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Osteoporosis

For further information, see CMDT Part 26-19: Osteoporosis

Key Features

Essentials of Diagnosis

  • Fracture propensity of spine, hip, pelvis, and wrist from depletion of bone matrix with subsequent demineralization

  • 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

  • Most common causes

    • Aging

    • Sex hormone deficiency

    • Alcohol use disorder

    • Cigarette smoking

    • Long-term proton pump inhibitor therapy

    • High-dose glucocorticoid administration

    • See Table 26–10

  • Vertebral fractures are the most common fracture; they are usually diagnosed incidentally on radiographs or CT scanning

  • Largely due to a reduction in smoking, the age-adjusted risk for hip fracture has declined in the United States in recent years

  • However, the risk for fragility fractures remains high and varies with ethnicity, sex, and age

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

Aging

Alcohol use disorder (alcoholism)

Cigarette smoking

Cola consumption in women (hip)

Ethnicity: White

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

 Hyperparathyroidism

 Thyrotoxicosis

Low physical activity and immobilization

Malignancy, especially plasma cell myeloma

Medications (long-term)

 Aromatase inhibitors

 Corticosteroids

 GnRH inhibitors

 Heparin

 Pioglitazone

 PPIs

 SSRIs (older adults)

 SGLT2 inhibitors

 Vitamin A excess, vitamin D excess

Underweight (BMI < 18.5)

Miscellaneous conditions

 Anorexia nervosa

 Celiac disease

 Copper deficiency

 Cystic fibrosis

 Diabetes mellitus (uncontrolled)

 HIV infection

 Hyponatremia (chronic)

 IBD

 Liver disease (chronic)

 Mastocytosis (systemic)

 Primary biliary cholangitis

 Protein-calorie malnutrition

 Rheumatoid arthritis

 Thalassemia major

 Vitamin C deficiency

1See Table 26–11 for causes of osteomalacia.

Table 26–11.Causes of osteomalacia.1
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Table 26–11. Causes of osteomalacia.1

Vitamin disorders

 Insufficient sunlight exposure

 Kidney: CKD, 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 alcohol use disorder (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 26–10 for causes of osteoporosis.

Demographics

  • Causes over 1.5 million fractures annually in the United States, most commonly vertebral fractures, followed by hip fractures (300,000 annually) and pelvic fractures

  • Prevalence of vertebral fractures in women older than 65 years is

    • 70% for White women

    • 68% for Japanese women

    • 55% for Mexican women

    • 50% for Black women

  • Lifetime risk ...

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