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Osteoporosis

Medicine > Endocrine & metabolic

Background knowledge 🧠

Definition

  • Osteoporosis is a systemic skeletal disorder characterised by low bone mass and micro-architectural deterioration of bone tissue.
  • Leads to increased bone fragility and susceptibility to fractures.

Epidemiology

  • Prevalence in the UK: affects around 3 million people.
  • Common in older adults, particularly postmenopausal women.
  • Incidence of osteoporotic fractures increases with age.
  • Hip, vertebrae, and wrist are common fracture sites.

Pathophysiology

  • Bone remodelling imbalance: Bone resorption outpaces bone formation, leading to decreased bone mass and deterioration of bone microarchitecture.
  • Key cells involved: Osteoclasts (bone resorption), osteoblasts (bone formation).

Aetiology

  • Aging: bone resorption exceeds formation.
  • Hormonal changes: decreased oestrogen in women, testosterone in men.
  • Nutritional factors: inadequate calcium and vitamin D.
  • Lifestyle factors: physical inactivity, smoking, alcohol.
  • Medical conditions: hyperthyroidism, rheumatoid arthritis.
  • Medications: glucocorticoids, anticonvulsants.

Types

  • Primary: postmenopausal and age-related.
  • Secondary: due to underlying medical conditions or medications.
  • Juvenile: rare, occurs in children and adolescents.

Clinical Features 🌡️

Symptoms

  • Often asymptomatic until a fracture occurs.
  • Back pain from vertebral fractures.
  • Loss of height over time.
  • Stooped posture (kyphosis).
  • Fractures with minimal trauma (pathological fracture).

Signs

  • Decreased bone density on imaging.
  • Vertebral deformities.
  • Fractures (hip, wrist, vertebrae).
  • Height loss.
  • Kyphosis.
  • Tenderness over affected bones.

Investigations 🧪

Tests

  • Dual-energy X-ray absorptiometry (DEXA) scan: gold standard for diagnosis.
  • Serum calcium, phosphate, and alkaline phosphatase.
  • Vitamin D levels.
  • Hormonal tests: Thyroid function tests and parathyroid hormone levels.
  • Bone turnover markers.

Diagnostic Criteria

  • Bone Mineral Density (BMD) testing using DEXA scan.
  • Diagnosis based on T-score:
    • Normal: T-score above -1.0.
    • Osteopenia: T-score between -1.0 and -2.5.
    • Osteoporosis: T-score at or below -2.5.
  • Laboratory tests to exclude secondary causes.

Management 🥼

Management

  • Lifestyle modification: weight-bearing exercise, smoking cessation, alcohol moderation.
  • Dietary supplements: calcium and vitamin D.
  • Pharmacotherapy: bisphosphonates, denosumab, selective estrogen receptor modulators (SERMs).
  • Hormone replacement therapy (HRT) in selected cases.
  • Regular monitoring with DEXA scans.
  • Fall prevention strategies.

Complications

  • Fractures: hip, vertebral, and wrist are most common.
  • Chronic pain and disability.
  • Decreased quality of life.
  • Increased mortality, especially after hip fractures.
  • Depression and anxiety.

Prognosis

  • Varies depending on fracture risk and management.
  • Early detection and treatment improve outcomes.
  • Regular follow-up is essential to monitor bone density and treatment efficacy.
  • Lifestyle changes can significantly reduce risk of fractures.

Key Points

  • Osteoporosis is a common and preventable condition.
  • Screening and early intervention are crucial.
  • Combination of lifestyle changes and pharmacotherapy is effective.
  • Patient education and adherence to treatment are key to management.
  • Regular monitoring and follow-up are necessary.

References

  • NICE Guidelines (https://www.nice.org.uk/guidance/cg146).
  • National Osteoporosis Society (https://theros.org.uk).

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Endocrine & metabolic