An Osteoporosis Overview: Screening and Self-care Recommendations

Key Takeaways:

• Guidelines from the American Association of Clinical Endocrinology/American College of Endocrinology recommend screening all postmenopausal women 50 years of age or older, getting a detailed history and assessment of clinical risk factors for osteoporosis, and considering bone mineral density testing in any patient who has a clinical fracture risk profile.
• It is important to identify patients with osteoporosis and a high or very high risk of fracture, as they can receive pharmacotherapy to reduce risk.
• Patient education about bone health and the importance of getting the appropriate amount of calcium and vitamin D can be offered in the primary care setting to further help patients reduce their risk of fracture.

As 2022 draws to a close, so is—we hope—the COVID-19 pandemic, and our patients are returning to see us in the clinic. Although I am happy that COVID-19 is getting under control, we have lost ground in osteoporosis management. In fact, at some level we are having an osteoporosis fracture crisis, and that is for a few reasons. First, patients did not come to their doctors for osteoporosis evaluation over the past few years because of the COVID-19 pandemic, and second, the confusion about adverse events related to osteoporosis medications has left people less interested in treating the disease. However, the professional societies have gotten together to refine osteoporosis guidelines for screening.

Guidelines for Screening
The 2020 update of the American Association of Clinical Endocrinology (AACE)/American College of Endocrinology clinical practice guidelines recommend screening all postmenopausal women aged 50 years or older, getting a detailed history and assessment of clinical risk factors for osteoporosis, and considering bone mineral density (BMD) testing in any patient who has a clinical fracture risk profile. Measurement of BMD is done by axial dual energy x-ray absorptiometry (DXA) of the spine, hip, and distal one third of the radius, if it is available. This is important as many people do not have access to DXA of the hip and spine, and instead one third of the radius can be used to give an assessment of fracture risk and obtain a T-score. The T-score is calculated by comparing a woman’s BMD with the average bone density of a healthy young woman. When we screen our patients by bone density, a DXA T-score of -1 and above is normal, a T-score of -1 to -2.5 indicates low bone mass, and a T-score of -2.5 or below indicates osteoporosis.

The International Osteoporosis Foundation recommends evaluating bone structure by using the DXA scan and special software to determine a trabecular bone score. The score provides information about the amount of trabecular bone within the vertebrae and helps identify patients who may have a normal DXA but actually have reduced trabecular bone and thus an increased risk of fracture.

The North American Menopause Society (NAMS) recommends measuring bone density in postmenopausal women with risk factors for low bone density. Who are these women? They are women older than 65 years of age and women older than 50 years of age with additional risk factors such as history of a fracture since menopause or known medical causes of bone loss and fracture (eg, a patient receiving glucocorticoids).

Very High–Risk Fracture Group
The AACE and other societies have identified the very high–risk fracture group. The AACE defines a patient with a very high risk of fracture as someone with fractures within the past 12 months, fractures while receiving osteoporosis therapy, multiple fractures, fractures while receiving medications causing skeletal harm (eg, steroids), T-scores below -3.0, a high risk or a history of falls, and a Fracture Risk Assessment Tool score showing a major osteoporotic fracture risk over 10 years of ≥30% and a hip fracture risk >4.5%.

The Endocrine Society also has put out guidelines that indicate a very high risk of fracture for patients with multiple spine fractures and a T-score below -2.5 with the spine or hip.

The NAMS describes patients at high risk as those with prior or recent fractures, T-scores below ‑3.0, and fractures or BMD loss while receiving an osteoporosis medication. These guidelines are important because they identify the patients who really need to be treated.

Bone Health
As we talk about diagnosing osteoporosis, we also should consider bone health. Getting the appropriate amount of calcium is an easy thing to do, and patients can do it themselves. So how much calcium is really needed?

It is recommended that the daily calcium intake from all sources (diet and calcium supplements) be 1200 mg/day in women and men greater than 50 years of age. Of interest, most women in the United States get approximately 750 mg/day of calcium, and men get approximately 900 mg/day. Therefore, one additional calcium supplement would get them to 1200 mg/day. After that amount, there is no benefit. The data from numerous studies have identified that the sweet spot for total calcium intake to be approximately 750-1200 mg/day. Both below and above that, there is an increased risk of hip fracture.

Many years ago, there was concern that our oral calcium supplements could be deposited in the blood vessels and this could be bad for the heart. A meta-analysis of 13 large randomized, controlled trials in healthy postmenopausal women found that calcium supplements increased cardiovascular disease risk by approximately 15%. In these studies, cardiovascular outcomes were secondary endpoints and considered adverse events. However, prospective studies that were conducted in men and women and had cardiovascular events as primary endpoints reported that there was no harm due to calcium supplementation in relation to heart disease. The only caveat is that if you take too much, you actually can have an increased risk of renal stones. I don’t have any concern about my patients whose calcium intake with diet and supplement is 1200 mg/day.

Regarding vitamin D supplementation for better absorption of calcium, serum vitamin D levels should be maintained at ≥30 ng/mL. I prefer to keep patients in the 30- to 50-ng/mL range. With serum vitamin D levels <12 ng/mL, the risk of mortality increases. Luckily, there is no toxicity until levels are >100 ng/mL, and most patients can get adequate vitamin D by taking supplements of 1000-2000 IU/day. I recommend that my patients do not take >4000 IU/day.

Patient Education
It is important to educate your patients about osteoporosis. How do you reduce your patient’s risk of osteoporosis, and what can they do?

Talk to your patients about the importance of adequate dietary intake of calcium and exercise—especially weight-bearing exercise, because that is going to improve balance and prevent falls— and get them to reduce unhealthy habits such as smoking and drinking excessive amounts of alcohol. For patients who are at a risk of falling, have their homes evaluated so they do not have any areas where they could lose their balance and fall. In addition, if they are weak and if appropriate, refer them to physical therapy for muscle-strengthening and balance exercises.

Because osteoporosis is a public health consequence that we can prevent, and primary care practitioners really are the key to intervention, we need to make sure BMD is measured in women aged 50 years and women with risk factors and that we encourage the beneficial lifestyle changes we just discussed. All of this can help patients reduce osteoporosis—and not just osteoporosis progression, but falls and fractures.

Your Thoughts?
In your practice, how do you identify your patients at very high risk for fractures? Please answer the poll and post your thoughts and questions in the discussion box.