age <45)
- 2) Malabsorption syndromes (e.g. Celiac Disease, CF)
- 3) Chronic infl.y conditions (e.g. RA)
- 4) Hypogonadism
- 5) Primary hyperparathyroidism
- For any pt who gets a DEXA: re-calculate fracture risk w/ BMD value
- Can use FRAX online calculator or CAROC tables
- Have high suspicion for osteoporosis risk in young athletes and pts w/ eating
disorders!
- In these pts emphasize primary prevention! (Smoking cessation, calcium, et
c)
####Fracture RFs
- 1) Previous fragility fracture
- 2) Vertebral fracture or osteopenia identified on X-ray
- 3) Prolonged use of glucocorticoids (or other high-risk meds)
- 4) Parental hip fracture
- 5) High EtOH intake (3 drinks/day)
- 6) Current smoker
- 7) Low body wt (<60 kg) or major wt loss (>10% of body wt at age 25)
- 8) Rheumatoid Arthritis
####Hx
- Any falls in the past 12 mo.s?
- Any gait or balance concerns/prbs?
####PEx
- "Get up and go" test (standing up from a chair without using arms)
- Accurate ht & wt measurements
####Investigations (for pts w/ confirmed osteoporosis)
- CBC, Cr
- Calcium (corrected for albumin)
- ALP
- TSH
- For pts w/ vertebral fractures: serum protein electrophoresis
- For pts on pharmacotherapy: 25-Hydroxyvitamin D
- Measure *after* 3-4 mo.s adequate supplementation
- Don't repeat if optimal level (75 nmol/L) achieved
- If clinical evidence suggests a vertebral fracture: lateral thoracic & lumbar
spine X-rays
###Management
- Management is based on 10 Yr fracture risk categories
- A) Low Risk (10 yr risk <10%): r/a q5yrs
- B) Mod Risk (10-20%):
- Lifestyle management measures
- Get thoracolumbar (T4-L4) X-ray or vertebral fracture assessment (via DEXA
)
- Repeat BMD & r/a risk q1-3yrs
- May consider meds in some individuals (see guidelines for further info)
- C) High Risk (risk >20%, or 1 fragility fracture of hip or spine, or >1 fragil
ity fracture elsewhere)
- Lifestyle measures & start meds
- Repeat BMD & r/a risk q1-3yrs
####Lifestyle Management Measures
- 1) Vitamin D
- If healthy & <50: 400-1000 IU/day (& don't measure Vit. D serum levels)
- If 50: 800-1000 IU/day (may need up to 2000 IU/d to reach optimal serum lev
el)
- 2) Calcium: total of 1200 mg daily (from diet & supplements)
- 3) Exercise: resistance training and/or wt-bearing aerobic exercise
- 4) Smoking Cessation
- 5) EtOH reduction
- Note: imp to avoid prescribing meds that - falls risk to pts w/ osteoporosis!
- Special cases:
- If pt has vertebral fracture: directed core stability exercises
- If pt as risk of falls: balance-focused exercises (e.g. Tai Chi)
- For pts in long-term care at high risk: use hip protectors
####Pharmacotherapy Options
- Note: no strong evidence to support stopping meds after a certain time period,
or for "drug holidays"
- Note: no benefit to combining any of these therapies!
- A) Bisphosphonates (1st line in & ):
- Alendronate (Fosamax): 70 mg q1wk
- Risedronate (Actonel): 35 mg q1wk
- Zoledronic acid (Aclasta, a bisphosphonate derivative): 5 mg IV q1yr
- B) Denosumab (can be used 1st line in , a monoclonal Ab):
- 60 mg as a single dose q6mo.s
- C) Teriparatide: can be used 1st-line for prevention of vertebral and non-vert
ebral fractures
- D) Raloxifene: can be used 1st-line for prevention only of vertebral fractures
- E) Hormone therapy
- Can use as 1st-line in who also need Rx for vasomotor menopause Sx
- F) Calcitonin (2nd-line)