Over 200 million women worldwide are affected by osteoporosis.¹

However, fewer than 1 in 5 women with postmenopausal osteoporosis will be evaluated.^2-4

And fewer than 1 in 3 postmenopausal women with osteoporosis are treated.^5-13

Obtain a DXA scan in all women ≥ 65 and women older than 50 who have clinical risk factors for osteoporosis.^14-17

Understanding clinical risk factors for osteoporosis and fracture risk can help in formulating the best questions to ask your patients for accurate screening and diagnosis.^14-18 Questions to consider asking your patients might be: Have you ever experienced a fracture? Has anyone in your family? Have you had any recent falls? Do you have prolonged unusual back pain? A yes, could indicate a vertebral fracture. Are you taking medications that increase bone loss like glucocorticoids? Or are you taking medications that increase your risk of falling like narcotic analgesics? Have you experienced significant weight loss? Do you consume alcohol or tobacco? Are you getting adequate calcium and vitamin D in your diet? What is your level of activity?¹⁸

In addition to asking these questions, on your clinical examination, look for kyphosis^14,17,18 or height loss^14-18 which are signs of osteoporosis, or difficulty performing the get up and go test which indicates risk for falls.¹⁹ Further, in patients at risk, consider spine x-rays to identify unrecognized vertebral fractures and consider adding "rule out vertebral fracture" to imaging orders.^15,16

Bone mineral density alone does not explain all fragility fracture risk. In fact 60% of women with fragility fractures have non-osteoporotic bone mineral density (T-score >-2.5).^14,20,21 Understanding clinical risk factors and BMD together improve fracture risk prediction²¹ in these patients.

Determining a patient's fracture risk requires consideration of several clinical risk factors of which a history of prior fracture, older age, and low bone mineral density are most important, followed by other non-modifiable and modifiable risk factors.^16,22-25

Some non-modifiable risk factors influencing a patient's fracture risk include: family history of hip fracture or osteoporosis, female sex, Asian or white ethnicity, small frame, comorbid conditions.^16,23-25 While some modifiable risk factors include: estrogen deficiency, fall-related risk factors and inadequate physical activity.^16,23

There are several methods you can use to identify women over age 50 at high risk for fracture that need treatment. Patients with a history of fracture at the hip or spine are at a high risk for future fracture.^16,26

Women over age 50 with bone mineral density T-scores below -2.5 are considered osteoporotic and at high risk for future fracture.²⁶

High risk patients are those women with FRAX 10-year probability of hip fracture ≥ 3%, or 10-year probability of major osteoporotic fracture ≥ 20%.²⁶

Fragility fractures at the proximal humerus, pelvis, and in some cases wrist qualify patients as high risk for future fracture, when occurring in combination with low bone mineral density at the hip or spine.²⁶ Please note that regional thresholds and criteria for treatment eligibility may vary.

References

1. International Osteoporosis Foundation. Facts and statistics. www.iofbonehealth.org/facts-statistics. Accessed February 13, 2018.
2. Boudreau DM, et al. J Am Geriatr Soc. 2017;65:1829-1835.
3. Fast Facts. Osteoporosis Canada. https://osteoporosis.ca/about-the-disease/fast-facts/.
4. Nguyen TV, et al. Med J Aust. 2004;180:S18-22.
5. Yusuf AA, et al. Arch Osteoporos. 2016;11:31.
6. Spångéus A, et al. Ann Rheum Dis. 2017;76(suppl2):72.
7. Sanfélix-Genovés J, et al. Osteoporos Int. 2013;24:1045-1055.
8. Hadji P, et al. Dtsch Arztebl Int. 2013;110(4):52-7.
9. Viprey M, et al. PLoS ONE. 2015;10(12):e0143842.
10. Bell JS, et al. Aust Fam Physician. 2012;41:110-118.
11. Eisman J, et al. J Bone Miner Res. 2004;19:1969-75.
12. Taiwanese Guidelines for Prevention and Treatment of Osteoporosis. Taiwanese Osteoporosis Association, 2013.
13. Boytsov NN, et al. Am J Med Qual. 2017;32(6):644-654.
14. Camacho PM, et al. Endocr Pract. 2016;22(suppl 4):1-42.
15. Papaioannou A, et al. CMAJ. 2010;182:1864-1873.
16. Cosman F, et al. Osteoporos Int. 2014;25:2359-2381.
17. Kanis JA, et al. Osteoporos Int. 2013;24:23-57.
18. Orimo H, et al. Arch Osteoporos. 2012;7:3-20.
19. Vondracek SF, et al. Clin lnterv Aging. 2009;4:121-136.
20. Siris ES, el al. JAMA. 2001;286:2815-2822.
21. Siris ES, et al. Arch Intern Med. 2004;164:1108-1112.
22. Kanis JA, et al. Bone. 2004;35:375-382.
23. Kanis JA, et al. Lancet. 2002;359:1929-1936.
24. Eisman JA, et al. J Bone Miner Res. 2012;27:2039-2046.
25. US Department of Health and Human Services. Bone health and osteoporosis: a report of the surgeon general. 2004. Rockville, MD.
26. Siris ES, et al. Osteoporos Int. 2014;25:1439-1443.

Osteoporosis is chronic and progressive in nature; when untreated there is ongoing bone loss contributing to a weakened skeleton and increased risk of fracture.¹

Bone mass decreases gradually after achieving its peak at 30 years of age.^2,3

After menopause, there can be accelerated loss of both trabecular and cortical bone ongoing with age⁴ that compromises bone strength and predisposes to fracture.

This is what healthy bone looks like at age 35. As bone loss progresses with age it continues to deteriorate in structural integrity.^5,6

Here is a bone at age 44.^5,6

Here is a bone at age 51.^5,6

Here is a bone at age 65.^5,6

Progressive bone loss is a key contributor to increased fracture risk with age.^5,6

This is the bone structure of a 74-year-old female who suffered an osteoporotic hip fracture.^5,6

For patients with osteoporosis, a timely diagnosis and appropriate treatment can reduce the risk of fractures.

References

1. Hanley DA, et al. Am J Med. 2017;130:862.e1-862.e7.
2. Zebaze RM, et al. Lancet. 2010;375:1729-1736.
3. Recker RR, et al. JAMA. 1992;268(17):2403-2408.
4. Khosla S, et al. Endocrinol Metab Clin North Am. 2005;34:1015-1030.
5. Muller R. Osteoporos Int. 2005;16(Suppl 2):S25-S35.
6. Schulte FA, et al. Bone. 2011;49:1166-1172.