Chapter 112: Osteoporosis

Update Summary

March 1, 2023

The following sections, tables, and figures were updated:

• Added discussion of the FRAX tool and FRAXPlus

• Updated Figure 112-3 to include additional clinical risk factors

• Added 2023 osteoporosis guideline recommendations for treatments of first choice

• Added section on the care of transgender people with osteoporosis

KEY CONCEPTS

• Osteoporosis is a public health epidemic that affects all ages, genders, races, and ethnicities. Lifestyle behaviors, diseases, and medications should be reviewed to identify the risk factors for developing osteoporosis and osteoporotic fractures. Healthcare professionals should identify and resolve reversible risks. Secondary causes of bone loss should be explored, especially for patients with early-onset or severe osteoporosis.

• Bone physiology and pathophysiology are complex involving coupled bone resorption and formation in bone remodeling processes. These processes result from many different cell lines, transmitters, pathways, and biofeedback systems. As these processes become more delineated, additional targets are identified for medications.

• All patients taking medications known to increase bone loss, falls, and fractures should practice a bone-healthy lifestyle, be evaluated for a switch to a safer alternative medication, and/or be considered for osteoporosis therapy. The most common causes of medication-induced osteoporosis are long-term oral glucocorticoids and certain chemotherapeutic agents.

• Ten-year probabilities for a major osteoporotic and hip fracture can be estimated for women (postmenopausal to 90 years old) and men (50-90 years old) with the fracture risk assessment tool (FRAX) tool. This tool is a questionnaire that can be used in any setting, including pharmacies, health fairs, and clinics. Central bone mass densitometry can determine bone mass, predict fracture risk, and influence patient and provider treatment decisions. A newer version, FRAXPlus, includes more risk factors and will soon be available.

• Throughout life, everyone should practice a bone-healthy lifestyle, which emphasizes regular exercise, nutritious diet, tobacco avoidance, minimal alcohol use, and fall prevention to prevent and treat osteoporosis.

• Treatment should be considered for postmenopausal women and men older than 50 years who have a low-trauma hip or vertebral fracture, T-score of −2.5 or less at the femoral neck, total hip, or spine, or low bone mass (T-score between −1.0 and −2.5) and a FRAX 10-year probability of major osteoporotic fracture of 20% or more or hip fracture of 3% or more. Patients with secondary causes might receive therapy at younger ages or higher T-scores.

• The recommended dietary calcium intake for American adults is 1,000 to 1,200 mg of elemental calcium daily with diet as the preferred source. Supplements are added when diet is insufficient.

• The recommended daily dietary vitamin D intake for American adults is 600 units and for older adults 800 units. Some organizations and guidelines recommend higher doses of at least 800 to 1,000 units daily. Vitamin D intake is achieved through ...