OSTEOPOROSIS:

DIAGNOSIS,
PREVENTION,
COMPLICATIONS
DIAGNOSIS
Risk Identification, Bone Mass Measurement, Routine
Laboratory Evaluations, Biochemical Markers of Bone
Turnover
  Assessment of clinical risk factors can improve identification of
individual patients who are more likely to suffer from vertebral
and non-vertebral fractures.
 The majority of fractures occur in postmenopausal women with T-
RISK scores that are better than −2.5.
 The age of the patient is the single most important contributor to
IDENTIFICATI fracture risk.
ON  The increased risk is similar in both men and women and is the
same as the risk of a first fracture in a woman who is 10 years
older.
 Half of patients will refracture within 10 years, and half of those
will occur within 2 years of the first fracture.
RISK
IDENTIFICATI
ON
  The FRAX index (http://www.shef.ac.uk/FRAX) estimates the
absolute risk of suffering a fracture in 10 years.
RISK  This calculator has been demonstrated to be extremely useful
IDENTIFICATI since it includes specific data obtained from major cohorts
worldwide.
ON  The Garvan tool (http://www.garvan.org.au/bone-fracture-risk)
includes history of previous falls in its algorithm.
RISK
IDENTIFICATI
ON
  Non-invasive techniques for estimating skeletal mass or density:
dual-energy x-ray absorptiometry (DXA), single-energy x-ray
absorptiometry (SXA), quantitative CT, and ultrasound (US).
 DXA is a highly accurate x-ray technique that has become the
standard for measuring bone density.
BONE MASS  Clinical determinations usually are made of the lumbar spine and
MEASUREME hip.

NT  In the DXA technique, two x-ray energies are used to estimate the
area of mineralized tissue, and the mineral content is divided by
the area, which partially corrects for body size.
 However, this correction is only partial because DXA is a two-
dimensional scanning technique and cannot estimate the depth or
posteroanterior length of the bone.
  T-scores (a T-score of 1 equals 1 SD), which compare individual
results to those in a young population that is matched for race and
sex.
 Z-scores (also measured in SD) compare individual results to those
of an age-matched population that also is matched for race and
BONE MASS sex.
MEASUREME  A T-score below –2.5 in the lumbar spine, femoral neck, or total
hip has been defined as a diagnosis of osteoporosis.
NT
BONE MASS
MEASUREME
NT
 Category T-Score
Range Examples
Normal Bone Density -1 and above +0.5
0
BONE MASS -1.0

MEASUREME Low Bone Density

(Osteopenia)
Between -1 and -2.5 -1.1
-1.5
NT
-2.4
Osteoporosis -2.5 and below -2.5
-3.0
-4.0
BONE MASS
MEASUREME
NT
  There is no established algorithm for the evaluation of women
who present with osteoporosis.
ROUTINE
 A general evaluation that includes complete blood count, serum
LABORATORY and 24-h urine calcium, renal and hepatic function tests, and a
25(OH)D level is useful for identifying selected secondary causes
EVALUATION of low bone mass, particularly for women with fractures or very
low Z-scores.
  Serum calcium level meningkat: hyperparathyroidism (PTH tinggi)
atau keganasan (PTH rendah)
 Serum calcium level menurun: malnutrisi dan osteomalacia

ROUTINE  Urine calcium rendah: osteomalacia, malnutrisi, malabsorpsi

 Urine calcium tinggi: renal calcium leak, absorptive hypercalciuria,
LABORATORY hematologic malignancies
EVALUATION  Individu yang mengalami patah tulang terkait osteoporosis atau
kepadatan tulang dalam kisaran osteoporosis harus memiliki
pengukuran tingkat serum 25(OH)D, karena asupan vitamin D
yang diperlukan untuk mencapai tingkat target >20-30 ng/mL
sangat bervariasi.
  Several biochemical tests are available that provide an index of
the overall rate of bone remodeling.
 Biochemical markers usually are characterized as those related
primarily to bone formation or bone resorption.
Biochemical  These tests measure the overall state of bone remodeling at a
Markers of single point in time.

Bone Turnover  Clinical use of these tests has been hampered by biologic
variability (in part related to circadian rhythm) as well as analytic
variability.
 C-telopeptide [CTX] is the preferred marker in measurement of
bone resorption.
Biochemical
Markers of
Bone Turnover
SCREENING AND
PREVENTION
  USPSTF recommends screening for osteoporosis in all women
65 years of age or older, and in younger women who have a risk
of osteoporotic fracture of at least that of a 65-year-old white
woman with no additional risk factors. Risk is determined using a
Screening and tool such as FRAX (http://www.shef.ac.uk/FRAX/).
 Screening for osteoporosis is done using a 2-site DEXA scan.
Prevention in  The USPSTF concluded that evidence was insufficient for
Osteoporosis recommending screening in men. However, the American College
of Physicians recommends screening men at increased risk (using
FRAX tool) and who are candidates for pharmacotherapy.
Recommendations from other organizations regarding screening
of men are highly variable.
  Methods to prevent osteoporosis include regular weight bearing
exercise, adequate dietary calcium and vitamin D, avoidance of
Screening and heavy alcohol use, avoidance of smoking, and avoidance of
Prevention in glucocorticoid therapy.
 Patients with a likely fragility fracture and those receiving long-
Osteoporosis term glucocorticoid therapy or other agents known to cause
osteoporosis should be screened for osteoporosis.
COMPLICATIONS
Fragility Fractures
  A fragility fracture is defined as a fracture that occurs as a result of
a low-energy force that is insufficient to break normal bone.
 The most common locations for these fractures are the spine, hip,
pelvis, proximal humerus, forearm, and wrist.
FRAGILITY  Hip fractures remain the most serious fragility fractures in terms
of morbidity and mortality; about half of these individuals never
FRACTURES regain their previous functional capacity.
 Vertebral compression fractures (VCFs) are very common in
patients with osteoporosis. Most cases occur in asymptomatic
patients. When symptomatic, a patient with a VCF experiences
acute onset of back pain with or without radiculopathy.
Harrison’s Principles of Internal Medicine
Hazzard’s Geriatric Medicine and Gerontology
Family Medicine: Ambulatory Care and Prevention
Osteoporosis and Its
Complications (Jurnal)
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