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Juliet Compston



This chapter has been thoroughly revised in December 2013, including emphasis that alendronate is the most cost-effective option in most postmenopausal women and older men.

Updated on 29 May 2014. The previous version of this content can be found here.
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date: 28 April 2017

Osteoporosis is characterized by a reduction in bone mass and disruption of bone architecture, resulting in increased bone fragility and fracture risk, with fractures of the distal radius (Colles’ fracture), spine and proximal femur being most characteristic. One in two women and one in five men over the age of 50 years will suffer an osteoporotic fracture during their remaining lifetime, with massive cost to health care services.

Pathogenesis—bone mass in later life depends both on (1) peak bone mass achieved in early adulthood—strongly influenced by genetic factors, also sex hormone status, nutrition and physical activity; and (2) rate of age-related bone loss—oestrogen deficiency is a major factor in menopausal bone loss in women.

Diagnosis—dual energy X-ray absorptiometry (DXA) is the best method for measuring bone mineral density (BMD) in the spine and hip, with osteoporosis defined as present when the BMD is 2.5 standard deviations or more below normal peak bone mass (T-score ≤ –2.5).

Risk assessment—an algorithm to estimate 10-year fracture probability (FRAX) uses (1) clinical risk factors—including age, glucocorticoid therapy, a previous history of fracture, a family history of hip fracture, current smoking, alcohol abuse, and certain diseases associated with osteoporosis, e.g. rheumatoid arthritis; with or without (2) BMD measurements. This enables intervention thresholds to be based on absolute risk rather than on BMD T-scores.

Treatment—appropriate levels of exercise should be recommended, and smoking and alcohol abuse discouraged. In postmenopausal women with osteoporosis, reductions of around 30 to 70% in vertebral fracture are seen after 3 years treatment with most drug interventions, with the current consensus being that this should usually be continued for a minimum of 3–5 years. (1) First-line treatment—for postmenopausal women alendronate is the most cost-effective option. (2) Other options include risedronate, zoledronic acid, ibandronate, denosumab, strontium ranelate or raloxifene (a selective oestrogen-receptor modulator). (3) Other considerations—(a) denosumab or zoledronic acid—the treatment of choice when oral medication cannot be given or will not be absorbed; (b) parathyroid hormone peptides—use limited to women with severe vertebral osteoporosis who are intolerant of or unresponsive to other treatments; (c) hormone replacement therapy—an appropriate option in younger postmenopausal women at high risk of fracture; (d) calcium and vitamin D—should be coprescribed with other treatments if there is evidence of inadequate calcium intake or vitamin D insufficiency; (e) glucocorticoid-induced osteoporosis—primary prevention with a bisphosphonate is recommended for patients committed to any oral dose of prednisolone for> 3 months who are aged ≥ 70 years, or who have sustained a previous fragility fracture. Parathyroid hormone peptide [1–34] is an alternative option. Other patients taking oral glucocorticoids for ≥3 months should have their BMD measured, and those with a T-score of—1.5 or lower should be considered for treatment.

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