Osteoporosis natural history, complications and prognosis

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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.
• Researchers have shown that relationship between age and decreased bone density of spine is not linear, but quadratic; in which bone loss tails off with increasing age. During the first years of the postmenopausal period, women would have a fast decrease in bone density of spine by the rate of 3.12% annually; then the rate slows down to 0.02% per square with increasing age.
• 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 slowed down.
• Another major factor that directly impacts changing BMD is body weight; women with increased body weight and body mass index (BMI) may have more change in their BMD in both hip and lumbar spine, during the course of 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 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". On the other hand, it may show the preventive effect of weight bearing on hip osteoporosis.

• 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, results in fracture leading to increased morbidity and mortality. The main type of fracture that influences the quality of life more and happens earlier, is the vertebral fracture.

Complications

• The major probable complications of osteoporosis include:
  • Fractures: hip and lumbar spine are among the most frequent sites of fracture.
  • 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 vertebral compression.
• 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.

Fracture risk

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

	Adults ≥ 40 years of age	Adults <40 years of age
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)
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
Low fracture risk	FRAX 10-year risk of major osteoporotic fracture <10% FRAX 10-year risk of hip fracture ≤1%	None of above risk factors other than glucocorticoid treatment

Prognosis

• Early identification of the bone mass density loss and appropriate treatment results in a good prognosis of osteoporosis.
• The most important issue to identify the osteoporosis prognosis is fractures; mainly affected by two factors:
  • Advancing age
  • Low BMD.

The relation consists of having about a 2-fold increase in the risk of various fractures following a decrease of BMD by every SD or an increase in age by 5 years.

• When the lifetime fracture at age 60 is adjusted with the death rate, it may be 44% for womean and 25% for men. The lifetime fracture risk for hip is 9% in women and 4% in men. The researchers suggest that lifetime risk of the hip fracture in 60 years old women is 1 in 7 (15%); which is higher than estimated lifetime risk of breast cancer (9.3%). Similarly, fracture risk of hip and vertebrae in men (15%) is totally noticeable along with their prostate cancer risk. This means that the impact of osteoporosis and also osteoporotic fractures on public life would be worse than lot of other life threatening diseases; especially with aging.
• 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. Unfortunately, in some cases, IJO can result in permanent disability such as kyphoscoliosis or collapse of the rib cage.

References

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