WORKUP	Section 5 of 10
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Lab Studies:

• Levels of serum calcium, phosphate, and alkaline phosphatase are usually normal in persons with primary osteoporosis, although alkaline phosphatase levels may be elevated for several months after a fracture.

• Checking thyroid function is prudent because abnormal values may indicate a cause of secondary osteoporosis.

• In men, low testosterone levels can contribute to bone loss; therefore, checking testosterone levels is important.

• Markers of bone turnover (both formation and resorption) may be elevated in high bone turnover states (eg, early type 1 osteoporosis) and may be useful in some patients for monitoring early response to therapy. However, further study is needed to determine their clinical utility in osteoporosis management. Some of these biochemical measures include the following:

• Bone-specific alkaline phosphatase (bone formation)

• Osteocalcin (bone formation)

• Type I procollagen peptides (bone formation)

• Urinary deoxypyridinoline and cross-linked N- and C-telopeptide of type I collagen (bone resorption)

Imaging Studies:

• Obtain radiographs of the affected area in patients who are symptomatic. Lateral spine radiographs are obtained in patients who are asymptomatic and at risk for detection of vertebral fracture.

• Radiographs may show fractures or other conditions, such as osteoarthritis, disk disease, or spondylolisthesis.

• Osteopenia (low bone density) may be apparent as radiographic lucency but is not always noticeable until 30% of bone mineral is lost.

• Radiograph findings also depend somewhat on technique and exposure.

• Plain radiography is not as accurate as bone mineral density (BMD) testing.

• BMD testing is the best predictor of fracture risk. Although measurement at any site can be used to assess overall fracture risk, measurement at a particular site is the best predictor of fracture risk at that site.

• According to guidelines from the National Osteoporosis Foundation, BMD should be measured in the following people:
  • Postmenopausal women older than 65 years because, although preventive measures may no longer be effective, these women are at risk and should be treated if they have osteoporosis

  • Postmenopausal women younger than 65 years who have 1 or more risk factor

  • Postmenopausal women who present with fragility fractures

  • Women who are considering therapy in which BMD will affect that decision

  • Women who have been on hormone replacement therapy (HRT) for prolonged periods

  • Men who experience fractures after minimal trauma

  • People with evidence of osteopenia on radiographs or a disease known to place them at risk for osteoporosis.

• BMD is reported as a T-score, which compares the patient's BMD to that of a healthy young adult. Based on criteria proposed by the World Health Organization, a normal value is within 1 standard deviation (SD) of a young adult, or greater than -1 SD.
  • T-score of -1 to -2.5 SD - By definition indicates osteopenia

  • T-score of less than -2.5 SD - By definition indicates osteoporosis

  • T-score of less than -2.5 SD with fragility fracture(s) - By definition indicates severe osteoporosis

• Quantitative computed tomography measures BMD as a true volume density in g/cm³, which is not influenced by bone size. This technique can be used for both adults and children. It has some disadvantages in that (1) it only determines bone density at the spine, (2) osteophytes can interfere with measurement, and (3) it is associated with significant radiation exposure and high cost.

• Dual-energy x-ray absorptiometry (DEXA) requires less radiation, is less expensive, and has better reproducibility than quantitative computed tomography. It can also measure bone density at the spine and the hip. It has become the standard method for determining bone density. However, differences in calibration have been noted. Whenever possible, the same technologist should perform subsequent measurements on the same patient using the same machine. This method can be used in both adults and children. Confounding factors in DEXA results interpretation (falsely high bone density) include spinal fractures, osteophytosis, and extraspinal (eg, aortic) calcification.

• Peripheral DEXA can measure BMD at the wrist.

• Quantitative ultrasonography of the calcaneus can be used for general screening; however, this is not as accurate as other methods and thus is less useful in following response to treatment. Its advantages include low cost, portability, and lack of ionizing radiation.

• Radiogrammetry, used to measure cortical dimensions, is usually performed on the hand, specifically the second metacarpal. It is useful in assessing BMD in children and is the simplest and least expensive method. It is not as precise as DEXA and, therefore, is less sensitive for detecting changes over time.

	TREATMENT	Section 6 of 10
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Medical Care: Osteoporosis is largely asymptomatic until a fracture occurs. Taking steps to identify patients at risk and implementing preventive measures, such as changes in diet and activity levels, are important.

Preventive measures should begin in childhood and adolescence, with adequate calcium intake and exercise. In patients who must take glucocorticoids for other medical conditions, some protective measures can be implemented. These include using the lowest dose possible, using inhaled (rather than oral) forms of glucocorticoids, instituting alternate-day dosing of steroids, and performing muscle-strengthening exercises.

Effective medical therapy is available to help prevent and treat osteoporosis, including gonadal hormone replacement, calcitonin, selective estrogen-receptor modulators, and bisphosphonates. However, these agents reduce bone resorption with little, if any, effect on bone formation. Experimental evidence indicates that slow-release sodium fluoride and low-dose PTH are capable of increasing bone formation and thus preventing bone loss in women who are estrogen deficient. The former has also been used to decrease vertebral fracture rates. These are not yet approved for the treatment of osteoporosis. A newer medication approved by the US Food and Drug Administration (FDA) for the treatment of osteoporosis is an anabolic agent, recombinant human PTH (rhPTH) (1-34), which has been shown to stimulate the formation of new bone. The newest medication to receive FDA approval is ibandronate, a once daily oral bisphosphonate.

Surgical Care: The goals of surgical treatment of fractures are rapid mobilization and return to normal function and activities.

Consultations:

• Orthopedist - For fixation and stabilization of hip or wrist fracture

• Rheumatologist - To assist with management and determination of underlying etiologies in complex cases

• Endocrinologist - To assist with management and determination of underlying etiologies in complex cases

Diet:

• Adequate calcium and vitamin D intake are important for persons of any age, particularly in childhood as the bones are maturing. If dietary intake is inadequate, add supplements.

• For women who are postmenopausal, men who are older than 50 years, and other persons at risk for osteoporosis, the recommendation is 1500 mg of calcium daily.

• For women who are premenopausal and men who are younger than 50 years without osteoporosis risk factors, the recommendation is 1000 mg/d.

• Vitamin D intake should be 400-800 IU/d.

Activity:

• Weight-bearing exercise has been shown to have a positive effect on BMD, although the exact mechanism is not known. Regular exercise should be encouraged in all patients, including children and adolescents in order to strengthen the skeleton during the maturation process.

• Exercise also improves agility and balance, thereby reducing the risk of falls.

• Encourage patients to be as active as possible.

• Physical therapists can assist in developing exercise regimens, instructing patients in proper techniques, and monitoring progress and consistency.

	MEDICATION	Section 7 of 10
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Several classes of medications have been studied to prevent and treat osteoporosis. Most studies have been conducted in women. Most of these medications are postulated to have a similar effect in men, with the exception of estrogen replacement therapy and selective estrogen-receptor modulators.

Several studies have demonstrated a beneficial effect on BMD, or at least maintenance of bone mass, with testosterone treatment in osteoporotic men with hypogonadism.

Calcium and vitamin D supplementation are important preventive measures.

	MISCELLANEOUS	Section 9 of 10
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Medical/Legal Pitfalls:

• Osteoporosis is a preventable disease with potentially devastating consequences. Failure to identify patients at risk, to educate them, and to implement preventive measures may cause legal pitfalls.

Special Concerns:

• Identify the underlying etiology whenever possible, and treat the underlying cause in addition to the osteoporosis.

• In pediatric patients, the treatment of osteoporosis consists of ensuring adequate calcium intake, vitamin D supplementation when needed, and supportive care.

• Institute screening and preventive measures immediately in patients who will be taking medications known to induce osteoporosis, including glucocorticoids, and in patients with diseases known to put them at risk. Preventive measures include adequate calcium, vitamin D, and exercise. Also, consider starting bisphosphonates or other medications early if BMD is noted to be decreasing, even if the patient does not yet meet the criteria for osteoporosis.