Use fracture risk to predict osteoporosis

Spinal MRI shows osteoporotic  compression of  the T8 vertebral  body in a man aged  72 years.
Spinal MRI shows osteoporotic compression of the T8 vertebral body in a man aged 72 years.

In the most recent revision of its Clinician's Guide to Prevention and Treatment of Osteoporosis, the National Osteoporosis Foundation (NOF) offers a comprehensive approach to prevention, diagnosis, and treatment.

Primary-care practitioners (PCPs) are typically involved in all phases of management, says Felicia Cosman, MD, clinical director of the NOF and professor of clinical medicine at Columbia University, New York City, but their role in recognizing persons at risk of osteoporosis-related fracture deserves special emphasis.

The inclusion of men is a recent addition to the guidelines. "Prevalence is a little lower [for men], because they start out with higher bone mineral density and don't lose as much bone in middle age," Dr. Cosman explains. Beyond delaying the timetable for screening by about five years, by and large the same principles for osteoporosis management apply.

Prevention

Recommendations for risk reduction apply to all patients. Besides an adequate intake of calcium (1,200 mg/day, including supplements if necessary), the guidelines emphasize vitamin D; the updated guideline increases the recommended daily intake from 400-800 IU to 800-1,000 IU.

Patient populations at risk of vitamin D deficiency—which include many elderly individuals and those with absorption disorders—should be tested to ensure 25-hydroxyvitamin D serum levels >30 ng/mL and prescribed supplements (up to 2,000 IU/day) if needed.

Regular weight-bearing and muscle-strengthening exercises are appropriate at all ages to increase bone density and reduce the risk of falls.

Tobacco smoking and excess alcohol use (three or more drinks daily) compromise bone health and increase fracture risk and should be actively discouraged.

Diagnosis

All women aged 65 years or older and men aged 75 years or older should undergo bone mineral density (BMD) testing. Screening should also be considered for individuals older than age 50 years who are judged to be at increased risk.

Risk factors include a sizable array of lifestyle issues, disorders, and medications. The major risks recognized by the World Health Organization (WHO) include low BMI, rheumatoid arthritis, a smoking habit, excessive alcohol use, history of oral glucocorticoid therapy (≥5 mg/day of prednisone or the equivalent for three or more months), and parental history of hip fracture.

History of fracture is an important indication of risk, notes Dr. Cosman. Rather than trying to identify "fragility fractures," she suggests "any fracture occurring after age 40 years should be considered possibly related to osteoporosis and evaluated as such."

PCPs should be more aggressive in detecting vertebral fractures, which are asymptomatic in 60% to 70% of cases but indicate a substantially increased risk of subsequent fractures. Loss of height is a key indicator: Patients who lose 1.5 inches or more from their peak height should be evaluated by means of vertebral fracture assessment using dual-energy x-ray absorptiometry (DEXA), if available, or by lateral spine x-ray.

Diseases that contribute to osteoporosis risk include inflammatory bowel disease and celiac disease, diabetes mellitus (types 1 and 2), and neurologic disorders. "Anyone who has any of these should be tested at a much earlier age," Dr. Cosman advises.

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