Updated: 11/30/2019

Osteoporosis

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Overview
 

 
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
  • 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 
  • Prognosis
    • generally good if detected early and appropriately managed
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 / rickets  Decreased Decreased Increased Increased
Osteoporosis   Normal Normal Normal Normal
Osteopetrosis  Normal Normal or decreased Normal Normal
Paget disease of the bone  Normal Normal Elevated Normal
Osteitis fibrosa cystica  Primary
• hyperparathyroidism- decreased
Secondary
• hyperparathyroidism
increased
Primary
• hyperparathyroidism
increased
Secondary
• hyperparathyroidism
decreased
Primary and secondary hyperparathyroidism
increased
Primary and secondary hyperparathyroidism
increas
ed
Hypervitaminosis D Increased Increased Normal Decreased
 
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
 

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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?
Tested Concept

QID: 108976
1

Osteopenia

4%

(2/48)

2

Osteoporosis

8%

(4/48)

3

Osteomalacia

44%

(21/48)

4

Hyperparathyroidism

29%

(14/48)

5

Clinical malnutrition

8%

(4/48)

L 2 D

Select Answer to see Preferred Response

(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. Laboratory work-up reveals normal serum calcium, phosphate, vitamin D, and PTH levels. She smokes 1-2 cigarettes per day. Which of the following measures would have reduced this patient's risk of developing osteoporosis? Tested Concept

QID: 102978
1

Reduced physical activity to decrease the chance of a fall

0%

(0/12)

2

Initiating a swimming exercise program three days per week

75%

(9/12)

3

Intranasal calcitonin therapy

0%

(0/12)

4

Calcium and vitamin D supplementation

17%

(2/12)

5

Weight loss

0%

(0/12)

L 3 E

Select Answer to see Preferred Response

(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? Tested Concept

QID: 102951
1

Age

0%

(0/2)

2

Body mass index

0%

(0/2)

3

Estrogen therapy

0%

(0/2)

4

Race

0%

(0/2)

5

Smoking history

100%

(2/2)

L 2 E

Select Answer to see Preferred Response

Evidences (5)
Topic COMMENTS (24)
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