By Dr. Steve March

1. GWEP Falls Prevention Workshop -
Osteoporosis
Steve March, M.D.
Eisenhower Medical Center
March 17th, 2018

3. Osteoporosis - Definition
• Low bone mass, architectural disruption and
skeletal fragility leading to increased fracture
risk
• First manifestation is fracture – hence
importance of early diagnosis and screening
– Vertebral fracture : most common manifestation.
2/3 asymptomatic and dx on incidentally. Often
leads to height loss
– Hip fracture. Affects 15% women 5% men by age
80

4. Asymptomatic Compression Fx

5. Osteoporosis - Definition
• First manifestation is fracture (cont.)
– Distal radius (Colles fractures)

6. Osteoporosis – Risk Factors
• Advanced age
• Previous fracture
• Glucocorticoids
• Parental history of hip fracture
• Current smoker
• Excess EtOH
• RA
• Secondary osteoporosis

7. Osteoporosis - Diagnosis
• Requires presence of fragility fracture
– Spine
– Hip
– Wrist
– Humerus
– Rib or pelvis OR
• T-score <= -2.5 standard deviations based on
bone mineral density measured DXA scan
– DXA measurements at hip and spine are
recommended

8. Osteoporosis – Fragility Fracture
• Fall from standing height or less
• No major trauma (MVA)
• Often spontaneous (e.g. spine)
• Not commonly seen in skull, C-spine, hands,
feet, ankles

9. Osteoporosis – Differential diagnosis
• In most postmenopausal women – age and
estrogen deficiency-related bone loss due to
excess bone resorption
• Ddx
– Malignancy (multiple myeloma)
– Paget’s disease
– Hyperparathyroidism (primary)
– Renal osteodystrophy (secondary)
– Hyperthyroidism
– Physical abuse

10. Osteoporosis – Secondary Causes
• GI/Nutritional disorders
– Alcoholism/liver cirrhosis
– Celiac disease
– Inflammatory bowel disease
– Post gastric bypass
– Pancreatic insufficiency
– Vitamin D/Ca deficiency
• Drugs
– Steroids
– Antiseizure (phenytoin)
– Chemotherapy

11. Osteoporosis – Evaluation
• History and Physical
• Fracture Risk Assessment Tool (FRAX) - risk
estimate for pts 40-90 years

12. 10-year probability of major osteoporotic
fracture – hip, spine, humerus, forearm

13. Osteoporosis – Evaluation
• Initial lab evaluation
– CMP, Ca, PO4
– 25-hydroxyvitamin D
– CBC

14. Osteoporosis – Additional Evaluation
• 24-urine calcium
• TSH
• PTH
• Celiac screen
• RF
• Serum, urine protein electrophoresis
• etc

15. Osteoporosis – Who Should be Screened
• All women over 65
• Postmenopausal women younger 65 with risk
factors
• Routine testing in men not recommended
• However, men with following should be
– Osteopenia on X-ray
– Low trauma fx
– Height loss 1.5 inches
– Long term steroids
– Androgen deprivation

16. Osteoporosis – Follow Up Testing
• T-score - 2.00-2.49 - > every 2 years
• T-score - 1.50 – 1.99 - > every 3-5 years
• T-score - 1.00-1.49 - > every 10-15 years

17. Osteoporosis – Treatment
• Hip or vertebral fractures
• T-scores <= -2.5 at femoral neck, hip or lumbar
spine
• In postmenopausal women and men over 50
with low BMD and 10 year FRAX>3%

18. Osteoporosis – Treatment
• Bisphosphanates
• Calcitonin
• Estrogen agonist/antagonist (raloxifine)
• PTH 1-34 (teriparatide)
• Nuclear factor kappa-B (RANK) ligand inhibitor
(denosumab)

20. Osteoporosis – References
• UpToDate