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Osteoporosis

For further information, see CMDT Part 26-18: Osteoporosis

Key Features

Essentials of Diagnosis

  • Fracture propensity of spine, hip, pelvis, and wrist

  • Asymptomatic until a fracture has occurred

  • Serum PTH, calcium, phosphorus, and alkaline phosphatase usually normal

  • Serum 25-hydroxyvitamin D levels often low as a comorbid condition

General Considerations

  • Causes over 1.5 million fractures annually in the United States

  • Most common causes

    • Aging

    • Sex hormone deficiency

    • Alcoholism

    • Smoking

    • Long-term proton pump inhibitor therapy

    • High-dose glucocorticoid administration

    • See Table 26–9

Table 26–9.Causes of osteoporosis.1
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Table 26–9. Causes of osteoporosis.1

Aging

Alcoholism

Cola consumption in women (hip)

Ethnicity: white or Asian

Female sex

Genetic disorders

 Aromatase deficiency

 Collagen disorders

 Ehlers-Danlos syndrome

 Homocystinuria

 Hypophosphatasia

 Idiopathic juvenile and adult osteoporosis

 Marfan syndrome

 Osteogenesis imperfecta

Hormone deficiency

 Estradiol (women)

 Testosterone (men)

Hormone excess

 Cushing syndrome or corticosteroid administration

 Hyperparathyroidism

 Thyrotoxicosis

Low physical activity and immobilization

Malignancy, especially plasma cell myeloma

Medications (long-term)

 Aromatase inhibitors

 Glucocorticoids

 Heparin

 Pioglitazone

 Proton pump inhibitors

 Selective serotonin reuptake inhibitors (elderly)

 SGLT2 inhibitors

 Vitamin A excess, vitamin D excess

Smoking

Underweight (BMI < 18.5)

Miscellaneous conditions

 Anorexia nervosa

 Celiac disease

 Copper deficiency

 Diabetes mellitus (uncontrolled)

 Hyponatremia (chronic)

 Inflammatory bowel disease

 Liver disease (chronic)

 Mastocytosis (systemic)

 Protein-calorie malnutrition

 Rheumatoid arthritis

 Vitamin C deficiency

1See Table 26–10 for causes of osteomalacia.

Table 26–10.Causes of osteomalacia.1
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Table 26–10. Causes of osteomalacia.1

Vitamin disorders

 Insufficient sunlight exposure

 Kidney: chronic kidney disease, nephrotic syndrome, kidney transplantation

 Liver disease

 Nutritional deficiency of vitamin D

 Malabsorption: aging, excess wheat bran, bariatric surgery, pancreatic enzyme deficiency, orlistat

 Vitamin D–dependent rickets types I and II

 Phenytoin, carbamazepine, valproate, or barbiturate therapy (long-term)

Dietary calcium deficiency

Phosphate deficiency

 Adefovir therapy

 Fanconi syndrome, renal tubular acidosis, and alcoholism

 Intestinal malabsorption

 Nutritional deficiency of phosphorus

 Phosphate-binding antacid therapy

 Renal loss

 Tumoral hypophosphatemic osteomalacia

 X-linked hypophosphatemic rickets

 Other disorders, including paraproteinemias, glycogen storage diseases, neurofibromatosis, Wilson disease

Inhibitors of mineralization

 Aluminum

 Bisphosphonates

Disorders of bone matrix

 Axial osteomalacia

 Hypophosphatasia

 Fibrogenesis imperfecta

1See Table 26–9 for causes of osteoporosis.

Demographics

  • Clinically evident in middle life and beyond

  • Develops frequently in hypogonadal men

  • White women aged ≥ 50 years (who do not receive estrogen replacement) have a 46% risk of sustaining an osteoporotic fracture during their lives

Clinical Findings

Symptoms and Signs

  • Usually asymptomatic until fractures occur

  • May present as back pain of varying degrees of severity or as spontaneous fracture or collapse of a vertebra

  • Loss of height common

  • Fractures of femoral neck and distal radius also common

  • Once osteoporosis is identified, careful history and physical examination are required to determine its cause

Differential Diagnosis

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