Osteoporosis --- Screening & Treatment

Osteoporosis is very much underdiagnosed, and under treated! I recently did my practice based learning exercise on Osteoporosis, and sadly...I havent screened or treated many of my patients!!


So lets see who needs to be screened, and who needs treatement...
DEXA Scan and scoring  - Screening /diagnosing is done by DEXA scan . The 2 preferred sites of scanning are lumbar spine and proximal femur,as these places show the earliest sign of osteoporosis. So next time when you see a score based on a heel DEXA ....it is not a complete test! A T-score( representing the number of standard deviations between the pts bone mineral density and a healthy young adult of same sex) less than -2.5 is called osteoporosis, and a score between -1 to -2.5 is osteopenia. 
The Z-score is used to classify the type of osteoporosis. A score below 1.5 indicates primary osteoporosis, which is age related. A score of 1.5 and higher indicates secondary osteoporosis, which is associated with calcitonin imbalance, malabsorption conditions ,alcohol abuse, smoking, medications etc.


Screening - The following are the group of people who need DEXA for screening

• women 65yrs and older,
•  men 70 yrs and older,
• Loss of height of >2 inches (before DEXA...do a vertebral fracture survey...and if +ve, treat as osteoporosis)
• postmenopausal women or, men >50 yrs with risk for fracture including h/o hip fracture in parents, current smoker or alcoholic, rheumatoid arthritis.
• chronic glucocorticoid therapy(5mg/d or more of prednisone for >3 mon)
• pts with medical diseaseassociated with decreased BMD(eg. renal disease, hyperthyroisim, cushings etc)
• pts on medications that might reduce BMD ( anticonvulsants, PPI,Cyclosporine, SSRI etc

Who needs treatment -  

• Anyone who has sustained a fragility fracture of hip or spine
• Those who have a T-score > or = 2.5, after evaluation for secondary causes of osteoporosis.
• Those who have osteopenia(a score between -1 & -2.5) if their 10 year probablity of osteoporotic fracture is >20% or 10 yr risk of hip fracture >3%. ( the risk called FRAX ..can be calculated online)

Treatment -  Bisphosphonates are the mainstay of treatment. A quick note is...of all the treatment modalities, Ibandronate, Calcitonin, Raloxifene, and Teriparatide are the ones which have not shown any hip fracture reduction. All of them reduce the incidence of spine fracture though.