• Osteoporosis is a progressive, systemic, skeletal disease characterized by decreased bone mass and microarchitectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures
  
  • Bone strength, reflecting both density and quality of the bone, is compromised thus increasing fracture risk
  • Fractures commonly occur in the hip, spine, and wrist with the hip fractures having a high morbidity
• Though osteoporosis in Asia is very much underdiagnosed and undertreated, it is projected that by 2050, >50% of osteoporotic hip fractures will happen in Asia
  •  In most developing Asian countries, DXA is expensive and is widely unavailable particularly in the rural areas  
• Calcium intake in almost all Asian countries is below the FAO/WHO recommendations of 1-1.3 g/day
• Studies done in both sexes and all age groups in different Southeast Asian countries demonstrated widespread incidence of vitamin D deficiency or insufficiency 

• Common presentations: Back pain, low-trauma fracture, height loss, increasing dorsal kyphosis

Postmenopausal women >50 years must be evaluated for risk of osteoporosis
The more risk factors that are present, the greater the risk of fracture

Non-modifiable

• Female
• Previous history of fracture as an adult
• History of osteoporotic hip fracture in 1st-degree relative
• Advanced age [low body weight and older age (Osteoporosis Self-Assessment Tool for Asians or OSTA)]
• Poor health/frailty
• Ethnic group (Asians generally have lower risk compared to Caucasians)
• Early natural or surgical menopause before 45 years or prolonged premenopausal amenorrhea >1 year
• Genetic diseases: Cystic fibrosis, osteogenesis imperfecta, Ehlers-Danlos, hemochromatosis, Marfan syndrome

Modifiable

• Recurrent falls
• Decreased body weight (<57.6 kg or <127 lb)
• Impaired vision
• Medical conditions: Rheumatoid arthritis, estrogen deficiency, vitamin D deficiency due to lack of sunlight exposure or low intake, thyrotoxicosis, or prolonged Levothyroxine intake
• Cigarette smoking
• Excessive alcohol and caffeine intake (≥3 drinks/day)
• Low calcium (Ca) intake, excessive salt or vitamin A intake
• Oral glucocorticoid use ≥5 mg/day of Prednisone for ≥3 months
• Sedentary lifestyle (lack of physical activity)
• Secondary osteoporosis
• Lack of sun exposure

Factors Associated with Steroid-Related Fractures

• Low bone density
• Cumulative steroid dose
• Age >65 years
• Body mass index (BMI) ≤20 kg/m²
• Smoking, excessive alcohol use
• Diseases associated with low bone density (eg rheumatoid arthritis, inflammatory bowel disease), sex hormone deficiency, family history of osteoporosis, history of fracture and immobilization

Using the Fracture Risk Assessment (FRAX^TM) score to categorize patient’s risk, treatment is recommended for postmenopausal women with:

• Low risk of fracture (<10%) and intake of ≥7.5 mg daily of prednisolone or its equivalent for >3 months
• Medium risk of fracture (10-20%) and intake of glucocorticoid at any dose for >3 months
• High risk of fracture (>20%) and intake of glucocorticoid at any dose for any length of time