Osteoporotic fracture

All postmenopausal women with a personal history of osteoporotic fracture and/or low bone mineral density with risk factors for osteoporosis should receive treatment for osteoporosis. 

Many of the risk factors for osteoporosis and osteoporotic fractures are predictors of low bone mineral density, such as age and ethnicity (Table 53-1). The most important risk factors for fracture are low bone mineral density, personal history of adult fracture, age, and family history of osteoporotic fracture. Other important risk factors for osteoporosis and osteoporotic fractures include menopausal status, smoking status, and low body weight. As bone mineral density decreases, the risk of fracture increases. However, the threshold at which individual patients develop a fracture varies, and other factors may play a role in fracture susceptibility. One such factor that can influence the development of fracture is falling. 

Father died at age 85 with Alzheimer s dementia mother died at age 86 with history of colon cancer and osteoporotic fractures of the hip and spine brother alive and well at age 71. SH... 

Treatment decisions regarding initiation of therapy for osteoporosis can be complex. Patients meeting criteria for osteoporosis (T-score below -2.5) or other high-risk patients with a history of osteoporotic fracture gain significant benefit from treatment. Drug therapy should be initiated in these patients. 

Assess patient risk factors for osteoporosis, with special attention to age, menopausal status, previous history of osteoporotic fracture, smoking status, low body weight, family history of osteoporotic fracture in first-degree relatives, and presence of secondary causes of osteoporosis. 

Assess nonpharmacologic interventions for preventing osteoporotic fractures, including nutrition, weightbearing and muscle-strengthening exercise regimens, and fall risk. 

Educate the patient about nonpharmacologic measures to prevent osteoporotic fractures. 

Bauer, D. C., Browner, W. S., Cauley, J. A., Orwoll, E. S., Scott, J. C., Black, D. M., Tao, J. L., Cummings, S. R., Factors associated with appendicular bone mass in older women. The study of osteoporotic fractures research group, University of California, San Francisco., Annals of Internal Medicine, 118, 741, 1993. 

Major risk factors include current smoker, low body weight (<127 lb in postmenopausal women), history of osteoporotic fracture in a first-degree relative, and personal history of low-trauma fracture as an adult. Other independent risk factors include age, high bone turnover, low body mass index (<19 kg/m2), rheumatoid arthritis, and glucocorticoid use. Decision tools may help identify individuals who should undergo BMD testing, such as the Osteoporosis Risk Assessment Instrument and the Simple Calculated Osteoporosis Risk Estimation. 

Goals in patients who have already suffered osteoporotic fractures include reducing future falls and fractures, improving functional capacity, reducing pain and deformity, and improving quality of life. 

Teriparatide is FDA approved for postmenopausal women and men who are at high risk for fracture. Candidates for therapy include patients with a history of osteoporotic fracture, multiple risk factors for fracture, very low bone density (e.g., T-score <—3.5), or those who have failed or are intolerant of previous bisphosphonate therapy. 

Chesnut III CH, Silverman S, Andriano K, Genant H, Gimona A, Harris S, Kiel D (2000) A randomised trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis the prevent recurrence of osteoporotic fractures study. Am J Med 109 267-276... 

Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, Genant HK (1993) Bone density at various sites for prediction of hip fractures. The study of osteoporotic fractures research group. Lancet 341 72-75... 

Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. Br Med J 312 1254-1259... 

Cauley J, Lucas FL, Kuller LH et al. (1996) Bone mineral density and risk of breast cancer in older women the study of osteoporotic fractures. J Am Med Assoc 276 1404-1408... 

Osteoporosis is a world wide problem with consequences for both the individual affected and society as a whole. Osteoporosis affects an estimated 75 million people in Europe, USA and Japan. The estimated cost for the treatment of osteoporosis in the world is 18.3 billion dollars a year. Hip, vertebrae and wrist are the most frequent sites for osteoporotic fractures. Due to the increase in the population over 60 years of age this scenario is about to escalate and regarding one of the most serious fractures, the hip fracture, an increase with more than 200% is likely to occur. Today, approximately 1.6 million hip fractures happen yearly in the world and, in the nearest forty to fifty years, this number can increase to about 5 million. The risk of hip fractures is highest in Norway, Iceland, Sweden, Denmark and the United States (NIH 2000). 

Osteoporosis is in many ways a silent disease and osteoporotic fractures occurs mainly in women, the ratio being 1.6 females to 1 male. There are many risk factors that have been identified as increasing the development of osteoporosis and age, sex and life styles factors are some (Box 5.13)... 

Colledge NR, Wilson 1A, Macintyre CC et al. (1994) The prevalence and characteristics of dizziness in an elderly community. Age Ageing 23(2) 117-120 The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. (1996) Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 46(5) 1470 Cooper C, Atkinson El, lacobsen SI et al. (1993) Population-based study of survival after osteoporotic fractures. Am 1 Epidemiol 137(9) 1001-1005 Cummings SR and Melton LI (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319) 1761-1767... 

Prince, R. L., Dick, I. M., Lemmon, J., and Randell, D. (1997). The pathogenesis of age-related osteoporotic fracture Effects of dietary calcium deprivation. /. Clin. Endocrinol. Metab. 82, 260-264. 

Non-compliance is a serious problem in the prevention of osteoporosis and osteoporotic fractures. This is due to adverse effects, lack of noticeable benefit and ignorance. It is difficult to convince regular intake of oral calcium, biphosphonates, vitamin D and in post-menopausal women hormone replacement. Long-term compliance to hormone replacement is worse in developing countries. The most cost-effective therapy for osteoporosis is primary prevention. 

Baltzan MA, Suissa S, Bauer DC, Cummings SR. Hip fractures attributable to corticosteroid use. Study Osteoporotic Fractures Group. Lancet 1999 353(9161) 1327. 

Musgrave DS, Vogt MT, Nevitt MC, Cauley JA. Back problems among postmenopausal women taking estrogen replacement therapy the study of osteoporotic fractures. Spine 2001 26(14) 1606-12. 

Since both raloxifene and the non-hormonal drug alendronate reduce the incidence of osteoporotic fractures in postmenopausal women it is relevant to determine which approach is better tolerated and thus most likely to promote long-term adherence to therapy. Adverse effects and compliance have been studied in a direct randomized comparison over 12 months in 902 women attending 154 treatment centres in Spain (21). They took either raloxifene 60 mg/day or alendronate 10 mg/day. Those who took raloxifene reported significantly better compliance than those who took alendronate more patients discontinued alendronate prematurely than raloxifene (26% versus 16%. The main reason for premature discontinuation was adverse reactions, particularly gastrointestinal reactions (9.9% with alendronate, 3.4% with raloxifene). 

However, signatures of susceptibility to osteoporotic fracture have been identified in osteoporotic tissue matched for bone volume fraction. Fracture is associated with more carbonated mineral [55], which is in turn associated with... 

Zizic TM. Pharmacologic prevention of osteoporotic fractures. Am Fam Physician. 2004 70 1293-1300. 

Col NF, Bowlby LA, McGarry K. The role of menopausal hormone therapy in preventing osteoporotic fractures a critical review of the clinical evidence. Minerva Med. 2005 96 331-342. 

Cooper C, Javaid MK, Taylor P, Walker-Bone K, Dennison E, Arden N (2002) The fetal origins of osteoporotic fracture. Calcif Tissue Int, 70 391-394. 

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