Osteoporosis

Osteoporosis

Screening:

Women >65 years or <65 with risk factors (early menopause, steroid use, smoking, low BMI).
Men >70 years (Medicare coverage varies).
Additional risk factors: IBD, low physical activity, corticosteroids.
FRAX Score for fracture risk assessment.

Diagnosis:

DEXA Scan: Measures BMD.
T-Score: Osteoporosis (≤ -2.5), Osteopenia (-1.0 to -2.4).
Fragility Fractures: Strong indicator regardless of DEXA results.

Treatment:

First-line: Bisphosphonates (Alendronate weekly, Zoledronic acid yearly IV).
Side Effects: Osteonecrosis of the jaw, atypical femur fractures.
Denosumab: SC injection q6 months; discontinuation risks rapid bone loss.
Duration: 3-5 years; extended in high-risk cases.
Severe Cases: Teriparatide or abaloparatide.
Drug Holidays: Every 3–5 years to minimize risks.

FRAX Calculator

Age: History of any fracture after age 50: Mother's history of hip fracture after age 50: Weight: Current smoker: Needs arms to assist when standing from chair: Total Hip T-score (if applicable):

Osteomalacia

Etiology:

Vitamin D Deficiency: Malabsorption (celiac, IBD), poor diet, low sunlight.
Phosphate Deficiency: Renal wasting or dietary insufficiency.
Often presents with adult rickets.

Clinical Features:

Bone pain, muscle weakness, fractures.
Low BMD, Looser’s zones on imaging.

Management:

Correct deficiencies: Vitamin D (ergocalciferol, cholecalciferol), calcium, phosphate repletion.

CKD-Related Bone Disorders

Pathophysiology:

Vitamin D Activation Decline: Impaired kidney function reduces 1,25-dihydroxyvitamin D.
Secondary Hyperparathyroidism: Phosphate retention, increased FGF-23 suppresses vitamin D, leading to bone resorption.

Treatment:

Phosphate Binders: Sevelamer, calcium acetate to reduce hyperphosphatemia.
Active Vitamin D (Calcitriol): Suppresses PTH, increases calcium absorption.
Goal: Maintain PTH levels at 2–9x upper limit of normal.

Screening & Monitoring:

BMD every 2 years (osteopenia), every 5–10 years (normal bone density).

Challenges:

Complex calcium-phosphate-PTH interplay; bone biopsies for renal osteodystrophy diagnosis.

Clinical Practice Considerations

Prevention: Weight-bearing exercises, adequate calcium/vitamin D, smoking cessation, minimize steroid use.
Patient Education: Adherence to treatment, side effects awareness.
High-Risk Groups: Elderly, postmenopausal women, CKD, malabsorption syndromes.