CMPH Journal

Introduction

Primary osteoporosis is a skeletal disorder characterized by decreased bone mass leading to increased bone fragility, increased fracture risk, morbidity, and mortality [1-3]. This condition often does not cause symptoms, and many people with osteoporosis may not be aware that they have this medical condition [4]. Osteoporosis is a common medical condition, affecting more than 10 million Americans. Another 43.3 million people have low bone mass associated with a considerable risk for progression to osteoporosis [5]. Due to a deficiency in the hormone estrogen, post-menopausal women are at greatest risk for developing osteoporosis [6]. Other risk factors include underweight individuals, medications (corticosteroids, insulin dependent diabetes mellitus), cigarette smoking, excess alcohol consumption, and a family history of osteoporosis.

Osteoporotic fractures can occur in any bones of the skeleton, but the risk for fracture is greatest in the hip and spine that leads to pain, disability, loss of independence, and even death [3,7]. Men and young individuals are less affected by this medical condition.

However, men with osteoporotic hip fractures have greater morbidity and mortality than women and seek medical treatment less than women [8-10]. This paper is a review about osteoporosis, and the latest screening recommendations by the United States Preventive Services Task Force (USPSTF) to prevent osteoporotic fracture [7].

In 1994, the World Health Organization defined osteoporosis in post-menopausal White women as bone density at the hip or lumbar spine that is 2.5 standard deviations or lower (T score –2.5) than the mean Bone Mineral Density (BMD) measured at that site for a reference population of young healthy White women [4]. This remains the clinical reference standard for people of all racial and ethnic groups, and for both sexes. However, the prevalence of osteoporosis and incidence of osteoporotic fractures differs among racial and ethnic groups. Prevalence is highest in women, individuals age 65 years or older (27.1% in women and 5.7% in men), compared with men and among Asian, Hispanic, and White persons [11].

Osteoporotic fractures are associated with psychological distress, subsequent fractures, loss of independence, reduced ability to perform activities of daily living, and death. Studies show lower fracture incidence in Asian, Black, and Hispanic populations compared with White populations among both sexes [12,13]. Differences in BMD alone do not completely explain the racial and ethnic differences in fracture incidence. Studies in Asian women have lower BMD than White women, and risk for fracture [14-16]. Although the underlying etiology for the differences in fracture incidence among racial and ethnic groups remain uncertain, this could be due to differences in social and environmental determinants. Although bone density is an important risk factor for fracture (especially fragility fractures), advancing age is a stronger determinant [17]. Further, older adults have much higher fracture rates than younger adults with the same BMD due to declining bone quality and from falling [1-3].

Treatment

Although this review is not about the treatment to prevent fractures from osteoporosis, the United States Food and Drug Administration has approved several drug therapies for the prevention of osteoporosis [3,18]. Therapies include the following: receptor activator of nuclear factor κB (RANK) ligand inhibitor (denosumab), bisphosphonates (alendronate, ibandronate, risedronate, zoledronate), selective estrogen receptor modulators (SERMs) (bazedoxifene, raloxifene), a sclerostin inhibitor (romosozumab), recombinant human parathyroid hormone (recombinant PTH) (teriparatide), analogue of human parathyroid hormone–related protein (PTHrP) (abaloparatide).

Screening Tests for Osteoporosis

To prevent osteoporotic fractures in women under 65 years old and who are at risk for fracture, screening for osteoporosis is recommended. For women over 65 years old, screening for osteoporosis is also recommended to prevent osteoporotic fractures. For men of all ages the risk for osteoporotic fracture is unknown and therefore, screening for osteoporotic fracture is not indicated (Figure 1).

Figure 1: Screening Recommendations to Prevent Osteoporotic Fracture.

The most common bone measurement test to screen for osteoporosis is Dual-energy X-ray Absorptiometry (DXA) at a central site such as the hip, femoral neck, or lumbar spine [17,19]. Centrally measured DXA correlates with bone strength and clinical fracture outcomes. Fracture risk at a specific site is best predicted if bone density is measured at that site. However, clinical evidence suggests that BMD alone may not be the most useful predictor of fracture risk, especially in younger populations [20]. Several risk assessment tools that incorporate age and sex, with or without other risk factors have been developed to either identify probability of osteoporosis or predict fracture risk.

A risk assessment tool that is frequently used with BMD studies is the fracture risk assessment tool (FRAX) [21]. FRAX predicts the 10-year probability of hip fracture for people aged 40 to 90 years by using demographic and clinical factors alone or in combination with BMD measured at the femoral neck [21-23]. In the United States, four different versions of FRAX using racial and ethnic specific fracture incidence data are available for Hispanic, nonHispanic Asian, non-Hispanic Black, and non-Hispanic White persons [21]. As hip fracture incidence in the United States is lower in most non-White racial ethnic groups, fracture risk estimates for Asian, Black, and Hispanic people will be lower than White people of the same age, sex, weight, BMD in the FRAX model. However, for multi-racial individuals, there is no consensus as to which FRAX version to use [24].

Conclusion

The United States Preventive Services Task Force has determined that screening for women over age 65 has moderate benefit. For women 65 years or younger at increased risk for osteoporotic fractures, screening is recommended. For men of all ages, there is insufficient evidence to recommend screening for osteoporosis to prevent osteoporotic fractures.

References

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