Osteoporosis

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Chapter 25 OSTEOPOROSIS

Theodore O’Connell

Primary osteoporosis results from deterioration of bone mass that is related to aging and decreased gonadal function but is not associated with any chronic illness. Because primary osteoporosis results from decreased gonadal function, early menopause or premenopausal estrogen deficiency may hasten the development of osteoporosis in women. Other risk factors for primary osteoporosis include female gender in general, white or Asian ancestry, sedentary lifestyle, tobacco use, low calcium intake, and low body weight.

Secondary osteoporosis results from chronic conditions that contribute to accelerated loss of bone density. Chronic conditions that may contribute to secondary osteoporosis include acromegaly, alcoholism, anorexia nervosa, chronic liver disease, diabetes mellitus type I, glycogen storage diseases, hemochromatosis, homocystinuria, hyperadrenocorticism, hyperparathyroidism, hyperprolactinemia, hypophosphatasia, malabsorption syndromes and gastric bypass surgery, Marfan syndrome, osteogenesis imperfecta, renal disease, thyrotoxicosis, and vitamin D deficiency.

Men are more likely than women to have a secondary cause of osteoporosis. In the patient with osteoporosis, initial evaluation should begin with a risk factor assessment (see risk factors listed later in this chapter), documentation of history, and a physical examination focusing on signs of chronic disease. If secondary osteoporosis is suspected on the basis of findings from the history and physical examination, a work-up should be performed.

Long-term glucocorticoid therapy is a common cause of osteoporosis. Medications that may cause osteoporosis are listed below.

Suggested Work-Up for Patients with Suspected Secondary Osteoporosis

Serum creatinine measurement	To evaluate for renal disease
Alanine transaminase (ALT) and aspartate transaminase (AST) measurement	To evaluate for liver disease
Alkaline phosphatase measurement	To evaluate for liver disease, Paget disease, or other bone pathologic processes
Albumin measurement	To evalvate for malnutrition
Serum calcium measurement	Decreased level may indicate malabsorption or vitamin D deficiency; increased level may indicate primary hyperparathyroidism or malignancy
Serum iron and ferritin measurements	Levels are increased with hemochromatosis
Serum phosphorus measurement	Decreased level may indicate osteomalacia
Thyroid-stimulating hormone (TSH) measurement	To evaluate for hyperthyroidism
Serum protein electrophoresis (SPEP), measurement of erythrocyte sedimentation rate (ESR), complete blood cell count (CBC), serum calcium measurement, parathyroid hormone (PTH) measurement	Abnormal SPEP, elevated ESR, anemia, hypercalcemia, and depressed parathyroid hormone level are suggestive of multiple myeloma
Estrogen level measurement	Decreased levels in premenopausal women are suggestive of hypogonadism
1,25-Hydroxyvitamin D measurement	Elevated levels occur with hyperparathyroidism
25-Hydroxycalciferol measurement	Decreased levels suggest vitamin D deficiency
24-hour urine calcium measurement	Decreased urinary calcium excretion is suggestive of malabsorption or vitamin D deficiency

Additional Work-Up

Dexamethasone suppression test	May be indicated when Cushing syndrome is suspected
Stool fat quantification or xylose breath test	Used when there is a history of gastrectomy or diarrhea to evaluate for malabsorption

FURTHER READING

Harper KD, Weber TJ. Secondary osteoporosis. Diagnostic considerations. Endocrinol Metab Clin North Am. 1998;27:325-348.

Kenny AM, Prestwood KM. Osteoporosis: pathogenesis, diagnosis, and treatment in older adults. Rheum Dis Clin North Am. 2000;26:569-591.

Simon LS. Osteoporosis. Clin Geriatr Med. 2005;21:603-629. viii

South-Paul JE. Osteoporosis: part I: evaluation and assessment. Am Fam Physician. 2001;63:897-904.

Tresolini CP, Gold DT, Lee LS, editors. Working with Patients to Prevent, Treat and Manage Osteoporosis: A Curriculum Guide for Health Professions, 2nd, San Francisco: National Fund for Medical Education, 1998.

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