|Year : 2014 | Volume
| Issue : 4 | Page : 833-839
Role of family medicine in the early detection and management of osteoporosis
Omaima Abo Elfatth Mohammed1, Hala Mohammed El Moselhey Shaheen2, Yasmin El Gamil Kaoud MBBCh 2
1 Department of Public Health and Community Medicine, Menoufiya University, Menoufiya, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
|Date of Submission||26-Nov-2013|
|Date of Acceptance||10-Mar-2014|
|Date of Web Publication||22-Jan-2015|
Yasmin El Gamil Kaoud
Family Medicine Department, Faculty of Medicine, Menoufiya University, Menoufiya
Source of Support: None, Conflict of Interest: None
The aim was to study the epidemiology, pathophysiology, and risk assessment of osteoporosis among adults as a major health problem and clarify the role of the family physician in the prevention, screening, early detection, and management of osteoporosis.
Osteoporosis is a multifactorial skeletal disease characterized by reduction in bone mass and deterioration of the microarchitectural structure of bone tissue, with resulting increase in bone fragility and fracture risk.
A decline in bone mineral density with age increases bone fragility because it reflects the progressive loss of bone mass and changes in the architecture of the bone, such as cortical thinning, cortical porosity, and thinning and loss of trabeculae with loss of connectedness of trabeculae. Bone loss is progressive and is not associated with symptoms until a fracture occurs - the main clinical feature of osteoporosis.
Worldwide, osteoporosis causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 s. Osteoporosis is estimated to affect 200 million women worldwide. Egyptian studies show that 53.9% of postmenopausal women have osteopenia, whereas 28.4% have osteoporosis, and 21.9% of men aged 20-89 years have osteoporosis.
As the clinical outcome of osteoporosis is bone fracture, attention is now increasingly focused on the identification of patients at high risk for fracture rather than the identification of people with osteoporosis as defined by bone mineral density alone.
Keywords: Family medicine, osteoporosis, risk assessment
|How to cite this article:|
Mohammed OA, Shaheen HE, Kaoud YE. Role of family medicine in the early detection and management of osteoporosis. Menoufia Med J 2014;27:833-9
|How to cite this URL:|
Mohammed OA, Shaheen HE, Kaoud YE. Role of family medicine in the early detection and management of osteoporosis. Menoufia Med J [serial online] 2014 [cited 2020 Mar 30];27:833-9. Available from: http://www.mmj.eg.net/text.asp?2014/27/4/833/149803
| Introduction|| |
Osteoporosis is a multifactorial skeletal disease characterized by a reduction in bone mass and deterioration of the microarchitectural structure of bone tissue, with resulting increase in bone fragility and fracture risk .
Osteoporosis is a global problem that is increasing in significance as the population of the world is both growing and aging. Depending on individual fragility, fractures result in great suffering, disability, as well as loss of productivity and quality of life; fractures also represent an enormous burden on healthcare systems. Older people who suffer hip fractures are often faced with long-term disability that results in loss of independence and higher risk of death. A new audit report by the international osteoporosis foundation shows that osteoporosis is a serious and growing problem throughout the Middle East but ignored in relation to other chronic diseases .
Worldwide, ~200 million women have osteoporosis. Although the likelihood of developing osteoporosis currently is greatest in North America and Europe, it will increase in developing countries as population longevity in these countries continues to increase the probability for osteoporosis .
In Egypt, based on different studies, it has been calculated that 53.9% of postmenopausal women have osteopenia and 28.4% have osteoporosis; among men, 26% have osteopenia and 21.9% have osteoporosis .
Etiology and risk factors of osteoporosis
The disease may be classified as primary type 1, primary type 2, and secondary type. The form of osteoporosis that is most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis or senile osteoporosis occurs after 75 years and is seen in both women and men at a ratio of 2 : 1. Secondary osteoporosis may arise at any age and affect men and women equally. This secondary type results from chronic predisposing medical problems or disease, or prolonged use of medications such as glucocorticoids, when the disease is called steroid-induced or glucocorticoid-induced osteoporosis .
Risk factors for osteoporotic fracture can be classified into nonmodifiable and (potentially) modifiable.
Nonmodifiable risk factors
The most important risk factors for osteoporosis are advanced age (in both men and women) and female sex. Estrogen deficiency following menopause or oophorectomy is correlated with a rapid reduction in bone mineral density (BMD) , and hypogonadism is considered one of the most frequent etiologies of secondary osteoporosis in men.
Potentially modifiable risk factors
Excess alcohol : Although small amounts of alcohol are probably beneficial (bone density increases with increasing alcohol intake), chronic heavy drinking (alcohol intake greater than three units/day) probably increases fracture risk despite other beneficial effects on bone density .
Low serum levels of vitamin D: Vitamin D plays a major role in bone health in all age groups. In younger individuals it contributes to achieving a good peak bone mass, whereas in adults lower levels of vitamin D lead to substantial losses in bone mass and subsequently to osteoporosis .
Tobacco smoking: Many studies have associated smoking with decreased bone health, but the mechanisms are unclear. Tobacco smoking has been proposed to inhibit the activity of osteoblasts and is an independent risk factor for osteoporosis .
Malnutrition: Nutrition has an important and complex role in the maintenance of good bone. Identified risk factors include low dietary calcium and/or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, and vitamins A, K, E, and C (and D when skin exposure to sunlight provides inadequate supply). Excess sodium is a risk factor. High blood acidity may be diet related and is a known antagonist of bone .
Physical activity: Bone remodeling occurs in response to physical stress; therefore, physical inactivity can lead to significant bone loss. Weight-bearing exercise can increase peak bone mass achieved during adolescence .
Soft drinks: Some studies indicate that soft drinks (many of which contain phosphoric acid) may increase the risk for osteoporosis, especially in women .
Other studies suggest that soft drinks may displace calcium-containing drinks from the diet rather than directly causing osteoporosis .
Certain medications have been associated with an increase in osteoporosis risk; only steroids and anticonvulsants are classically associated, but evidence is also emerging with regard to other drugs.
Steroid-induced osteoporosis arises due to the use of glucocorticoids - analogous to Cushing's syndrome and involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Some professional guidelines recommend prophylaxis in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when taken for more than 3 months . Alternate day use may not prevent this complication .
Clinical manifestation of osteoporosis
Clinical signs and symptoms
According to the National Osteoporosis Foundation (NOF) (2009), osteoporosis is often a silent disease without obvious indications of its presence. However, there are some signs and symptoms that may accompany the development of the condition:
- Decreasing height (patients may lose 10-15 cm in height due to collapsing vertebrae).
- Back pain (typically in the lower thoracic and lumbar areas, T5-L5).
- Development of a kyphosis or curvature of the upper back (Dowager's hump).
- Fracture occurring with minimal trauma.
- Low body weight and weight loss of more than 1% per year in the elderly.
- Suspicion of vitamin D deficiency (e.g. due to low intake or little exposure to sunshine) .
Any of these findings in a patient should lead to an evaluation for osteoporosis. A fracture in at-risk populations, especially one that is disproportionate to the amount of trauma, should prompt a workup. Subtle vertebral fractures may be identified incidentally on chest radiographs or bone scans .
The key to diagnosis is a thorough history and physical examination, followed by bone measurement tests. Because a low BMD may indicate metabolic bone disease other than osteoporosis (e.g. hyperparathyroidism or osteomalacia), it should not be used as the sole indicator of osteoporosis .
Physicians should also ask about other risk factors for osteoporosis, as well as any family history, pain or tenderness in bones or joints, recent broken bones, current and recent past medication use, and level of physical activity. For men, physicians should enquire about changes in libido. During examination, it is important that height be measured and compared with the results from past measurements. There should also be a focus on the evidence of old fractures during a skeletal survey, as previous fractures often may signal the presence of osteoporosis or a metabolic abnormality. If suspicion for osteoporosis is high, bone measurement testing should be carried out .
Radiological diagnosis of osteoporosis
Bone density measurement tests
Bone measurement tests include the following: dual-energy X-ray (DEXA) of the hip, spine, or wrist; quantitative ultrasound of the heel; spinal computed tomography (CT); radiographic absorptiometry; and MRI.
Dual-energy X-ray absorptiometry
The most commonly used BMD assessment is DEXA, which may be carried out either at central or peripheral (pDEXA) sites. DEXA utilizes two distinct beams of X-ray photons. The amounts of each X-ray beam that pass through bone and soft tissue are compared to estimate the bone density. DEXA measures the sum of cortical and trabecular bone and can detect as little as 2% bone loss .
Central DEXA measures BMD at the spine, upper femur, and hip, whereas peripheral DEXA measures BMD at the heel, finger, and forearm. Measurement of hip BMD represents a good approach because there is less soft tissue and other artifacts compared with other sites. Individuals with osteoporosis have a greater risk for fractures in the hip and spine, which can lead to longer recovery time, greater pain, and permanent disability .
Central DEXA is generally preferred over peripheral DEXA as it can measure whole-body bone mass. It has minimal radiation exposure and may be completed in less than 10-15 min .
Quantitative computed tomography
Quantitative computed tomography (QCT) can measure the lumbar spine, hip, and peripheral sites. In general, the results are less likely to be affected by degenerative spinal changes compared with spinal DEXA scanning. Unlike DEXA, QCT allows for the assessment of both cortical and trabecular bone. As a result, it can make volume BMD determinations .
Trabecular bone, because of its higher rate of turnover compared with cortical bone, is expected to show metabolic changes earlier .
Magnetic resonance imaging
The use of MRI in diagnosing osteoporosis is still evolving and is unlikely to become widely used because of the expense and time required to obtain a scan .
Risk assessment tools
Assessment tools that may be used to determine a patient's osteoporosis risk include the Osteoporosis Risk Assessment Instrument (ORAI), the Simple Calculated Osteoporosis Risk Estimation (SCORE), and the WHO Fracture Risk Assessment Tool (FRAX) .
The ORAI is a simple three-item tool based on age, weight, and current hormone use. The SCORE tool combines six risk factors, including age, weight, race, estrogen use, presence of rheumatoid arthritis, and fracture history. A Canadian study using the DEXA of the hip as the standard for diagnosing osteoporosis (T-score below -2.5) found that the ORAI had a sensitivity of 97.5% and a specificity of 28%. In the same study, the SCORE tool had a higher sensitivity, at 99.6%, but a lower specificity, at 18% .
Both of these assessment tools had higher sensitivity than those indicated in the NOF guidelines. FRAX is a web-based tool that assesses the 10-year risk of osteoporosis fracture in women and men. Individual risk factors (i.e. age, sex, weight, height, and femoral neck BMD, if available) and clinical risk factors (i.e. prior fragility fracture, parental history of hip fracture, current tobacco use, long-term glucocorticoid use, rheumatoid arthritis, daily alcohol consumption, and secondary causes of osteoporosis) are entered into the web tool, which calculates and provides a 10-year fracture probability (as a percentage) of absolute, rather than relative, risk as occurs on the output of DEXA equipment .
No changes to osteoporosis practices guidelines have been anticipated as a result of the FRAX algorithm .
Benefits and limitations of FRAX
To use FRAX, one needs to understand its benefits and limitations. FRAX can be used to estimate fracture risk in untreated women and men from ages 40 to 90 .
However, the NOF guidelines recommend that it be used to make treatment decisions only in untreated postmenopausal women and in men aged 50 and older with osteopenia who otherwise do not qualify for treatment .
Expressing fracture risk as a 10-year probability is more clinically useful than expressing it as a relative risk. For example, if the relative risk of fracture is five times that of a comparator population in which the risk is close to zero, then the patient's risk is low, although a physician might feel compelled to treat upon learning that the relative risk is 5. A 50-year-old woman and an 80-year-old woman with identical T-scores of -2.5 have the same relative risk of fracture , although the 10-year probability of fracture is far greater for the older woman .According to Lewiecki, the limitation of FRAX is that it has not been validated in treated patients, in women and men outside the specified age range, or in children. In the USA, the use of FRAX is limited to four ethnic groups - white, black, Hispanic, and Asian. FRAX has not been validated in patients of mixed ethnicity or of other ethnic groups in the USA.
Limitation risk factors in FRAX are entered as yes-or-no responses, whereas the actual risk in an individual patient may depend on the dose or severity of the risk factor. For example, a patient who had been treated with the glucocorticoid prednisone at 5 mg/day for 4 months many years ago has a much lower risk compared with a similar patient who has been taking prednisone at 10 mg/day for the past 10 years, although the FRAX input ('yes' for glucocorticoid therapy) is the same and the FRAX estimation of fracture risk is the same .
Only the BMD in the femoral neck is used in FRAX, although in some patients the density at another skeletal site may be better correlated with fracture risk (e.g. low lumbar spine density may be associated with high fracture risk even when femoral neck density is not low). Other important risk factors, such as falling, rate of bone loss, and high bone turnover, are not part of the FRAX algorithm. These limitations of FRAX may lead to the overestimation or underestimation of actual fracture risk when used in some clinical circumstances, with an uncertain range of error for the calculated 10-year fracture probability .
Clinical guidelines for the treatment of osteoporosis
The challenge for physicians and other clinicians is to diagnose, prevent, and treat osteoporosis before fractures occur. However, several studies have indicated that there has been a failure in the USA to apply preventive and treatment measures to many individuals at risk for bone disease .
According to the NOF guidelines (2008), postmenopausal women and men 50 years of age and older who present with any of the following should be considered for treatment:
- Hip or vertebral (clinical or morphometric) fracture.
- T-score at the femoral neck or spine less than -2.5 (after exclusion of secondary causes).
- Low bone mass (T-score between -1.0 and -2.5 at femoral neck or spine) and 10-year probability of hip fracture greater than 3% or 10-year probability of major osteoporosis-related fracture greater than 20%. Although the guidelines are helpful, it is important to remember that treatment should be considered on an individual basis because T-scores and Z-scores are only part of a patient's workup .
Besides drug prescription, nonpharmacological osteoporosis management is an important and very broad concept. It must be considered as part of the long-term prevention of fractures for men and women, not only during the postmenopausal age but also from childhood through adolescence, premenopause, and perimenopause. Nonpharmacological treatment includes diet control and protein and nutrient supplementation.
According to WHO , protein-energy malnutrition is the most common nutritional deficiency in the elderly. Aging is typically associated with a reduction in lean body mass and a decrease in physical activity, resulting in decreased energy requirements. Protein deficiency can contribute to the risk of osteoporotic fractures in various ways. The recommended dietary intake of protein is 0.8 g/kg in young adults but 1 g/kg in healthy elderly people.
The skeletal structures contain 99% of the body's calcium stores. When the extraskeletal calcium level is inadequate, bone tissues are resorbed in an attempt to maintain equilibrium. To prevent excessive skeletal calcium loss, an adequate amount of calcium, as well as vitamin D, must be ingested. Clinical trials have shown that adequate consumption of calcium and vitamin D may significantly reduce fracture risk .
According to the NOF recommendations (2008), adults aged 50 years or younger should obtain at least 1000 mg/day of calcium and adults aged 50 years or older should obtain 1200 mg/day of calcium.
According to the NOF recommendations (2008), adults aged 50 years or older should obtain 800-1000 IU of vitamin D per day; however, high-risk patients (e.g. the elderly) may need more. The safe upper limit of daily vitamin D intake has been set at 2000 IU/day .
The beneficial physiologic effects most likely result from imposing repetitive stress upon the muscular and skeletal systems. The mechanical strain and loading on bone may decrease the rate of bone loss as well as produce an actual increase in bone mass .
Smoking has adverse skeletal effects and current smoking is associated with an increased fracture risk .
Between 28 and 35% of adults aged 65 years or older and living in the community experience at least one fall each year, and the annual fall prevalence increases with aging .
Medications may be divided into antiresorptives, which reduce bone loss, and anabolic, or bone formation, agents. Antiresorptive therapies include estrogen, selective estrogen receptor modulators (SERMs), bisphosphonates, and calcitonin. The only US Food and Drug Administration-approved anabolic agent is teriparatide, which is a synthetic form of parathyroid hormone. The effectiveness of these therapies, and combinations of them, is being studied .
Bisphosphonates act to decrease resorption by causing apoptosis and decreased function of osteoclasts. Several medications or drug combinations have been approved by the FDA for the prevention and treatment of osteoporosis, including alendronate, alendronate plus D (alendronate and cholecalciferol), ibandronate, risedronate, risedronate with a calcium supplement, and zoledronic acid .
Selective estrogen receptor
Modulators (SERMs) are designed to mimic the beneficial effects of estrogen on bone, the heart, and the central nervous system and at the same time minimize the adverse effects on the breast and the uterus .
For example, raloxifene is an estrogen receptor modulator that acts as an estrogen agonist for bone and lipoproteins but as an antagonist at the breast and uterus. It was the first SERM approved for the prevention and treatment of osteoporosis in postmenopausal women and has been shown to increase BMD, structurally recover bone, and decrease the risk of vertebral fractures .
Calcitonin is a hormone normally produced by the parafollicular cells of the thyroid gland. Salmon calcitonin is approved by the FDA for the treatment and prevention of osteoporosis in women who have been postmenopausal for at least 5 years; however, it has not been recommended as a first-line treatment .
Parathyroid acts normally to increase bone resorption in response to low serum calcium levels; however, in intermittent doses, it has been shown to have a favorable impact on BMD .
Denosumab is a human monoclonal antibody being studied for its effects on bone metastases, rheumatoid arthritis, multiple myeloma, and osteoporosis .
It acts by binding to and inhibiting receptor activator of nuclear factor kappaB ligand (RANKL). RANKL controls the differentiation, proliferation, and survival of osteoclasts. The inhibition of RANKL provides a lengthened period of absorption and inhibition of bone resorption .
Role of the family physician
Screening for osteoporosis
The US Preventive Services Task Force (USPSTF) recommends that women aged 65 or older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures, B recommendation.
The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures, C recommendation.
Health education and prevention of osteoporosis
Health education should comprise the following:
- Adequate intake of calcium and vitamin D.
- Treatment of vitamin D deficiency.
- Regular weight-bearing and muscle-strengthening exercise.
- Fall prevention.
- Cessation of tobacco use and avoidance of excessive alcohol intake.
Application of risk assessment tools
The ORAI, SCORE, and FRAX are used .
| Conclusion|| |
Osteoporosis is a disease of the bones in which the bone becomes thin, fragile, and prone to fractures. Osteoporosis is a serious health problem; bone fracture is a serious complication of osteoporosis, especially in older people. Broken bones due to osteoporosis are most likely to occur in the hip, spine, and wrist, but other bones can break too. Patients with osteoporotic fractures need long-term home care, and unfortunately they are prone to subsequent fractures. Twenty percent of seniors who break a hip die within 1 year from problems related to the broken bone itself or from surgery to repair it. Many of those who survive need long-term nursing home care. The role of the family physician in osteoporosis involves the screening of osteoporosis for all women above 65 years of age, provision of health education on calcium intake and vitamin D, on regular weight-bearing exercise, on and fall prevention, and application of risk assessment tools.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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