1. 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: Burge R, et al. J Bone Miner Res. 2007;22:

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

3. “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.

4. 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: With permission from the American Association of Clinical Endocrinologists.

5. 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.

6. 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.

7. 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: American College of Rheumatology Hotline summary of FRAX. March 18, FRAX. WHO Fracture Risk Assessment Tool Accessed April 21, 2009.

8. 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.

9. 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.

10. 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.

11. 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.