The diagnosis of osteoporosis in adults aged 50 years and above can be in patients with a history of hip or clinical vertebral fracture not due to excessive trauma, those with existing vertebral fractures identified on the basis of a spinal imaging study alone (radiographic vertebral fractures), and those with a BMD at or below the cutoff value (i.e., ≥2.5 SDs below that of a young white woman). BMD should be measured at the hip and its subregions and the lumbar spine (posterior–anterior view of the L1–L4 vertebrae) using DXA. Measurement of BMD at the hip is preferred for diagnosing osteoporosis since it is a strong predictor of risk for nonvertebral fracture, including hip fracture. Measurements at the total hip and femoral neck subregion (but not those at Ward's area or greater trochanter subregions) should be used to make the diagnosis. Of note, spine BMD may increase with aging because of calcium deposition related to degenerative joint disease and abdominal aortic calcification.
BMD results on DXA are reported as T-scores and Z scores (see Box below). T-score should be reported in postmenopausal women and in men aged 50 years or older. It compares the patient's BMD with the average BMD in the young adult reference population and is the SD below or above the mean BMD for young adults. The reference group of young adults for calculation of total hip and femoral neck BMD T-scores in both men and women and individuals of all racial/ethnic groups should be non-Hispanic white women aged 20 –29 years from the Third National Health and Nutrition Examination Survey (NHANES III) (4). Because there is no internationally recommended reference group for lumbar spine measurements, the reference group for calculation of lumbar spine BMD T-scores should be the DXA manufacturer-specific reference database of young white women. BMD within 1 SD of this reference group is classified as normal BMD, 1.0 –2.5 SDs below that of a young white woman is considered to be osteopenia or low bone mass, and ≥2.5 SDs below that of a young white woman is defined as osteoporosis.
It is recommended that BMD Z scores are reported in premenopausal women and in men younger than 50 years. The Z score represents a comparison of the patient's BMD with average age-, sex-, and race-matched BMD and is the number of SDs below or above mean BMD for people of the same age, sex, and race.
When to consider laboratory testing to assess for underlying secondary causes or to determine whether consultation is necessary?
Although there is a lack of consensus regarding the clinical value of laboratory testing to identify secondary causes of osteoporosis, some organizations (3, 8, 12-13) recommend ordering laboratory tests in “patients with osteoporosis or high fracture risk” or “patients in whom a specific secondary, treatable cause of osteoporosis is being considered.” There are studies that have evaluated the value of laboratory evaluation for secondary causes of osteoporosis. However, several limitations have been identified, including a small sample size or data based on tertiary care patient populations (35-38). Consequently, the findings may not be extrapolated to patients seen in the primary care practice setting.
Measurement of 25-(OH)D levels is commonly recommended in osteoporotic patients. However, there is no evidence that vitamin D supplementation to achieve a target serum level (e.g 30 ng/mL) is superior to a more conservative approach (e.g., supplementation if needed to reach the RDA of 600 – 800 IU/d) in reducing risk for falls or fractures. The clinical utility of this measurement is likely to be greatest in patients with problems absorbing or metabolizing vitamin D.
Patients with suspected specific secondary causes of osteoporosis should be referred to subspecialists for further evaluation and management. Thus, referral to a gastroenterologist should be considered for those with suspected celiac disease or inflammatory bowel syndrome. Patients suspected of Cushing syndrome, hyperthyroidism, hyperparathyroidism, or hyperprolactinemia should be referred to an endocrinologist. Patients with suspected Paget disease of bone or autoimmune disease should be referred to a rheumatologist, those with possible systemic mastocytosis should be referred to an allergist/immunologist, and those with multiple myeloma or other types of cancer should be referred to a hematologist/oncologist.
This article is intended for medical professionals.
Dr Reshma Ramracheya
Diabetes UK RD Lawrence Research Fellow
Senior Research Fellow at Wolfson College
Investigator at Oxford Centre for Diabetes, Endocrinology & Metabolism
University of Oxford, UK
Reshma.ramracheya@ocdem.ox.ac.uk
Tel: 59111128
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