When it comes to the topic of osteoporosis, this is a disease state that can truly be a “silent” disorder, with many only being diagnosed after a fracture. It is estimated that approximately 10 million individuals in the United States have osteoporosis. Up to half of women and a quarter of men over age 50 will sustain a low impact fracture in their remaining lifetime. Consequences of fracture are costly for patient quality of life and to the healthcare system- only 40% of those who have a low impact fracture fully regain their pre-fracture level of independence. The good news is, there are effective treatment options to decrease the risk of fracture even after a patient has suffered a fracture.
Osteoporosis is defined as: a skeletal disorder characterized by comprised bone strength, predisposing an individual to an increased risk of fracture (NIH). What counts as a low impact (aka fragility or spontaneous) fracture? A fracture with trauma that would not usually result in a fracture, such as a fall from standing height or from lifting an object. These types of fractures often occur with household activities. A concerning fact related to these fractures is the probability of low impact fracture increases with each subsequent fracture. This is referred to as the “fracture cascade.” It is not uncommon for a patient who has fractured to suffer another fracture within a year.
Patients with osteoporosis are seen across the healthcare system, and many go untreated due to the silent nature of poor bone quality. It is key for medical providers to educate patients that bone strength = bone quality + bone mineral density. All postmenopausal women and men over age 50 should complete osteoporosis screening. A thorough history and physical exam will determine if further testing should include bone mineral density testing and/or looking for secondary causes of osteoporosis. Use of a fracture risk calculator tool such as FRAX can be helpful for the screening process. FRAX is a diagnostic tool used to evaluate the 10-year probability of bone fracture and available at http://www.shef.ac.uk/FRAX/tool.aspx?country=9
Current treatment recommendations for osteoporosis include: counseling on risk, lifestyle habits (nutrition, exercise, smoking cessation), fall risk assessment, and consideration of oral medications for those with risk of fracture, with a bone density score T-score ? -2.5, or who have previously fractured. Physical therapy is beneficial to address balance and strength, to assist in reducing fall risk.
Medications that may be considered for patients diagnosed with osteoporosis are either classified as antiresorptive or anabolic. Antiresorptive medications include bisphosphonates and RANKL inhibitor denosumab. There are two anabolic medications currently available for those at high fracture risk, teriparatide and abaloparatide. Both of these are given by a daily injection for 18-24 months, followed by maintenance with an antiresorptive medication.
For additional information on osteoporosis assessment and treatment, the Clinician’s Guide to Prevention and Treatment of Osteoporosis was developed by the National Osteoporosis Foundation and is available at https://cdn.nof.org/wp-content/uploads/2016/01/995.pdf