Understanding Osteoporosis: A Comprehensive Patient Guide to Prevention and Treatment

Osteoporosis is a serious bone disease affecting millions, often going unnoticed until a fracture occurs. This guide translates the latest 2022 clinical recommendations into clear, actionable information for patients. It covers who should be screened, how osteoporosis is diagnosed, the full range of treatment options, and why consistent management is crucial for preventing debilitating fractures that can lead to disability and premature death.

Table of Contents

• The Impact and Overview of Osteoporosis
• How Widespread is This Problem?
• The Crisis in Osteoporosis Patient Care
• The Medical Impact of Fractures
• The Economic Toll of Osteoporosis
• Understanding How Osteoporosis Develops
• Universal Recommendations for All Patients
• Diagnostic Testing and Assessment
• Medication Treatment Recommendations
• Monitoring Patients and Treatment Response
• Source Information

The Impact and Overview of Osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and worldwide. It's often called a "silent disease" because it typically shows no symptoms until a fracture occurs. The condition is characterized by low bone density, deterioration of bone tissue, disrupted bone microarchitecture, compromised bone strength, and increased fracture risk.

According to the World Health Organization (WHO) diagnostic classification, osteoporosis is defined by a bone mineral density (BMD) measurement at the hip or lumbar spine that is less than or equal to 2.5 standard deviations below the mean BMD of a young adult reference population (known as a T-score of -2.5 or lower).

Think of osteoporosis as a risk factor for fracture, similar to how hypertension is a risk factor for stroke or high cholesterol is for heart disease. While risk is highest in people with extremely low BMD, the majority of fractures actually occur in patients with T-scores better than -2.5. Non-BMD factors also contribute significantly to fracture risk, including falls, frailty, and poor bone quality that isn't fully captured by density measurements alone.

How Widespread is This Problem?

Osteoporosis affects an enormous number of people—both men and women of all racial and ethnic backgrounds. Among Caucasian adults in the USA aged 50 years and older, approximately 50% of women and 20% of men will experience an osteoporotic fracture in their remaining lifetime.

Fracture rates differ significantly across ethnic and racial populations and by skeletal site:

• For fracture at any site in women, after adjusting for BMD, weight, and other factors, non-Hispanic white and Hispanic-American women have the highest risk for fracture
• This is followed by Native Americans, African Americans, and Asian Americans
• For hip fracture in men, age-adjusted incidence was highest for non-Hispanic white men
• Rates were similar among Hispanic-American and black men, and lowest in Asian men

In a 2014 analysis of data from five large cohorts, prevalence of self-reported non-traumatic fracture in men was:

• Non-Hispanic white American: 17.1%
• African American: 15.1%
• Hispanic-American: 13.7%
• Asian American: 10.5%
• Afro-Caribbean: 5.5%
• Hong Kong Chinese: 5.6%
• Korean: 5.1%

Based on data from the National Health and Nutrition Examination Survey III (NHANES III), it's estimated that more than 10.2 million Americans have osteoporosis and an additional 43.4 million have low bone density. The current projection is that 12.3 million Americans have osteoporosis.

At present, the 2 million new cases of osteoporotic fracture per year exceeds the annual number of new cases of myocardial infarction (heart attack), breast cancer, and prostate cancer combined. Annual fracture incidence is expected to increase 68%, to 3.2 million by 2040.

The Crisis in Osteoporosis Patient Care

Despite effective treatments, osteoporosis remains significantly underdiagnosed and undertreated. This is particularly concerning given the potentially lethal consequences of fractures. Hip fractures significantly increase risk of death in the year following fracture and are highly predictive of additional fractures.

Shockingly, as many as 80-95% of patients in some practice settings are discharged following hip fracture repair with no antifracture treatment or management plan. This represents a major gap in patient care.

The benefits of timely diagnosis and treatment have been well documented. Treatment reduces fracture incidence, forestalling injury, disability, and excess mortality. Medicare claims analyses demonstrate a significant drop in age-adjusted risk for hip fracture between 2002 and 2012—a decade-long decline that coincided with the advent of bone density testing and application of effective osteoporosis therapies.

However, after declining for decades, incidence rates plateaued between 2013 and 2015. Multiple factors have likely contributed to this troubling trend. In the USA, patient access to osteoporosis care has declined with fewer office-based DXA facilities performing smaller numbers of DXA studies. Fewer women and men are being diagnosed with osteoporosis and/or treated to prevent fractures.

The osteoporosis treatment gap—the difference between the number of people who meet treatment indications and those actually receiving treatment—is recognized globally as a crisis in patient care. Since many factors contribute to this crisis, multifaceted approaches are needed to reverse the trend.

The Medical Impact of Fractures

Fractures and their complications are the clinical consequences of osteoporosis. The most common fractures are those of the vertebrae (spine), proximal femur (hip), and distal forearm (wrist). Most fractures in older adults are due at least in part to low bone mass, even when they result from considerable trauma.

All fractures are associated with some degree of low BMD and increased risk of subsequent fracture in older adults. In fact, a large cohort study found high-trauma and low-trauma fractures to be comparably predictive of low BMD and elevated future fracture risk.

A recent fracture at any major skeletal site in an adult 50 years or older should be considered a sentinel event that indicates urgent need for further assessment and treatment. Fractures of fingers, toes, face, and skull are not typically considered osteoporotic fractures since they are usually traumatic and unrelated to bone fragility.

Fractures may be followed by full recovery or by chronic pain, disability, and premature death. Hip, vertebral, and distal radius fractures lead to a substantial reduction in quality of life, with the greatest hardship among hip fracture patients. Low-energy fractures of the pelvis and/or humerus are common in people with osteoporosis and contribute to increased illness and death rates.

Psychosocial symptoms, most notably depression and loss of self-esteem, are common consequences of fracture as patients grapple with pain, physical limitations, and loss of independence.

Hip Fractures

Hip fractures are associated with 8.4-36% excess mortality at 1 year, with higher mortality in men than in women. Hip fracture can have devastating impacts on a patient's life. Approximately 20% of hip fracture patients require long-term nursing home care, and 60% do NOT fully regain pre-fracture independence. Hip fractures are also associated with a 2.5-fold increased incidence of secondary fractures.

Vertebral Fractures

Although the majority of vertebral fractures are subclinical (without obvious symptoms), they can cause pain, disability, deformity, and premature death. Pain and postural changes associated with multiple vertebral compression fractures (kyphosis) can limit mobility and independent function, resulting in significantly diminished quality of life.

Multiple thoracic fractures can cause restrictive lung disease. Lumbar fractures can alter abdominal anatomy, leading to constipation, abdominal pain, early satiety (feeling full quickly), and weight loss. Vertebral fractures, whether clinically apparent or silent, are associated with a 5-fold increased risk for additional vertebral fractures and a 2-to 3-fold increased risk for fractures at other sites.

Wrist Fractures

Wrist fractures are five times more common in women than men. They tend to occur earlier in life than other fractures (typically between 50 and 60 years of age). When wrist fractures are recognized as evidence of bone fragility and appropriate osteoporosis treatment is prescribed, future fractures could be avoided.

While less disabling than hip or vertebral fractures, wrist fractures can be equally detrimental to quality of life, causing pain and limiting activities necessary for independent living. Wrist fractures are strongly predictive of future fractures, as demonstrated in longitudinal studies of women and men.

Among recipients of Medicare, increased risk of other fractures following a wrist fracture (regardless of BMD) is comparable to risk following hip or spine fracture in the year after the initial event. Unfortunately, rates of evaluation and treatment for osteoporosis after wrist fractures are low in women and even lower in men.

In one prospective, randomized study, seventy-nine percent of adult male wrist fracture patients did not receive a bone density test following fracture repair. This is significant because patients who received BMD measurement were more likely to be prescribed effective antifracture therapy.

The Economic Toll of Osteoporosis

The personal and economic costs of fractures are enormous. Fractures result in more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions in the US each year. Annual fracture-related costs are expected to increase from $57 billion to over $95 billion by 2040.

This heavy financial burden could be significantly reduced with routine use of effective treatments and screenings, including vertebral fracture assessment (VFA) in women aged 65 and older with osteopenia (T-score of -1.0 or lower).

Understanding How Osteoporosis Develops

The human skeleton is comprised of living tissue that constantly remodels itself. Critical to skeletal strength is the continuous process of bone resorption (breakdown) and bone formation. In healthy bone, these processes are balanced. In osteoporosis, bone resorption exceeds formation, resulting in net bone loss over time.

Continued removal of bone tissue degrades skeletal microarchitecture, thereby elevating risk for fractures that occur spontaneously or from minimal trauma.

The Skeletal Lifecycle

During childhood and adolescence, bones undergo a process called modeling, during which new bone is formed at one site and old bone is removed from another site within the same bone. This process enables individual bones to develop in size, shape, and position. Childhood and adolescence are critical periods of skeletal development.

This is particularly important for girls, who acquire 40-50% of their total bone mass during early teen years. During rapid skeletal growth, it takes several months to mineralize the protein scaffolding for new bone (called osteoid). This lag between formation and mineralization produces periods of relatively low bone density and increased propensity to fracture, particularly between ages 10 and 14 years.

In the early 20s, fracture rates level off with attainment of peak bone mass. Mineral density stabilizes in most adults by their early 40s, when it begins a gradual decline that accelerates at menopause in women (approximately 2% per year for the 10 years following menopause). Age-related bone loss thins trabecular bone and increases cortical porosity, creating the preconditions for future fragility and fractures.

Genetic factors appear to account for 60-80% of total adult bone mass. Substantial contributions are made by multiple modifiable factors that include nutrition, physical activity, smoking, chronic illness, and bone-damaging medications. Suboptimal bone acquisition is associated with fracture earlier in adulthood. Conversely, high peak adult bone mass, all other things being equal, protects against osteoporosis later in life.

Bone Remodeling

The skeleton responds dynamically to hormonal, mechanical, and pharmacologic stimuli through the resorption and formation processes of bone remodeling, or turnover. After growth plate closure, the skeleton repairs damage through bone remodeling, which occurs on bone surfaces throughout the skeleton.

The majority of bone surface area resides in trabecular bone, the resilient bony latticework predominantly found at the ends of long bones and in vertebral bodies. This architecture provides maximum strength with minimal weight but offers numerous surfaces where bone breakdown can occur.

Universal Recommendations for All Patients

These recommendations apply to postmenopausal women and men aged 50 years and older:

• Healthcare providers should counsel individual patients on their risk for osteoporosis, fractures, and potential consequences of fractures (functional deterioration, loss of independence, increased mortality)
• Recommend a diet with adequate total calcium intake: 1000 mg/day for men aged 50-70 years; 1200 mg/day for women 51 years and older and men 71 years and older, incorporating calcium supplements if dietary intake is insufficient
• Monitor serum 25-hydroxyvitamin D levels and maintain vitamin D sufficiency (≥ 30 ng/mL but below ≤50 ng/mL)
• Prescribe supplemental vitamin D (800-1000 units/day) as needed for individuals aged 50 years and older to achieve a sufficient vitamin D level (higher doses may be necessary in some adults, especially those with malabsorption)
• Identify and address modifiable risk factors associated with falls, such as sedating medications, multiple medication use, low blood pressure, gait or vision disorders, and out-of-date prescription glasses
• Provide guidance for smoking cessation, and avoidance of excessive alcohol intake; refer for specialized care as appropriate
• Counsel or refer patients for instruction on balance training, muscle-strengthening exercise, and safe movement strategies to prevent fracture(s) in activities of daily life
• In community-dwelling patients, refer for at-home fall hazard evaluation and remediation
• In post-fracture patients who are experiencing pain, prescribe over-the-counter pain relief, heat/ice home care, limited bed rest, physical therapy, and alternative non-pharmacologic therapies when appropriate
• In cases of intractable or chronic pain, refer to a pain specialist or physiatrist (rehabilitation physician)
• Coordinate post-fracture patient care via fracture liaison service (FLS) and multidisciplinary programs in which patients with recent fractures are referred for osteoporosis evaluation and treatment, rehabilitation, and transition management

Diagnostic Testing and Assessment

Specific recommendations for diagnostic assessment include:

• Investigate any broken bone in adulthood as suspicious for osteoporosis, regardless of cause
• Measure height annually, preferably with a wall-mounted stadiometer (without shoes)
• Record history of falls
• Perform BMD (bone mineral density) testing in the following situations:
  • Women aged 65 years and older and men aged 70 years and older
  • Postmenopausal women and men aged 50-69 years, based on risk profile
  • Postmenopausal women and men aged 50 years and older with history of adult-age fracture
  • At DXA facilities that employ accepted quality assurance measures
  • At the same facility and on the same densitometry device for each test whenever possible
• Maintain diagnosis of osteoporosis in patient diagnosed by fracture in adulthood or T-score (-2.5 or below), even if subsequent DXA T-score is above -2.5
• To detect subclinical vertebral fractures, perform vertebral fracture imaging (X-ray or DXA vertebral fracture assessment) in the following:
  • Women aged 65 years and older if T-score is less than or equal to -1.0 at the femoral neck
  • Women aged 70 years or older and men aged 80 years or older if T-score is less than or equal to -1.0 at the lumbar spine, total hip, or femoral neck
  • Men aged 70-79 years if T-score is less than or equal to -1.5 at the lumbar spine, total hip, or femoral neck
  • Postmenopausal women and men aged 50 years and older with specific risk factors including:
    • Fracture(s) during adulthood (any cause)
    • Historical height loss of ≥1.5 inches (difference between current height and peak height)
    • Prospective height loss of ≥0.8 inches (difference between current height and last documented height measurement)
    • Recent or ongoing long-term glucocorticoid (steroid) treatment
    • Diagnosis of hyperparathyroidism
• Rule out secondary causes of bone loss, osteoporosis, and/or fractures
• In appropriate untreated postmenopausal women, selectively measure bone turnover markers to help gauge rapidity of bone loss
• Prior to elective orthopedic procedures, evaluate skeletal health and measure BMD as indicated by risk profile (e.g., inflammatory arthritis, osteoarthritis, chronic kidney disease, or adverse events from surgery or other risk factors)

Medication Treatment Recommendations

Treatment recommendations include:

• No uniform recommendation applies to all patients—management plans must be individualized
• Current FDA-approved pharmacologic options for osteoporosis include:
  • Bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid)
  • Estrogen-related therapy (ET/HT, raloxifene, conjugated estrogens/bazedoxifene)
  • Parathyroid hormone analogs (teriparatide, abaloparatide)
  • RANK-ligand inhibitor (denosumab)
  • Sclerostin inhibitor (romosozumab)
  • Calcitonin salmon
• Consider initiating pharmacologic treatment in postmenopausal women and men 50 years of age and older who have:
  • For primary fracture prevention:
    • T-score ≤ -2.5 at the femoral neck, total hip, lumbar spine, or 33% radius by DXA
    • Low bone mass (osteopenia: T-score between -1.0 and -2.5) at the femoral neck or total hip by DXA with a 10-year hip fracture risk ≥ 3% or a 10-year major osteoporosis-related fracture risk ≥ 20% based on the US-adapted FRAX® model
  • For secondary fracture prevention:
    • Fracture of the hip or vertebra regardless of BMD
    • Fracture of proximal humerus, pelvis, or distal forearm in persons with low bone mass (osteopenia: T-score between -1.0 and -2.5)
    • The decision to treat should be individualized in persons with a fracture of the proximal humerus, pelvis, or distal forearm who do not have osteopenia or low BMD
• Initiate antiresorptive therapy following discontinuation of denosumab, teriparatide, abaloparatide, or romosozumab

Monitoring Patients and Treatment Response

Recommendations for monitoring include:

• Perform BMD testing 1 to 2 years after initiating or changing medical therapy for osteoporosis and at appropriate intervals thereafter according to clinical circumstances
• More frequent BMD testing may be warranted in higher-risk individuals (multiple fractures, older age, very low BMD)
• Less frequent BMD testing may be warranted as follow-up for patients with initial T-scores in the normal or slightly below normal range (osteopenia) and for patients who have remained fracture-free on treatment
• In patients receiving osteoporosis pharmacologic treatment:
  • Routinely reassess risk for fracture, patient satisfaction and adherence with therapy, and need for continued or modified treatment (the appropriate interval differs with each medication)
  • Serially measure changes in BMD at lumbar spine, total hip, or femoral neck; if lumbar spine, hip, or both are not evaluable, consider monitoring at 33% distal radius
  • Reassess patient and BMD status for consideration of a drug holiday after 5 years of oral and 3 years of intravenous bisphosphonate in patients who are no longer at high risk of fracture (T-score ≥ -2.5, no new fractures)
  • At each healthcare encounter, ask open-ended questions about treatment to elicit patient feedback on possible side effects and concerns
  • Communicate risk-benefit trade-offs and confirm understanding: both the risk of adverse events with treatment (usually very low) and risk of fractures and their negative consequences without treatment (usually much higher)

Source Information

Original Article Title: The clinician's guide to prevention and treatment of osteoporosis

Authors: M.S. LeBoff, S.L. Greenspan, K.L. Insogna, E.M. Lewiecki, K.G. Saag, A.J. Singer, E.S. Siris

Publication: Osteoporosis International (2022) 33:2049–2102

DOI: https://doi.org/10.1007/s00198-021-05900-y

This patient-friendly article is based on peer-reviewed research and represents a comprehensive translation of the original clinical guidelines for educational purposes. Always consult with your healthcare provider for personalized medical advice.