Osteopenia

Last updated
Osteopenia
Other nameslow bone mass, low bone density
Specialty Rheumatology, Endocrinology
Complications development into osteoporosis

Osteopenia, preferably known as "low bone mass" or "low bone density", is a condition in which bone mineral density is low. Because their bones are weaker, people with osteopenia may have a higher risk of fractures, and some people may go on to develop osteoporosis. [1] In 2010, 43 million older adults in the US had osteopenia. [2] Women are at higher risk, particularly those with early menopause. Some symptoms, however, may be improved with menopause treatment.

Contents

There is no single cause for osteopenia, although there are several risk factors, including modifiable (behavioral, including dietary and use of certain drugs) and non-modifiable (for instance, loss of bone mass with age). For people with risk factors, screening via a DXA scanner may help to detect the development and progression of low bone density. Prevention of low bone density may begin early in life and includes a healthy diet and weight-bearing exercise, as well as avoidance of tobacco and alcohol. The treatment of osteopenia is controversial: non-pharmaceutical treatment involves preserving existing bone mass via healthy behaviors (dietary modification, weight-bearing exercise, avoidance or cessation of smoking or heavy alcohol use). Pharmaceutical treatment for osteopenia, including bisphosphonates and other medications, may be considered in certain cases but is not without risks. Overall, treatment decisions should be guided by considering each patient's constellation of risk factors for fractures.

Osteopenia exists on a spectrum of normal to dangerously low bone density (osteoporosis). Depiction of a woman suffering from Osteopenia.png
Osteopenia exists on a spectrum of normal to dangerously low bone density (osteoporosis).

Risk factors

Many divide risk factors for osteopenia into fixed (non-changeable) and modifiable factors. Osteopenia can also be secondary to other diseases. An incomplete list of risk factors: [3] [4] [5]

Bone density peaks at 35 and then decreases with age. 615 Age and Bone Mass.jpg
Bone density peaks at 35 and then decreases with age.

Fixed

Modifiable / behavioral

Other diseases

Medications

Screening and diagnosis

The ISCD (International Society for Clinical Densitometry) and the National Osteoporosis Foundation recommend that older adults (women over 65 and men over 70) and adults with risk factors for low bone mass, or previous fragility fractures, undergo DXA testing. [14] The DXA (dual X-ray absorptiometry) scan uses a form of X-ray technology, and offers accurate bone mineral density results with low radiation exposure. [15] [16]

The United States Preventive Task Force recommends osteoporosis screening for women with increased risk over 65 and states there is insufficient evidence to support screening men. [17] The main purpose of screening is to prevent fractures. Of note, USPSTF screening guidelines are for osteoporosis, not specifically osteopenia.

A DXA scanner in use. DEXA scanner in use ALSPAC.jpg
A DXA scanner in use.

The National Osteoporosis Foundation recommends use of central (hip and spine) DXA testing for accurate measure of bone density, emphasizing that peripheral or "screening" scanners should not be used to make clinically meaningful diagnoses, and that peripheral and central DXA scans cannot be compared to each other. [18]

DXA scanners can be used to diagnose osteopenia or osteoporosis as well as to measure bone density over time as people age or undergo medical treatment or lifestyle changes.

Information from the DXA scanner creates a bone mineral density T-score by comparing a patient's density to the bone density of a healthy young person. Bone density between 1 and 2.5 standard deviations below the reference, or a T-score between −1.0 and −2.5, indicates osteopenia (a T-score greater than or equal to −2.5 indicates osteoporosis). Calculation of the T-score itself may not be standardized. The ISCD recommends using Caucasian women between 20 and 29 years old as the baseline for bone density for ALL patients, but not all facilities follow this recommendation. [19] [20] [21] [14]

The ISCD recommends that Z-scores, not T-scores, be used to classify bone density in premenopausal women and men under 50. [22]

Prevention

Prevention of low bone density can start early in life by maximizing peak bone density. Once a person loses bone density, the loss is usually irreversible, so preventing (greater than normal) bone loss is important. [23]

Actions to maximize bone density and stabilize loss include: [24] [25] [26] [27]

Pharmaceutical treatment

The pharmaceutical treatment of osteopenia is controversial and more nuanced than well-supported recommendations for improved nutrition and weight-bearing exercise. [28] [29] [5] The diagnosis of osteopenia in and of itself does not always warrant pharmaceutical treatment. [30] [31] Many people with osteopenia may be advised to follow risk prevention measures (as above).

Risk of fracture guides clinical treatment decisions: the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) estimates the probability of hip fracture and the probability of a major osteoporotic fracture (MOF), which could occur in a bone other than the hip. [32] [33] In addition to bone density (T-score), calculation of the FRAX score involves age, body characteristics, health behaviors, and other medical history. [34]

As of 2014, The National Osteoporosis Foundation (NOF) recommends pharmaceutical treatment for osteopenic postmenopausal women and men over 50 with FRAX hip fracture probability of >3% or FRAX MOF probability >20%. [35] As of 2016, the American Association of Clinical Endocrinologists and the American College of Endocrinology agree. [36] In 2017, the American College of Physicians recommended that clinicians use individual judgment and knowledge of patients' particular risk factors for fractures, as well as patient preferences, to decide whether to pursue pharmaceutical treatment for women with osteopenia over 65. [37]

Pharmaceutical treatment for low bone density includes a range of medications. Commonly used drugs include bisphosphonates (alendronate, risedronate, and ibandronate)—some studies show that decreased fracture risk and increased bone density after bisphosphonate treatment for osteopenia. [38] Other medications include selective estrogen receptor modulators (SERMs) (e.g., raloxifene), estrogens (e.g., estradiol), calcitonin, and parathyroid hormone-related protein analogues (e.g., abaloparatide, teriparatide). [39]

These drugs are not without risks. [40] [41] In this complex landscape, many argue that clinicians must consider a patient's individual risk of fracture, not simply treat those with osteopenia as equally at risk. A 2005 editorial in the Annals of Internal Medicine states "The objective of using osteoporosis drugs is to prevent fractures. This can be accomplished only by treating patients who are likely to have a fracture, not by simply treating T-scores." [42]

History

Osteopenia, from Greek ὀστέον (ostéon), "bone" and πενία (penía), "poverty", is a condition of sub-normally mineralized bone, usually the result of a rate of bone lysis that exceeds the rate of bone matrix synthesis. See also osteoporosis.

In June 1992, the World Health Organization defined osteopenia. [43] [29] An osteoporosis epidemiologist at the Mayo Clinic who participated in setting the criterion in 1992 said "It was just meant to indicate the emergence of a problem", and noted that "It didn't have any particular diagnostic or therapeutic significance. It was just meant to show a huge group who looked like they might be at risk." [44]

See also

Related Research Articles

Osteoporosis Bone resorption disease characterized by the thinning of bone tissue and decreased mechanical strength

Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the vertebrae in the spine, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. After a broken bone, chronic pain and a decreased ability to carry out normal activities may occur.

Dual-energy X-ray absorptiometry

Dual-energy X-ray absorptiometry is a means of measuring bone mineral density (BMD) using spectral imaging. Two X-ray beams, with different energy levels, are aimed at the patient's bones. When soft tissue absorption is subtracted out, the bone mineral density (BMD) can be determined from the absorption of each beam by bone. Dual-energy X-ray absorptiometry is the most widely used and most thoroughly studied bone density measurement technology.

Pagets disease of bone

Paget's disease of bone is a condition involving cellular remodeling and deformity of one or more bones. The affected bones show signs of dysregulated bone remodeling at the microscopic level, specifically excessive bone breakdown and subsequent disorganized new bone formation. These structural changes cause the bone to weaken, which may result in deformity, pain, fracture or arthritis of associated joints.

Teriparatide

Teriparatide is a form of parathyroid hormone consisting of the first (N-terminus) 34 amino acids, which is the bioactive portion of the hormone. It is an effective anabolic agent used in the treatment of some forms of osteoporosis. It is also occasionally used off-label to speed fracture healing. Teriparatide is identical to a portion of human parathyroid hormone (PTH) and intermittent use activates osteoblasts more than osteoclasts, which leads to an overall increase in bone.

Alendronic acid

Alendronic acid, sold under the brand name Fosamax among others, is a bisphosphonate medication used to treat osteoporosis and Paget's disease of bone. It is taken by mouth. Use is often recommended together with vitamin D, calcium supplementation, and lifestyle changes.

Zoledronic acid

Zoledronic acid, also known as zoledronate, is a medication used to treat a number of bone diseases. These include osteoporosis, high blood calcium due to cancer, bone breakdown due to cancer, and Paget’s disease of bone. It is given by injection into a vein.

Bone density

Bone density, or bone mineral density (BMD), is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone, although clinically it is measured by proxy according to optical density per square centimetre of bone surface upon imaging. Bone density measurement is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk. It is measured by a procedure called densitometry, often performed in the radiology or nuclear medicine departments of hospitals or clinics. The measurement is painless and non-invasive and involves low radiation exposure. Measurements are most commonly made over the lumbar spine and over the upper part of the hip. The forearm may be scanned if the hip and lumbar spine are not accessible.

Quantitative computed tomography

Quantitative computed tomography (QCT) is a medical technique that measures bone mineral density (BMD) using a standard X-ray Computed Tomography (CT) scanner with a calibration standard to convert Hounsfield Units (HU) of the CT image to bone mineral density values. Quantitative CT scans are primarily used to evaluate bone mineral density at the lumbar spine and hip.

Relative energy deficiency in sport (RED-S) is a syndrome in which disordered eating, amenorrhoea/oligomenorrhoea, and decreased bone mineral density are present. It is caused by eating too little food to support the amount of energy being expended by an athlete, often at the urging of a coach or other authority figure who believes that athletes are more likely to win competitions when they have an extremely lean body type. RED-S is a serious illness with lifelong health consequences and can potentially be fatal.

Osteonecrosis of the jaw

Osteonecrosis of the jaw (ONJ) is a severe bone disease (osteonecrosis) that affects the jaws. Various forms of ONJ have been described over the last 160 years, and a number of causes have been suggested in the literature.

Denosumab

Denosumab is a human monoclonal antibody for the treatment of osteoporosis, treatment-induced bone loss, metastases to bone, and giant cell tumor of bone.

Strontium ranelate

Strontium ranelate, a strontium(II) salt of ranelic acid, is a medication for osteoporosis marketed as Protelos or Protos by Servier. Studies indicate it can also slow the course of osteoarthritis of the knee. The drug is unusual in that it both increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclasts. It is therefore promoted as a "dual action bone agent" (DABA).

Senile osteoporosis has been recently recognized as a geriatric syndrome with a particular pathophysiology. There are different classification of osteoporosis: primary, in which bone loss is a result of aging and secondary, in which bone loss occurs from various clinical and lifestyle factors. Primary, or involuntary osteoporosis, can further be classified into Type I or Type II. Type I refers to postmenopausal osteoporosis and is caused by the deficiency of estrogen. While senile osteoporosis is categorized as an involuntary, Type II, and primary osteoporosis, which affects both men and women over the age of 70 years. It is accompanied by vitamin D deficiency, body's failure to absorb calcium, and increased parathyroid hormone.

Medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw is progressive death of the jawbone in a person exposed to a medications known to increase the risk of disease, in the absence of a previous radiation treatment. It may lead to surgical complication in the form of impaired wound healing following oral and maxillofacial surgery, periodontal surgery, or endodontic therapy.

FRAX is a diagnostic tool used to evaluate the 10-year probability of bone fracture risk. It was developed by the University of Sheffield. FRAX integrates clinical risk factors and bone mineral density at the femoral neck to calculate the 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture. The models used to develop the FRAX diagnostic tool were derived from studying patient populations in North America, Europe, Latin America, Asia and Australia.

Abaloparatide is a parathyroid hormone-related protein (PTHrP) analog drug used to treat osteoporosis. Like the related drug teriparatide, and unlike bisphosphonates, it is an anabolic agent.

The trabecular bone score is a measure of bone texture correlated with bone microarchitecture and a marker for the risk of osteoporosis. Introduced in 2008, its main projected use is alongside measures of bone density in better predicting fracture risk in people with metabolic bone problems.

Eldecalcitol

Eldecalcitol is a drug used in Japan for the treatment of osteoporosis. It is an analog of vitamin D. Osteoporosis is a common bone disease among the older generation, with an estimated prevalence of over 200 million people. This condition often results in bone fractures due to abnormally low bone mass density, and is a leading cause of disability, especially among developed countries with longer average life spans. Osteoporosis is more common in women than with men.

Dual X-ray absorptiometry and laser technique (DXL) in the area of bone density studies for osteoporosis assessment is an improvement to the DXA Technique, adding an exact laser measurement of the thickness of the region scanned. The addition of object thickness adds a third input to the two x-ray energies used by DXA, better solving the equation for bone and excluding more efficiently these soft tissues components.

Radiofrequency Echographic Multi Spectrometry Medical diagnostic

Radiofrequency Echographic Multi Spectrometry (R.E.M.S.) is an innovative, non-ionizing technology for osteoporosis diagnosis and for fracture risk assessment. R.E.M.S. processes the raw, unfiltered ultrasound signals acquired during an echographic scan of the axial sites, femur and spine. The analysis is performed in the frequency domain and it is based on the comparison of the spectra obtained from the patient under examination with a series of spectral reference models, a process which allows the estimation of bone mineral density (BMD). The accuracy of this technology for BMD estimation and fracture risk evaluation has been validated in different clinical studies by comparing R.E.M.S. to DXA technology, currently considered the Gold Standard for bone mass evaluation, which partially measures bone strength.

References

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