Osteoporosis Evaluation

Aka: Osteoporosis Evaluation, Osteoporosis Screening, Osteoporosis Risk Factors, Osteoporosis Risk Assessment, Vertebral Imaging Indications in Osteoporosis, Fracture Risk Stratification in Osteoporosis

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II. Indications: Osteoporosis Screening

  1. Precautions
    1. Conflicting guidelines between 3 organizations (AACE/ACE, BHOF, USPTF)
    2. Where AACE/ACE = American Association of Clinical Endocrinologists and American College Endocrinology
    3. Where BHOF = Bone Health and Osteoporosis Foundation
    4. Where USPTF = U.S. Preventive Services Task Force (most commonly followed guidelines in U.S.)
  2. All women over age 65 years
  3. Consider in all men over age 70 years (per BHOF guidelines)
  4. Postmenopausal women 60 to 65 years with 1 risk below
    1. Fracture after age 45 years
    2. Hip Fracture in a parent
    3. Tobacco Abuse
    4. Body Mass Index <22
    5. Extended gluococorticoid use (>3 months)
  5. Indications in Men over age 50 and Postmenopausal Women at any age
    1. Nontraumatic Fracture or Fragility Fracture (esp. hip, Vertebrae, wrist)
    2. Incidental finding of Osteopenia on plain XRay
    3. Glucocorticoid use (e.g. Prednisone 5 mg per day for >3 months)
    4. Hypogonadism
    5. Hyperparathyroidism
    6. Multiple Osteoporosis Risk Factors (see below)
    7. See Osteoporosis Secondary Causes
  6. Risk Calculators
    1. See Osteoporosis Self-Assessment Tool
    2. See Osteoporosis SCORE Estimation
    3. Male Osteoporosis Risk Estimation Score
    4. FRAX Calculator
      1. http://www.shef.ac.uk/FRAX/

III. Risk Factors: WHO Model for Fracture Risk (10 year risk)

  1. Age over 65 in women and over 70 in men
  2. Female gender
  3. Personal history of Fracture
  4. Parental history of Hip Fracture
  5. Femoral neck Bone Mineral Density (based on DEXA Scan)
  6. Glucocorticoid use (e.g. Prednisone >5 mg/day for >3 months)
  7. Current Tobacco Abuse
  8. Heavy Alcohol use (3 or more drinks per day)
  9. Body Mass Index <22 kg/m2
  10. Resources
    1. https://frax.shef.ac.uk/FRAX/

IV. Risk Factors: Osteoporosis

  1. See Osteoporosis Secondary Causes
  2. Natural Progression
    1. Increasing age (over age 65 in women or over age 70 in men)
    2. Female gender
  3. Constitutional
    1. White (fair-skinned) or Asian origin
      1. Black and Hispanic patients have lower rates
    2. Low body weight or small stature
      1. Weight below 58 kilograms (127 pounds) in adults
      2. Body Mass Index (BMI) <20-22 kg/m2
    3. Height Loss
      1. Height loss of 2 cm within 3 years or 4 cm from early adult height are indications for Vertebral imaging
      2. Height loss of 5 cm increases the risk of hip and nonspine Fractures by 60%
  4. Family History
    1. Parental history of Hip Fracture
    2. Osteoporosis
    3. Kyphosis
    4. Pathologic Fracture
  5. Lack of Bone loading or Exercise
    1. Sedentary
    2. Physical Disability interfering with weight-bearing
  6. Early Hypogonadism
    1. Premature Ovarian Failure (e.g. Female Athlete Triad)
    2. Orchiectomy for Prostate Cancer in men
  7. Lifestyle
    1. Low Calcium intake or absorption
    2. Low Vitamin D intake (or inadequate sunlight exposure)
    3. Smoking (female RR 2.0, male RR 5.0)
    4. Excessive Alcohol (>3-4 drinks per day in men, >2 drinks per day in women)
    5. High Caffeine intake (>2.5 cups of coffee per day)
  8. No longer considered a risk factor
    1. High phosphate (soda) does not cause Osteoporosis
      1. Heaney (2001) Am J Clin Nutr 74(3):343-7 [PubMed]
  9. Other factors
    1. Diabetes Mellitus
    2. Nulliparity

V. Causes: Secondary

  1. See Osteoporosis Secondary Causes
  2. See Corticosteroid Associated Osteoporosis
  3. See Medication Causes of Osteoporosis

VI. Findings

  1. Keep High level of suspicion in both men and women
  2. Inquire at routine clinic visits
    1. Menopause
    2. Calcium intake
    3. Activity Level
    4. Tobacco Use
  3. Look for spine deformity, pain, and immobility
  4. Loss of total height measurement
    1. Women: >4 cm height loss since age 25 years
    2. Men: >6 cm height loss since age 25 years
    3. Some use 1.5 inch height loss for criteria
    4. Evaluation
      1. Prompts thoracic and Lumbar Spine XRay
      2. Evaluate for Vertebral Compression Fracture

VII. Imaging: Bone Mineral Density

  1. See Bone Mineral Density
  2. XRays taken for other reasons
    1. XRays show changes after 40-50% skeletal mass loss
  3. DEXA Scan (single most important BMD testing)
    1. Can be followed as often as every 2 years
    2. See DEXA Scan for indications
    3. Typically measured at the hip and Lumbar Spine (or distal radius)
  4. Qualitative Ultrasound of Calcaneus
    1. Less precise than DEXA Scan
    2. Less expensive than DEXA Scan and portable
    3. Measurement based on two factors
      1. Broadband ultrasonic attenuation (BUA)
      2. Speed of Sound (SOS)

VIII. Imaging: Vertebral Indications (primarily AACE/ACE guidelines)

  1. T Score <-1 in men age>80 years, women >70 years old (age >65 years in BHOF guidelines)
  2. T Score <-1.5 in men 70 to 79 years, women 65 to 69 years
  3. Postmenopausal women and men age >50 years with at least one risk factor
    1. Low trauma Fracture (fragility Fracture) in age >50 years
    2. Historical height loss decreased from peak height by 4 cm (1.5 inches)
    3. Cummulative height loss 2 cm (0.8 inches) between reassessments
    4. Ongoing Glucocorticoid use (or recent use)
    5. Medical conditions associated with bone loss (e.g. Hyperparathyroidism, per BHOF)

IX. Grading: Fracture Risk Stratification in Osteoporosis

  1. Low Risk for Fragility Fracture
    1. T Score >-1.0
    2. FRAX Score <3% for Hip Fracture
    3. FRAX Score <20% for major osteoporotic Fracture
  2. Moderate Risk for Fragility Fracture
    1. T Score >-2.5
    2. FRAX Score <3% for Hip Fracture
    3. FRAX Score <20% for major osteoporotic Fracture
  3. High Risk for Fragility Fracture
    1. Prior spine or Hip Fracture OR
    2. T Score <= -2.5 OR
    3. FRAX Score >3% for Hip Fracture OR
    4. FRAX Score >20% for major osteoporotic Fracture
  4. Very High Risk for Fragility Fracture
    1. Multiple Spine Fractures AND T-Score <=-2.5
    2. Fracture within last 12 months
    3. Fracture during Osteoporosis Management
    4. Multiple Fractures
    5. Corticosteroid Associated Osteoporosis (or other medications with significant risk)
    6. T Score <-3.0
    7. High risk for falls
    8. FRAX Score >4.5% for Hip Fracture OR
    9. FRAX Score >30% for major osteoporotic Fracture

X. Labs: Initial at Diagnosis (evaluating for Osteoporosis Secondary Causes)

  1. Complete Blood Count
    1. Multiple Myeloma
  2. Comprehensive Metabolic Panel
    1. Alkaline Phosphatase increased
      1. Paget's Disease
    2. Hepatic Aminotransferase levels (AST, ALT) increased
      1. Hepatic disease
    3. Serum Albumin decreased
      1. Malnutrition
    4. Serum Creatinine increased
      1. Renal disease
    5. Corrected Serum Calcium (or Ionized Serum Calcium)
      1. Increased Calcium
        1. Hyperparathyroidism
        2. Cancer
      2. Decreased Calcium
        1. Vitamin D Deficiency
        2. Malabsorption
  3. Thyroid Stimulating Hormone (TSH) decreased
    1. Hyperthyroidism
  4. Vitamin D Deficiency
    1. Serum 1,25-Hydroxy Vitamin D decreased
  5. Hypogonadism
    1. Men: Total Serum Testosterone
      1. Testicular Failure
    2. Women: Estradiol
      1. Consider in pre- or peri-menopausal women
      2. Unnecessary in post-menopausal women
  6. Other Labs to consider
    1. Hypercalciuria
      1. 24 hour Urine Calcium excretion >250 mg
    2. Hyperparathyroidism
      1. Intact Parathyroid Hormone (PTH) increased

XI. Labs: High Risk for Secondary Cause

  1. Cushing's Disease
    1. 24 hour Urine Cortisol
  2. Multiple Myeloma evaluation
    1. Serum Protein Electrophoresis (SPEP)
  3. Hemochromatosis
    1. Serum Iron increased
    2. Ferritin level increased
  4. Celiac Sprue
    1. Tissue transglutaminase and Endomysial antibodies

XII. References

  1. (2021) Obstet Gynecol 138(3):494-506 +PMID: 34412075 [PubMed]
  2. Harris (2023) Am Fam Physician 107(3): 238-46 [PubMed]
  3. Jeremiah (2015) Am Fam Physician 92(4): 261-8 [PubMed]
  4. Kanis (1994) J Bone Miner Res 8:1227-34 [PubMed]
  5. Kleerekoper (1998) Postgrad Med 103(4):45-68 [PubMed]
  6. Kroger (1998) Ann Med 30:278-87 [PubMed]
  7. Rosen (1998) Postgrad Med 104(4):101-14 [PubMed]
  8. Tosteson (2008) Osteoporos Int 19(4):437-47 [PubMed]
  9. Weber (1998) Endocrinol Metab Clin North Am 27(2):325 [PubMed]

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