Updated: 12/26/2021

Osteoporosis

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  • Snapshot
    • A 67-year-old woman presents to the emergency department after falling while walking down the stairs of her home. She landed on her rear on a carpeted floor and denies hitting her head. She experienced severe pain in her right hip after the fall and is unable to bear weight on the affected side. Menopause began 17 years ago. She has smoked 1-pack of cigarettes for the past 40 years. On physical exam, her right leg is shortened, adducted, and externally rotated. Laboratory testing is unremarkable.
  • Introduction
    • Clinical definition
      • decreased bone mass (osteopenia) that significantly increases the patient's risk of fracture
  • Epidemiology
    • Incidence
      • most common types of osteoporosis are
        • post-menopausal
        • senile
    • Risk factors
      • post-menopausal women
      • being ≥ 65 years of age
      • people of Caucasian and Asian descent
      • lifestyle factors such as
        • poor physical activity
        • vitamin D deficiency and poor calcium intake
        • smoking
        • alcohol use disorder
      • medications such as
        • warfarin, lithium, proton pump inhibitors, and glucocorticoids
      • hyperparathyroidism
      • hyperthyroidism
      • multiple myeloma
      • malabsorption syndromes
  • Etiology
    • Pathogenesis
      • in young adulthood, peak bone mass is achieved and this is determined by a number of factors (e.g., genetics)
        • after this peak bone mass is attained, there is a small decrease in bone formation with every cycle of bone remodeling
          • senile osteoporosis
            • osteoblasts have their biosynthetic and proliferative ability reduced with age
          • poor physical activity
            • mechanical force on bone stimulates bone remodeling
              • athletes have increased bone density
            • decreased physical activity results in bone loss
          • decreased estrogen levels
            • such as in menopause, decreased estrogen levels increase bone resportion and formation
              • however, the rate of formation is less than resorption resulting in a net bone loss
              • increased osteoclast activity is significant in areas of bone with large surface area
                • such as the vertebral bodies, leading to vertebral compression fractures
          • there is trabecular and cortical bone loss
  • Presentation
    • Symptoms
      • fractures (e.g., vertberal and hip), otherwise, patients are typically asymptomatic
    • Physical exam
      • may see loss in height
  • Imaging
    • DEXA
      • indication
        • all women ≥ 65 and all men ≥ 70 years of age
        • smoking and sedentary lifestyles are risk factors
      • notes
        • T-score ≤ -2.5
  • Studies
    • Labs
      • serum calcium, phosphorus, parathyroid hormone, and alkaline phosphatase are normal
    • Histology
      • histologically normal; however, there is a decreased quantity of normal bone
  • Differential
    • Laboratory Abnormalities in Select Bone Disorders
      Etiology
      Serum Phosphate
      Serum Calcium
      Serum Alkaline Phosphatase
      Parathyroid Hormone
      Osteomalacia / ricketsDecreasedDecreasedIncreasedIncreased
      OsteoporosisNormalNormalNormalNormal
      OsteopetrosisNormalNormal or decreasedNormalNormal
      Paget disease of the boneNormalNormalElevatedNormal
      Osteitis fibrosa cysticaPrimary
      •hyperparathyroidism- decreased
      Secondary
      •hyperparathyroidism
      increased
      Primary
      •hyperparathyroidism
      increased
      Secondary
      •hyperparathyroidism
      decreased
      Primary and secondary hyperparathyroidism
      increased
      Primary and secondary hyperparathyroidism
      increased
      Hypervitaminosis DIncreasedIncreasedNormalDecreased
  • Treatment
    • Conservative
      • calcium and vitamin D supplementation
      • strength training
      • smoking cessation
    • Medical
      • bisphosphonates
        • indication
          • first-line for pharmacologic therapy in osteoporosis
      • raloxifene
        • second line therapy for osteoporosis
        • can cause hot flashes and venous thromboembolism
        • does not cause endometrial hyperplasia or increase risk of breast cancer
      • teriparatide
        • indication
          • considered first-line in patients with a very high risk of fracture
  • Complications
    • Fractures
  • Prognosis
    • Generally good if detected early and appropriately managed
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(M2.OR.17.4754) A 64-year-old female presents to her primary care physician for an annual checkup. She states that her health is adequate, but she has not been doing well since her husband died last year. She is able to get by but admits to having trouble caring for herself, cooking, cleaning, and paying her bills. The patient complains of diffuse muscle aches and pains. She has a past medical history of anxiety and seasonal affective disorder. She is not currently taking any medications. On physical exam, you note a gaunt woman with a depressed affect. You note that her body mass index (BMI) and height have both decreased since her last annual visit. On physical exam, her cardiac, pulmonary, and abdominal exams are within normal limits. Lab work is drawn and is as follows:

Serum:
Na+: 135 mEq/L
K+: 3.7 mEq/L
Cl-: 100 mEq/L
HCO3-: 23 mEq/L
Urea nitrogen: 7 mg/dL
Glucose: 70 mg/dL
Creatinine: 0.8 mg/dL
Ca2+: 8.0 mg/dL
Mg2+: 1.5 mEq/L
Parathyroid hormone: 855 pg/mL
Alkaline phosphatase: 135 U/L
Phosphorus: 2.6 mg/dL

Hemoglobin: 14 g/dL
Hematocrit: 36%
Platelet count: 187,000/mm^3
Leukocyte count: 4,700/mm^3

What is the most likely diagnosis?

QID: 108976

Osteopenia

4%

(2/52)

Osteoporosis

8%

(4/52)

Osteomalacia

44%

(23/52)

Hyperparathyroidism

29%

(15/52)

Clinical malnutrition

8%

(4/52)

M 6 D

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(M2.OR.16.37) A 67-year-old Caucasian female presents to her primary care physician after a screening DEXA scan reveals a T-score of -3.0. She smokes 1-2 cigarettes per day. She lifts weights several times a week. Which of the following measures would have reduced this patient's risk of developing osteoporosis?

QID: 102978

Reduced physical activity to decrease the chance of a fall

0%

(0/15)

Initiating a swimming exercise program three days per week

60%

(9/15)

Intranasal calcitonin therapy

0%

(0/15)

Calcium and vitamin D supplementation

33%

(5/15)

Weight loss

0%

(0/15)

M 7 E

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(M3.OR.15.10) A 47-year-old African-American woman presents to her primary care physician for a general checkup appointment. She works as a middle school teacher and has a 25 pack-year smoking history. She has a body mass index (BMI) of 22 kg/m^2 and is a vegetarian. Her last menstrual period was 1 week ago. Her current medications include oral contraceptive pills. Which of the following is a risk factor for osteoporosis in this patient?

QID: 102951

Age

0%

(0/4)

Body mass index

0%

(0/4)

Estrogen therapy

0%

(0/4)

Race

0%

(0/4)

Smoking history

75%

(3/4)

M 10 E

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