Osteoporosis and Fractures Are Common, and Becoming More So About 10 million Americans age >50 years have osteoporosis1 Almost 34 million more have osteopenia1 In 2005, >2 million osteoporotic fractures were sustained, costing an estimated $17 billion2 As the population continues to age, the incidence and prevalence will increase1 By 2020, 1 in 2 Americans older than age 50 years will have, or be at risk of, developing osteoporosis of the hip1 By 2025, the number of fractures is expected to increase to >3 million at an estimated cost of $25.3 billion every year2 1. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004. 2. Burge R, et al. J Bone Miner Res. 2007;22:465-475.

Osteoporotic Fractures Are Associated with Increased Mortality With permission from Bluic D, et al. JAMA. 2009;301:513-521.

“Red Flags” that Warrant Further Assessment Prior low-trauma fracture as an adult Family history of osteoporosis, especially parental history of hip fracture Weight loss of >1%/year in the elderly Treatment with drugs that adversely affect bone metabolism Disease or conditions linked to secondary osteoporosis Unusual cessation of menstrual periods Anorexia nervosa (marked weight reduction) Athletic amenorrhea syndrome related to intense physical activity US Department of Health and Human Services. Bone Health and Osteoporosis:A Report of the Surgeon General. Rockville, MD: 2004.

Selected Secondary Causes of Osteoporosis in Adults Endocrine Disease or Metabolic Causes Nutritional Conditions Drugs Disorders of Collagen Metabolism Other Hypogonadism Cushing’s syndrome Hyperthyroidism Hyperparathyroidism Anorexia nervosa Hyperprolactinemia Porphyria Hypophosphatasia Diabetes mellitus, type 1 Acromegaly Malabsorption syndromes (eg, celiac disease) Malnutrition Chronic cholestatic liver disease Gastric operations Vitamin D deficiency Calcium deficiency Alcoholism Hypercalciuria Glucocorticoids Medroxyprogesterone Excess thyroid hormone Heparin Antiepileptics Gonadotropin- releasing hormone analog agonists Aromatase inhibitors Thiazolidinedione drugs Selective serotonin reuptake inhibitors Proton pump inhibitors Osteogenesis imperfecta Homocystinuria Ehlers-Danlos syndrome Marfan syndrome Chronic obstructive pulmonary disease Rheumatoid arthritis Myeloma, leukemia, lymphoma Immobilization Renal tubular acidosis Organ transplantation Mastocytosis Thalassemia AACE Osteoporosis Guidelines. Endocr Pract. 2003;9:544-564. With permission from the American Association of Clinical Endocrinologists.

Who Should Have BMD Screening? The National Osteoporosis Foundation recommends BMD screening for: Women age ≥65 years and men age ≥75 years, regardless of risk factors Younger postmenopausal women, women in the menopausal transition, and men age 50–70 years if they have risk factors associated with increased fracture risk Adults with a previous fracture after age 50 Anyone at risk for secondary osteoporosis Anyone receiving osteoporosis treatment, to monitor treatment effect National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation; 2002:1-55.

Osteoporosis Defined Based on DXA Measurement of BMD Normal BMD within 1 SD of young normal adult (T-score ≥-1.0) Osteopenia (low bone mass) BMD 1.1–2.49 SD below young normal adult (T-score -1.1 to -2.49) Osteoporosis BMD ≥2.5 SD below young normal adult (T-score ≤-2.5) National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

FRAX—Fracture Risk Assessment Tool www.shef.ac.uk/FRAX Estimates absolute 10-year risk of a hip fracture or major osteoporotic fracture (ie, vertebral, hip, forearm, humerus)1 Incorporates clinical risk factors for fracture2,3 Age Gender Previous fragility fracture after age 50 years History of glucocorticoid use Parental history of hip fracture Rheumatoid arthritis Secondary osteoporosis Current smoker Alcohol consumption >3 drinks per day Body mass index More sensitive than bone mineral density alone in identifying those at high risk of fracture2 Pertains only to previously untreated patients1 1. National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55. 2. American College of Rheumatology Hotline summary of FRAX. March 18, 2008. 3. FRAX. WHO Fracture Risk Assessment Tool. 2008. www.shef.ac.uk/FRAX. Accessed April 21, 2009.

Primary Prevention for All Patients Well-balanced nutrition Calcium = at least 1200 mg/day Vitamin D = 800 to 1000 mg/day Active, healthy lifestyle Regular weight-bearing and muscle-strengthening exercise Improves agility, posture, and balance May provide modest increases in bone density Avoid or stop cigarette smoking Avoid or stop excessive alcohol consumption (>3 drinks/day) National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

Fall Prevention Strategies Falls frequently cause fractures; preventing falls helps prevent fractures Address risk factors for falls Environmental factors: low lighting, obstacles in the walking path, lack of assist devices in the bathroom Medical factors: poor vision, previous fall, orthostatic hypotension, medications that may affect balance or cause sedation Consider muscle strengthening and balance retraining US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004.

Pharmacologic Therapy in Primary Prevention Antiresorptive Agent MOA: reduce bone loss Bisphosphonates Alendronate Ibandronate Risedronate Zoledronate Estrogen Raloxifene Calcitonin Anabolic Agents MOA: build bone Parathyroid hormone Teriparatide National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

Monitoring Patients on Pharmacotherapy Assess adherence to therapy and lifestyle modifications Continue to evaluate and address risk factors for falls Measure bone mineral density every 2 years in patients on pharmacotherapy Monitoring with DXA should be in accordance with medical necessity, expected response, and in consideration of local regulatory requirements Use consistent DXA instrument, facility, and personnel for repeat monitoring Consider measurement of biochemical markers of bone turnover in patients whose bone density has decreased despite treatment compliance; evaluate for other secondary causes of bone loss National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.