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Definition
Deterioration in bone mass and microarchitecture (skeletal fragility) with increased fragility/T-score <2.5
Bone mineral density 2.5 standard deviations below normal peak values for young adults
o (T score of -2.5 or less)
Predisposes bone to fractures
Can lead to chronic pain, disability, loss of independence
Aetiology
Primary osteoporosis
o Post-menopausal
Secondary osteoporosis
o Hyperparathyroidism
o Multiple myeloma
o Malabsorption
o Diabetes mellitus (with/without low BMD)
o Inflammatory bowel disease
Risk factors
Modifiable
o Smoking RF Mnemonic: SHATTERED
o Alcohol intake Steroid use >5mg/day prednisolone
o Calcium/vitamin D intake Hyperthyroidism; hyperparathyroidism,
o Sedentary lifestyle hypercalciuria
o Low BMI Alcohol and tobacco use
o Sex hormones (Oestrogen)
Thin (BMI <22)
o Medication (steroid/GCS use)
o Inflammatory bowel disease Testosterone low (e.g. anti androgen in
o COPD cancer of prostate)
o Cushing’s Early menopause
o Hyperthyroidism Renal or liver failure
Non-modifiable Erosive/inflammatory bone disease (e.g.
o Previous fractures RA or myeloma)
o Pathological fracture (falling from standing) Dietary Ca low/malabsorption or
o Genetic predisposition Diabetes mellitus type 1
o Age >60
Family history
o Post-menopausal women
o Family history
o Gender (Females >> Males)
Falls risk
o Impaired vision
o Balance
Classification
Type 1: Post-menopausal
Type 2: Senile
Type 3: Secondary
Endocrine GIT Haem Renal Autoimmune Drug-induced
GCS, thyroid, Malabsorption Multiple myeloma CKD GCE-related Heparin, loop
hypogonadism, diuretics, PPI
hyper-PTH, GH def,
acromegaly
Investigations
Look for causes of secondary osteoporosis (See above)
Bloods
o Serum vitamin D look at levels
o Serum calcium, phosphate, alkaline phosphatase, 25(OH) vitamin D – osteomalacia
Disease Serum calcium Serum PO4 Serum PTH Serum ALP
Osteoporosis N N N N/high
Osteomalacia Low Low High High
Hypo-PTH Low High Low
Malignancy High N N ++++
Prevention
Chronic glucocorticosteroid use bone scan every 6 months
Lifestyle modifications
o Fall prevention
o Dietary calcium/vitamin D supplementation
Guidelines
o BMD assessment at or around 65 years of age
o Assess fracture risk using the FRACTURE RISK ASSESSMENT TOOL (FRAX)
Prognosis
Psychological
o Poor quality of life
o Dependent living situation
Overall increased risk of death
Complications
Fragility fractures
Can be chronic
Hip fracture/vertebral compression fracture
Compromise patient’s quality of life, significant healthcare costs
FRAX tool: WHO Fracture risk assessment tool
Pathophysiology
Type 1: Post-menopausal
o Oestrogen deficiency after menopause accelerated bone loss
o Increased production of TNF by T-cells
o TNF potentiates RANK-L induced osteoclast production
o Reduced absorption of calcium and increased calcium metabolism
o Suppression of OPG release from B-cells, downregulation of OPG reduction from stromal cells
o Result: Reduced calcium, increased osteoclast activity and formation, reduced osteoblast activity and formation more
bone RESORPTION
Type 2: Senile
o Accumulation of fat in bone marrow
o Reduced formation of osteoblasts and increased apoptosis of osteoblast
o Increased osteoclast activity due to increased RANKL and decreased apoptosis of osteoclasts
o Same result as above
Type 3: Secondary
Endocrine GIT Haem Renal Autoimmune Drug-induced
GCS, thyroid, Malabsorption Multiple myeloma CKD GCE-related Heparin, loop
hypogonadism, diuretics, PPI
hyper-PTH, GH def,
acromegaly