Osteoporosis

Postmenopausal white female > 40 y/o with presents for follow-up status post hip fracture. Reports sedentary lifestyle, poor diet, active smoking status, consuming > 2 alcoholic drinks daily. Medications include chronic glucocorticoids. Mother suffered hip fracture. Low BMI on exam.

  • Obtain CMP, TSH, and 25-hydroxyvitamin D

  • Obtain DEXA for any of the following:

    • Age ≥ 65 years with no previous DEXA

    • FRAX calculation indicates 10-year risk > 8.5% risk for major osteoporotic fracture and > 1.0% for hip fracture: Refer for DEXA scan

  • DEXA scan shows bone mineral density (BMD) ≤ 2.5: Start treatment

    • No esophageal abnormalities: Alendronate 35 mg weekly x 5 years

      • Patient counseled to take medication with water only and remain upright for 30 minutes afterward

      • Discussed small, but potential risk for jaw osteonecrosis/fracture

    • Bisphosphonates (e.g. alendronate) contraindicated

      • Obtain CMP: Verify creatinine clearance ≥ 35 mL/min and no hypocalcemia

      • Start zoledronic acid 4 mg IV every 4 weeks

    • Consider

      • Vitamin D 800 IU daily

      • Intranasal calcitonin x 4 weeks for vertebral compression fracture pain

  • Counseling

    • Stop smoking, consume 7 or fewer alcoholic drinks/week (females), and reduce caffeine consumption to ≤ 2.5 cups of coffee daily

    • Exercise to maintain bone mineral density

    • Fall prevention

Notes

  • Epidemiology

    • Fifty percent and 20% of white women and men, respectively, will suffer an osteoporosis-related fracture

      • 20% require long-term nursing care

      • 10% mortality rate

    • Risk factors include: Postmenopausal state, parental history of hip fracture, smoking, excessive alcohol consumption, low body weight, previous fracture/fall within the past year

    • Secondary causes of osteoporosis: Primary hyperthyroidism, vitamin D deficiency, chronic glucocorticoid use (≥ 5 mg prednisone daily for ≥ 3 months)

  • Risk assessment

    • FRAX tool: Calculates 10 year risk for major osteoporotic and hip fractures for men and women

    • Average 10-year risk for 65 y/o white woman with no other risk factors:

      • Major osteoporotic fracture ~8.5%

      • Hip fracture ~1.0%

  • DEXA scan screening

    • Recommended by USPSTF for

      • All women age ≥ 65 years

      • Women age < 65 years with fracture risk ≥ average risk for a 65 y/o white woman (8.5%) with no additional risk factors

    • Osteoporosis z-score (standard deviation)

      • Defined in relation to the young adult female mean (z = 0)

      • Osteoporosis defined as z ≤ 2.5 (consider bisphosphonate therapy)

    • Do not repeat for at least 2-3 years

  • Therapy

    • Start bisphosphonates per National Osteoporosis Foundation criteria, i.e. one of the following:

      • DEXA score ≤ 2.5 and FRAX ≥ 20%

      • Hip fracture risk ≥ 3%

    • Second line medications for women who cannot take bisphosphonates include teriparatide and raloxifene