Osteoporosis natural history, complications and prognosis: Difference between revisions

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==Overview==
==Overview==
[[Osteoporosis]] can be complicated by the development of [[fractures]].  The prognosis is generally good and mortality from the disease will depend on the the type of fracture.  The major type of fractures contributing to mortality in these patients are [[vertebral fractures]] and [[hip fractures]].
If left untreated, most of the patients with osteoporosis develop [[fracture|fractures]]. With the appropriate and timely usage of [[medications]] along with [[calcium]] and/or [[vitamin D]] supplementation, the outcome of osteoporosis is usually good. Apart from the risk of death and other complications, osteoporotic [[fractures]] are associated with [[deep venous thrombosis]], [[kyphosis]], and a reduced [[quality of life]] due to [[immobility]].


==Natural history==
==Natural History, Complications, and Prognosis==
* Typically, symptoms of [[osteoporosis]] are developed in the sixth decade of life. The risk of getting [[osteoporosis]] is increased proportionately with age.
* Researchers have shown that relationship between lowering bone density of spine and age is not linear, but quadratic; in which bone loss tailing off when age raised. During the first years of post-menopausal period, women would have a fast decrease in bone density of spine by rate of 3.12% annually; then the rate slowed down to 0.02% per square age increased.<ref name="pmid18305885">{{cite journal| author=Zhai G, Hart DJ, Valdes AM, Kato BS, Richards JB, Hakim A et al.| title=Natural history and risk factors for bone loss in postmenopausal Caucasian women: a 15-year follow-up population-based study. | journal=Osteoporos Int | year= 2008 | volume= 19 | issue= 8 | pages= 1211-7 | pmid=18305885 | doi=10.1007/s00198-008-0562-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18305885  }}</ref>
* However, Guthrie also mentioned that in first 3 years after menopause, the rate of decreasing bone density increased annually; then with years past from menopause, the rate of bone loss will slow down.<ref name="pmid9797914">{{cite journal |vauthors=Guthrie JR, Ebeling PR, Hopper JL, Barrett-Connor E, Dennerstein L, Dudley EC, Burger HG, Wark JD |title=A prospective study of bone loss in menopausal Australian-born women |journal=Osteoporos Int |volume=8 |issue=3 |pages=282–90 |year=1998 |pmid=9797914 |doi=10.1007/s001980050066 |url=}}</ref> 
* One another major factor that directly impact on changing BMD is body weight; women with heavier weight and also higher body mass index (BMI) may have more change in their BMD in both hip and lumbar spine, during the time.
* Surprisingly, the bone site is an important factor to determine the measure of bone loss. The studies have found that magnitude of bone density loss is higher at spine (-3.12% annually) compared to femoral neck (1.67% annually). The main proposed theory for the phenomenon is "different effect of estrogen deficiency on different bone sites". On the other hand it may show the preventive effect of weight bearing on hip osteoporosis.<ref name="pmid18305885" />


* The outcome is usually good with appropriate and timely usage of medications and with [[calcium]] and / or [[vitamin D]] supplementation. Persons who are elderly, who are taking medications which deplete calcium, who are thin or of Caucasian or asian race and female, are at higher risk for osteoporosis. Having osteopenia, which is decreased mineral bone density, is also a risk factor for osteoporosis.
=== Natural history ===
*Symptoms of [[osteoporosis]] typically develop in the sixth decade of life. 
*The risk of [[osteoporosis]] increases proportionately with age.<ref name="pmid9797914">{{cite journal |vauthors=Guthrie JR, Ebeling PR, Hopper JL, Barrett-Connor E, Dennerstein L, Dudley EC, Burger HG, Wark JD |title=A prospective study of bone loss in menopausal Australian-born women |journal=Osteoporos Int |volume=8 |issue=3 |pages=282–90 |year=1998 |pmid=9797914 |doi=10.1007/s001980050066 |url=}}</ref>
*Another major factor that directly affects [[Bone mineral density|BMD]] is [[body weight]]. Women with increased body weight and [[Body mass index|body mass index (BMI)]] have more changes in their [[Bone mineral density|BMD]] in both [[hip]] and [[lumbar spine]] as they age.
*[[Bone]] site is an important factor to determine the measure of [[bone]] loss. The magnitude of [[bone density]] loss is higher at the spine (-3.12% annually) compared to the [[femoral neck]] (1.67% annually). The main proposed theory for the phenomenon is "different effect of [[estrogen]] deficiency on different [[bone]] sites".  


==Complications==
* With the appropriate and timely usage of [[medications]] along with [[calcium]] and/or [[vitamin D]] supplementation, the outcome of [[osteoporosis]] is usually good. But if the disease is left untreated, or not treated optimally, osteoporosis results in [[Fractures|fracture]] leading to increased morbidity and mortality.
* The major probable complications of osteoporosis include:
* [[Vertebral]] [[fracture|fractures]] are more common and affect the quality of life more significantly.<ref name="pmid9102060">{{cite journal |vauthors=Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Liberman U, Minne H, Reeve J, Reginster JY, de Vernejoul MC, Wiklund I |title=Quality of life as outcome in the treatment of osteoporosis: the development of a questionnaire for quality of life by the European Foundation for Osteoporosis |journal=Osteoporos Int |volume=7 |issue=1 |pages=36–8 |year=1997 |pmid=9102060 |doi= |url=}}</ref>
** [[Fractures]]: hip and lumbar spine are among the most frequent sites of fracture.
 
{| align="center"
===Complications===
|+ '''Pathologic fractures'''
The major complications of [[osteoporosis]] include:
* [[Fractures]]: [[hip]] and [[lumbar]] spine are among the most frequent sites of [[fracture]].
* [[DVT|Deep venous thrombosis (DVT)]]: It can be caused by prolonged [[immobility]].
* [[Kyphosis]] (Dowager's hump): Due to decreased height of anterior aspect of [[cervical]] [[vertebrae]] body (wedge shape).
* [[Restrictive lung disease]]: Due to decreased [[thoracic]] space, due to [[vertebrae|vertebral]] compression.
 
* Apart from the risk of death and other complications, osteoporotic [[Bone fracture|fractures]] are associated with a reduced [[quality of life]] due to [[immobility]] and other emotional problems resulting from osteoporosis.<ref>{{cite journal |author=Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris ES |title=Impact of recent fracture on health-related quality of life in postmenopausal women |journal=J. Bone Miner. Res. |volume=21 |issue=6 |pages=809–16 |year=2006 |pmid=16753011 |doi=10.1359/jbmr.060301}}</ref>
 
=== Fracture risk ===
[[Fracture]] risk categories in [[glucocorticoid]]-treated patients are listed in the table below.<ref name="BuckleyGuyatt2017">{{cite journal|last1=Buckley|first1=Lenore|last2=Guyatt|first2=Gordon|last3=Fink|first3=Howard A.|last4=Cannon|first4=Michael|last5=Grossman|first5=Jennifer|last6=Hansen|first6=Karen E.|last7=Humphrey|first7=Mary Beth|last8=Lane|first8=Nancy E.|last9=Magrey|first9=Marina|last10=Miller|first10=Marc|last11=Morrison|first11=Lake|last12=Rao|first12=Madhumathi|last13=Robinson|first13=Angela Byun|last14=Saha|first14=Sumona|last15=Wolver|first15=Susan|last16=Bannuru|first16=Raveendhara R.|last17=Vaysbrot|first17=Elizaveta|last18=Osani|first18=Mikala|last19=Turgunbaev|first19=Marat|last20=Miller|first20=Amy S.|last21=McAlindon|first21=Timothy|title=2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis|journal=Arthritis & Rheumatology|volume=69|issue=8|year=2017|pages=1521–1537|issn=23265191|doi=10.1002/art.40137}}</ref>
{| class="wikitable"
!
!
|- valign="top"
!Adults ≥ 40 years of age
| [[Image:Pathologic_fracture_hip_x-ray.jpg|200px|]]
!Adults <40 years of age
| [[Image:Vertebral_body_compression_fracture_.jpg|140px|]]
|}
** [[DVT|Deep venous thrombosis (DVT)]]: it can be caused by prolonged immobility.
** [[Kyphosis]] (Dowager's hump): the main reason could be decreasing the height of anterior aspect of cervical vertebrae body (wedge shape).
** [[Restrictive lung disease]]: because of decreasing thoracic space, due to vertebrae body compression.
* Apart from risk of death and other complications, osteoporotic fractures are associated with a reduced quality of life due to immobility; emotional problems may also arise as a consequence.<ref>{{cite journal |author=Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris ES |title=Impact of recent fracture on health-related quality of life in postmenopausal women |journal=J. Bone Miner. Res. |volume=21 |issue=6 |pages=809–16 |year=2006 |pmid=16753011 |doi=10.1359/jbmr.060301}}</ref>
* Drug side-effects may include:
** [[Bisphosphonates]]: [[esophagitis]], [[osteonecrosis]] of the jaw, bone pain, and muscle pain
** [[Raloxifene]]: [[thromboembolism]], aggravates [[hot flashes]], [[nausea]], [[weight gain]], [[depression]], [[insomnia]], leg cramps, and rash
** [[Teriparatide]]: [[orthostatic hypotension]], [[asthenia]], [[Nausea and Vomiting|nausea]], [[leg cramps]], and [[hypercalcemia]] (if taken along with corticosteroids, thiazide diuretics, and calcium supplementation); must not be given to patients with [[Paget's disease]] or a history of [[osteosarcoma]] or [[chondrosarcoma]]
** Nasal [[calcitonin-salmon ]]: [[bronchospasm]], [[rhinitis]], [[epistaxis]], and [[arthralgia]]
 
==Prognosis==
* The prognosis of the disease is good if the decrease in bone mass density is identified early, and the appropriate anti-osteoporotic medications are started. 
* [[DVT]] caused by prolonged immobility from hip fractures is associated with a poorer prognosis among patients with disease.
{| class="wikitable" align="right"
|+ Hip fractures per 1000 patient-years<ref name="pmid17846439">{{cite journal |author=Cranney A, Jamal SA, Tsang JF, Josse RG, Leslie WD|title=Low bone mineral density and fracture burden in postmenopausal women |journal=CMAJ |volume=177 |issue=6 |pages=575–80 |year=2007|pmid=17846439 |doi=10.1503/cmaj.070234}}</ref>
! WHO category !! Age 50-64  !! Age > 64 || Overall
|-
|-
| Normal || 5.3 || 9.4 || 6.6
|'''High fracture risk'''
|
* Prior osteoporotic [[fracture]](s)
* Hip or spine [[bone mineral density]] T score ≤ -2.5, in men age ≥50 years and [[postmenopausal]] women
* FRAX 10-year risk of major osteoporotic [[fracture]] ≥ 20%
* FRAX 10-year risk of [[hip fracture]] ≥ 3%
|
* Prior osteoporotic [[fracture]](s)
|-
|-
| [[Osteopenia]] || 11.4 || 19.6 || 15.7
|'''Moderate fracture risk'''
|
* FRAX 10-year risk of major osteoporotic [[fracture]] 10–19%
* FRAX 10-year risk of [[hip fracture]] >1% and <3%
|
* [[Hip]] or [[spine]] [[bone mineral density]] Z score <-3
or
* Rapid [[bone loss]] (≥10% at the [[hip]] or [[spine]] over 1 year)
and
* Continuing [[glucocorticoid]] treatment at ≥7.5 mg/day for ≥6 months
|-
|-
| Osteoporosis || 22.4 || 46.6 || 40.6
|'''Low fracture risk'''
|}
|
* The lifetime fracture risk in caucasian women is 18% for hip fractures, 16% for spine fractures, and 16% for wrist fractures.  In men the same fractures account for 6%, 5%, and 3% respectively.
* FRAX 10-year risk of major osteoporotic [[fracture]] <10%
* More than half of all women, and one third of all men, have osteoporotic fractures in their lifetime.
 
* Men have a higher mortality from fractures when compared to women.
* FRAX 10-year risk of [[hip fracture]] ≤1%
* The 6-month mortality rate following hip fracture is approximately 13.5%.
|
* Vertebral fractures, while having a smaller impact on mortality than hip fractures, can lead to severe chronic pain of neurogenic origin which is difficult to treat, as well as postural deformity.
* None of above risk factors other than [[glucocorticoid]] treatment
|}
 
===Prognosis===
* Early identification of the [[Bone mineral density|bone mass density]] loss and appropriate treatment results in a good prognosis of osteoporosis.  
* Osteoporotic fractures are increased by:
**Advancing age
**Low [[Bone mineral density|BMD]]
 
* The lifetime [[Bone fracture|fracture]] at age 60 adjusted with the death rate may be as high as 44% for women and 25% for men.   
* The lifetime [[fracture]] risk for [[hip]] is 9% in women and 4% in men. 
* Similarly, [[fracture]] risk of [[hip]] and [[vertebrae]] in men (15%) is totally noticeable along with their [[prostate cancer]] risk.  
* Most children with [[idiopathic]] juvenile [[osteoporosis]] (IJO)&nbsp;experience a complete recovery of [[bone]] tissue. Although growth may be somewhat impaired during the acute phase of the disorder, normal growth resumes and catch-up growth often occurs afterwards.
* In some cases, IJO can result in permanent disability such as [[kyphoscoliosis]] or collapse of the [[rib cage]].<ref name="urlJuvenile Osteoporosis">{{cite web |url=https://www.niams.nih.gov/health_info/bone/Bone_Health/Juvenile/juvenile_osteoporosis.asp |title=Juvenile Osteoporosis |format= |work= |accessdate=}}</ref>
 
==Monitoring==
Suggested follow-up:<ref name="pmid22256806">{{cite journal| author=Gourlay ML, Fine JP, Preisser JS, May RC, Li C, Lui LY | display-authors=etal| title=Bone-density testing interval and transition to osteoporosis in older women. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 3 | pages= 225-33 | pmid=22256806 | doi=10.1056/NEJMoa1107142 | pmc=3285114 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22256806  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22782920 Review in: Evid Based Med. 2013 Feb;18(1):e7]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23000664 Review in: J Fam Pract. 2012 Sep;61(9):555-6] </ref>
* Normal (T score, −1.00 or higher)- 15 years
* Mild osteopenia (T score, −1.01 to −1.49) - 15 years
* Moderate osteopenia (T score, −1.50 to −1.99) - 5 years
* Advanced osteopenia (T score, -2.00 to −2.49) - 1 year


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WS}}
{{WH}}


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Latest revision as of 14:57, 1 June 2023

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

If left untreated, most of the patients with osteoporosis develop fractures. With the appropriate and timely usage of medications along with calcium and/or vitamin D supplementation, the outcome of osteoporosis is usually good. Apart from the risk of death and other complications, osteoporotic fractures are associated with deep venous thrombosis, kyphosis, and a reduced quality of life due to immobility.

Natural History, Complications, and Prognosis

Natural history

  • Symptoms of osteoporosis typically develop in the sixth decade of life.
  • The risk of osteoporosis increases proportionately with age.[1]
  • Another major factor that directly affects BMD is body weight. Women with increased body weight and body mass index (BMI) have more changes in their BMD in both hip and lumbar spine as they age.
  • Bone site is an important factor to determine the measure of bone loss. The magnitude of bone density loss is higher at the spine (-3.12% annually) compared to the femoral neck (1.67% annually). The main proposed theory for the phenomenon is "different effect of estrogen deficiency on different bone sites".
  • With the appropriate and timely usage of medications along with calcium and/or vitamin D supplementation, the outcome of osteoporosis is usually good. But if the disease is left untreated, or not treated optimally, osteoporosis results in fracture leading to increased morbidity and mortality.
  • Vertebral fractures are more common and affect the quality of life more significantly.[2]

Complications

The major complications of osteoporosis include:

  • Apart from the risk of death and other complications, osteoporotic fractures are associated with a reduced quality of life due to immobility and other emotional problems resulting from osteoporosis.[3]

Fracture risk

Fracture risk categories in glucocorticoid-treated patients are listed in the table below.[4]

Adults ≥ 40 years of age Adults <40 years of age
High fracture risk
Moderate fracture risk
  • FRAX 10-year risk of major osteoporotic fracture 10–19%
  • FRAX 10-year risk of hip fracture >1% and <3%

or

and

Low fracture risk
  • FRAX 10-year risk of major osteoporotic fracture <10%

Prognosis

  • Early identification of the bone mass density loss and appropriate treatment results in a good prognosis of osteoporosis.
  • Osteoporotic fractures are increased by:
    • Advancing age
    • Low BMD
  • The lifetime fracture at age 60 adjusted with the death rate may be as high as 44% for women and 25% for men.
  • The lifetime fracture risk for hip is 9% in women and 4% in men.
  • Similarly, fracture risk of hip and vertebrae in men (15%) is totally noticeable along with their prostate cancer risk.
  • Most children with idiopathic juvenile osteoporosis (IJO) experience a complete recovery of bone tissue. Although growth may be somewhat impaired during the acute phase of the disorder, normal growth resumes and catch-up growth often occurs afterwards.
  • In some cases, IJO can result in permanent disability such as kyphoscoliosis or collapse of the rib cage.[5]

Monitoring

Suggested follow-up:[6]

  • Normal (T score, −1.00 or higher)- 15 years
  • Mild osteopenia (T score, −1.01 to −1.49) - 15 years
  • Moderate osteopenia (T score, −1.50 to −1.99) - 5 years
  • Advanced osteopenia (T score, -2.00 to −2.49) - 1 year

References

  1. ↑ Guthrie JR, Ebeling PR, Hopper JL, Barrett-Connor E, Dennerstein L, Dudley EC, Burger HG, Wark JD (1998). "A prospective study of bone loss in menopausal Australian-born women". Osteoporos Int. 8 (3): 282–90. doi:10.1007/s001980050066. PMID 9797914.
  2. ↑ Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, Kanis JA, Liberman U, Minne H, Reeve J, Reginster JY, de Vernejoul MC, Wiklund I (1997). "Quality of life as outcome in the treatment of osteoporosis: the development of a questionnaire for quality of life by the European Foundation for Osteoporosis". Osteoporos Int. 7 (1): 36–8. PMID 9102060.
  3. ↑ Brenneman SK, Barrett-Connor E, Sajjan S, Markson LE, Siris ES (2006). "Impact of recent fracture on health-related quality of life in postmenopausal women". J. Bone Miner. Res. 21 (6): 809–16. doi:10.1359/jbmr.060301. PMID 16753011.
  4. ↑ Buckley, Lenore; Guyatt, Gordon; Fink, Howard A.; Cannon, Michael; Grossman, Jennifer; Hansen, Karen E.; Humphrey, Mary Beth; Lane, Nancy E.; Magrey, Marina; Miller, Marc; Morrison, Lake; Rao, Madhumathi; Robinson, Angela Byun; Saha, Sumona; Wolver, Susan; Bannuru, Raveendhara R.; Vaysbrot, Elizaveta; Osani, Mikala; Turgunbaev, Marat; Miller, Amy S.; McAlindon, Timothy (2017). "2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis". Arthritis & Rheumatology. 69 (8): 1521–1537. doi:10.1002/art.40137. ISSN 2326-5191.
  5. ↑ "Juvenile Osteoporosis".
  6. ↑ Gourlay ML, Fine JP, Preisser JS, May RC, Li C, Lui LY; et al. (2012). "Bone-density testing interval and transition to osteoporosis in older women". N Engl J Med. 366 (3): 225–33. doi:10.1056/NEJMoa1107142. PMC 3285114. PMID 22256806. Review in: Evid Based Med. 2013 Feb;18(1):e7 Review in: J Fam Pract. 2012 Sep;61(9):555-6

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