Recognition of the Often Overlooked Malady of Osteoporosis
John C. Parker, M.D., C.C.D.
Health care providers have spent less and less time with their patients. Conditions ranging from a runny nose to chest pain with shortness of breath get folks in their doctor’s door. But unless it declares itself with a painful fracture, osteoporosis speaks more softly, and thus can easily be unrecognized.
What is osteoporosis? An international consensus defined it as “a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
This essentially means thin bones are likely to break. “Fragility” fractures are the hallmark of this disorder of osteoporosis, where broken bones are due to minimal trauma, such as after a fall from standing height or less.
Osteoporosis is a common problem. It is present in ten million Americans. To place this into perspective, the “epidemic” of diabetes is encountered in fourteen million Americans. After the age of 65, the number of new hip fractures each year in white women is greater than the number of new cases of stroke, breast cancer, and diabetes.
Osteoporosis is a serious problem. Not only can the disease process of osteoporosis and metabolic bone disease (caused by disturbances in the body’s minerals, vitamins, or other hormones) lead to disfigurement, discomfort, and disability, but even death may occur as a consequence of fractured bones and its complications (such as pulmonary embolism and hemorrhage). Nearly 65,000 American women die from complications of hip fracture each year. Fifty percent of hip fracture survivors are permanently incapacitated and twenty percent of these will require long-term nursing home care.
Osteoporosis is a costly problem. The annual direct costs of osteoporosis are nearly fourteen billion dollars. Indirect cost due to lowered productivity and lost wages is unknown but likely to be substantial.
Who is at risk for osteoporosis? Women aged 65 and older and postmenopausal women under age 65 with specific risk factors (such as prior fragility fracture, positive family history of osteoporosis or fragility fracture in first degree relative, smoking, or low body weight) are at risk.
Men aged 70 and older are too. Any adults with prior fragility fracture, diseases or conditions associated with low bone mass (like certain gastrointestinal diseases), or those taking medications associated with low bone mass or bone loss (for example, corticosteroids like prednisone) are similarly at risk.
One of the simplest ways to determine whether osteoporosis is present involves testing for decreased bone mineral density (BMD) by a method called dual-energy X-ray absorptiometry (DXA). Measurement of BMD at the hip and spine is simple, quick, and safe. It is done in the office and it takes just a few minutes. The radiation exposure by DXA is minimal; it is twenty to sixty times less than that obtained from a transcontinental airline flight.
Osteoporosis may be diagnosed based on the BMD as an absolute endpoint (densitometric osteoporosis) or by considering clinical history (particularly prior fragility fracture or specific predisposing conditions like men with too little testosterone) in concert with BMD. The information learned from DXA not only aids in diagnosing osteoporosis but also serves as an assessment of fracture risk. You should review the results of this test with your doctor so that you can understand exactly where you stand in the spectrum of osteoporosis. Additional testing of blood and urine specimens may be warranted to fully discern particular causes of osteoporosis and metabolic bone disease. For instance, up to one-half of people with osteoporosis in general practice have occult deficiency of vitamin D.
Certain conditions require follow-up testing to assess for interval change in BMD. This change may represent worsening in certain conditions (like hyperparathyroidism or long-term use of corticosteroids) or stabilization or improvement, as in patients treated with osteoporosis medications.
Multiple treatments for osteoporosis are available. Some build bone (anabolic) whereas some keep it from breaking down any further (antiresorptive). Some are taken as a daily or weekly tablet indefinitely (selective estrogen receptor modulators, like raloxiphene, and bisphosphonates, like alendronate and risedronate) and at least one currently available treatment called teriparatide is administered as a daily injection (exactly like an insulin shot) for two years only. There is even a daily nasal spray (calcitonin) that is used in osteoporosis management. Reduction of fracture and possibly pain relief is achieved by most of these therapies. Simple interventions like taking adequate calcium and vitamin D, having a safe home environment in order to prevent falls, and avoiding smoking and excessive alcohol consumption have been proven to lessen osteoporotic fractures as well. Your doctor’s understanding of individual medication regimens (what they do, how well they work) is critical to successful management of those with osteoporosis.
Osteoporosis is all around us but still may remain silent. Simple testing is available to determine whether it is present. Treatments that preserve bone and prevent fracture exist, and when used appropriately these may prevent the dreaded consequences of osteoporosis.
Dr. Parker received his medical degree from UNC School of Medicine in Chapel Hill, and completed his internship and residency in Internal Medicine at the University of Lexington in Kentucky. He received his Fellowship in Endocrinology, Metabolism, and Nutrition from Duke University in Durham.