osteoporosis
OSTEOPOROSIS
Treatment Guideline Chart
Osteoporosis is a progressive, systemic skeletal disease characterized by decreased bone mass and micro-architectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures.
The more risk factors (eg history of fracture, advanced age, comorbidities, etc) that are present, the greater the risk of fracture.

Osteoporosis Signs and Symptoms

Definition

  • Progressive, systemic skeletal disease characterized by decreased bone mass and micro-architectural 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
  • Often asymptomatic until patient presents with a fragility fracture  
    • Vertebral fracture can cause back pain, height loss and increasing kyphosis
  • Primary osteoporosis refers to bone loss which happens after menopause and with aging while secondary osteoporosis is bone loss resulting from diseases or medications (eg glucocorticoids)   
  • 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 countries, dual energy X-ray absorptiometry (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

Glucocorticoid-induced Osteoporosis (GIOP)

  • When on oral glucocorticoid therapy, bone loss occurs in the 1st 6-12 months and fracture risk increases within 3-6 months of initiating glucocorticoids
  • Intake of ≥5 mg daily of Prednisolone or its equivalent for ≥3 months is associated with osteoporosis
    • Similar risk is also shown with higher glucocorticoid dose taken for a shorter period of time
    • Strong glucocorticoids inhaled for 7 years are associated with significant bone loss

Risk Factors

Risk Factors in Women for Fracture and Osteoporosis

The more risk factors that are present, the greater the risk of fracture


Non-modifiable
  • Previous history of fracture as an adult
  • History of osteoporotic hip fracture in 1st-degree relative
  • Advanced age 
  • Poor health/frailty
  • Ethnic group (Asians generally have lower risk compared to Caucasians)
  • Early natural or surgical menopause before 45 year of age or prolonged premenopausal amenorrhea >1 year
  • Genetics and genetic diseases: Cystic fibrosis, osteogenesis imperfecta, Ehlers-Danlos, hemochromatosis, Marfan syndrome, thalassemia, hypophosphatasia 
Modifiable
  • Recurrent falls
  • Decreased body weight [<57.6 kg (<127 lb)]
  • Impaired vision
  • Medical conditions: Rheumatoid arthritis, celiac disease, estrogen deficiency, vitamin D deficiency due to lack of sunlight exposure or low intake, thyrotoxicosis, or prolonged Levothyroxine intake, multiple myeloma
  • Cigarette smoking
  • Excessive alcohol and caffeine intake (≥3 drinks/day)
  • Low calcium intake, excessive salt and vitamin A intake
  • Oral glucocorticoid use ≥5 mg/day of prednisone for ≥3 months
  • Sedentary lifestyle (lack of physical activity)
Risk Factors in Men for Fracture and Osteoporosis
  • Non-traumatic fractures of the hip, vertebrae or wrist
  • Prior osteoporotic fracture from age 50 years
  • Hypogonadism, growth hormone deficiency
  • Idiopathic hypercalciuria
  • Hyperparathyroidism
  • Rheumatoid arthritis
  • Lymphoma, multiple myeloma
  • Hyperthyroidism
  • Oral glucocorticoid use ≥5 mg/day of Prednisone for ≥3 months
  • Physical inactivity, immobilization
  • Low body mass index (kg/m2)
  • Anticonvulsants (eg Phenytoin, Phenobarbital)
  • Smoking
  • Alcohol intake (≥3 drinks/day)

Factors Associated with Glucocorticoid-induced Osteoporosis or Fractures

  • Low bone density
  • Cumulative steroid dose
  • Age >65 years
  • 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 FRAX™ score to categorize patient's risk, treatment is recommended for postmenopausal women with:
  • Low risk of major osteoporotic fracture (<10%) and intake of ≥7.5 mg daily of Prednisolone or its equivalent for >3 months
  • Moderate risk of major osteoporotic fracture (10-19%) and intake of glucocorticoid at any dose for >3 months
  • High risk of major osteoporotic fracture (≥20%) and intake of glucocorticoid at any dose for any length of time
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