The Silent Disease Osteoporosis

HEALTH

According to the Bone Health and Osteoporosis Foundation, over 54 million Americans have been diagnosed with osteoporosis or low bone density also known as osteopenia which increases one’s risk for fracture. Why is osteoporosis known to be a silent disease? Many people do not know they have osteoporosis until after they fracture which leads to further increased risk for subsequent fractures in addition to disability from chronic pain or complications from the fracture(s). Osteoporotic fractures most commonly occur from a fall, but depending on how fragile your bones are, you can fracture from sneezing, coughing, or simply stepping off the curb. It is a fragility fracture that is a red flag one may have osteoporosis and should be screened to prevent future fractures, disability, and death.

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Quality of life is greatly reduced in patients with fragility fractures. Many patients hospitalized with osteoporotic fractures do not get discharged back to their homes but are transferred to a rehabilitation center or a nursing care facility for further recovery or permanent residence. Up to twenty percent of hip fractures result in death in one year because of complications from the fracture, or surgical repair of the fracture, increased immobility, decreased ability to perform activities of daily living, higher risk for subsequent falls, or even worse, they develop another fracture. According to the Bone Health and Osteoporosis foundation over 740,000 people lose their lives to hip fractures each year. As a result of the COVID-19 pandemic, identification and management of osteoporosis has been severely affected with further delays in patients getting diagnosed and treated appropriately.

Osteoporosis occurs more commonly in women than men and risk for osteoporosis increases with age. One out of two women and one out of four men over the age of 50 will break a bone due to osteoporosis. This disease causes about two million broken bones annually. Osteoporosis can occur in any race and is more common in whites and Asians. In women, osteoporosis risk increases the first five to seven years after menopause. It is important for women to be screened after menopause and men and women need to be screened if they have significant risk factors or have had a fragility fracture.

It is important to know the risk factors for osteoporosis. Family history is a strong risk factor such as a parent with a history of a hip or fragility fracture. Certain chronic medications are also a risk factor including warfarin, steroids, anti-seizure, or certain psychiatric medications. Reflux medications such as proton pump inhibitors affect absorption and have also been associated with low bone density. Smoking, increased alcohol use, low body mass index, conditions that affect absorption such as inflammatory bowel disease or celiac, and immobility are also significant risk factors as well. It is important for your primary care doctor to screen everyone over the age of 50 for osteoporosis in those patients with secondary risk factors.

As a rheumatologist, assessing bone health is a key component of all our patients visits. Many of the diseases we treat or care for affects bone density. For example, active rheumatoid arthritis accelerates bone loss and commonly steroids are used to treat flares of different autoimmune or inflammatory diseases which also affects bone density. We treat many patients with osteoarthritis, the aging arthritis, which not only can cause joint pain but can increase risk for falls. Therefore, we evaluate their bone health and determine if osteoporosis screening is warranted. Within our practice at Lehigh Valley Hospital and Health Network, osteoporosis screening is one of three quality metrics measured and followed assessing appropriate screening for osteoporosis.

How is someone diagnosed with osteoporosis? Screening for osteoporosis is done by a bone density test also known as a DXA (dual energy x-ray absorptiometry). It is a noninvasive test consisting of an x-ray of your lower back, total hip, neck of the hip and sometimes forearm to calculate bone density and risk for fracture. Low bone density is reported as a T-Score and there is a scoring system in which 0 to -1.0 is normal, -1.0 to –2.5 is osteopenia or the stage before osteoporosis, and scores less than -2.5 is osteoporosis. Patients who have osteopenia, treatment is determined based on another scoring system called a FRAX score. The FRAX score is a fracture risk calculator that should be reported on your DXA scan if you have osteopenia. It takes in account your femoral neck (hip) t-score and other secondary risk factors as well as age, sex, and BMI. If your 10-year probability of having a major osteoporotic fracture (spine, hip, shoulder, forearm) is greater than or equal to 20% or if your 10year probability of having a hip fracture is greater than or equal to 3%, you should be on therapy to prevent fractures. Screening with a DXA scan should take place if you are female 65 years or older or a male 70 years or older, 50 years old with osteoporosis risk factors, or someone with a fragility or nontraumatic fracture.

There are a variety of treatments for osteopenia and osteoporosis. Treatments vary from oral weekly or monthly medications to annual once a year 15-minute infusions. There are a variety of injectable medications used for preventing osteoporosis or osteopenia and some injectable medications are used to treat severe osteoporosis. Medications are dependent on many variables including other comorbid conditions and the severity of one’s bone loss. In addition to prescription medications, it is important to exercise regularly and make sure your vitamin D levels are within normal range. If you are vitamin D deficient, anti-osteoporosis therapy may not be effective. Many clinicians can treat osteoporosis including primary care physicians, gynecologists, endocrinologists, rheumatologists, orthopedics, and other specialists.

At Lehigh Valley Hospital and Health Network on average there are ninety hip fractures admitted to the Cedar Crest Campus each month. As a result, they are announcing the launch of a Bone Health/Fracture Liaison program for the facilitation of timely transition of care for patients discharged from the hospital with osteoporosis. This program will enhance the transition of care post discharge and improve ambulatory access to timely care. This is a multidisciplinary program under the direction of Dr. Scott Sexton, Orthopedics, in collaboration with Dr. Phillip Dunn, Rheumatology, and Dr. Mal Homan, Endocrinology. This program will be focused on the proper diagnosis of osteoporosis, education on risk factors and lifestyle modifications, treatment options and prevention of future fractures.

For more information visit www.bonesource.org