Osteoporosis monitoring and treatment

A process covering bone mineral density measurement, fracture risk assessment, and pharmacologic treatment for the prevention and management of osteoporosis.

Indication

• Routine bone density screening in women aged 65 and older and men aged 70 and older
• Earlier screening in postmenopausal women with risk factors such as early menopause, low body weight, or family history of hip fracture
• Patients who have sustained a low-energy (simple fall or inappropriate trauma) hip, vertebral, or wrist fracture
• Long-term corticosteroid use (≥3 months, ≥5 mg/day prednisolone) or hormone-suppressive therapy
• Secondary causes of osteoporosis such as rheumatoid arthritis, hyperthyroidism, primary hyperparathyroidism, celiac disease
• Patients with a history of low-trauma fracture or significant height loss
• Assessment of effectiveness of current osteoporosis treatment and need to continue it

Preparation

• Calcium-containing supplements should be discontinued 24 hours before the DEXA scan
• Inform your physician if you have had a barium contrast study or nuclear medicine examination in the last 1-2 weeks
• Wear comfortable clothing without metal buttons, zippers, or underwire for the scan
• Bring previous DEXA reports and results of calcium/vitamin D and renal function tests
• Always inform staff before scanning if there is any possibility of pregnancy

How it's performed

1. A detailed history is taken: fracture history, age at menopause, family history of osteoporosis, smoking, alcohol, corticosteroid use are reviewed
2. Height and weight are measured (height loss may suggest vertebral compression fracture); physical examination is performed
3. Bone mineral density of the hip and lumbar spine is measured by DEXA (Dual-Energy X-ray Absorptiometry); T-score and Z-score are calculated (T-score ≥ -1 normal, -1 to -2.5 osteopenia, ≤ -2.5 osteoporosis)
4. Blood tests: calcium, phosphorus, 25-OH vitamin D, creatinine, alkaline phosphatase, TSH, parathyroid hormone (PTH); testosterone may be requested in male patients
5. FRAX score is used to calculate 10-year risk of major osteoporotic fracture and hip fracture
6. Based on findings, medication options such as bisphosphonates (alendronate, zoledronic acid), denosumab, romosozumab, or teriparatide are considered; vitamin D and calcium supplementation are planned

Post-procedure

• DEXA is repeated 1-2 years after starting therapy to evaluate response; in stable patients, every 2-3 years may be sufficient
• After 3-5 years of bisphosphonate therapy, a 'drug holiday' (temporary break) may be considered; treatment is continued in high-risk patients
• Denosumab must be continued without interruption; abrupt discontinuation increases the risk of vertebral fracture
• Calcium (1000-1200 mg/day, prioritizing dietary intake) and vitamin D (usually 800-2000 IU/day) levels are monitored
• Fall prevention: home safety, vision examination, strength and balance exercises (walking, tai chi) are recommended
• Discontinuation of smoking and excessive alcohol use is supported as both adversely affect bone health

Risks

• DEXA scanning involves low-dose radiation; outside of pregnancy it carries no additional risk
• Bisphosphonates have rarely been associated with atypical femur fracture (with long-term use) and osteonecrosis of the jaw (especially after dental surgery)
• Esophageal irritation and stomach upset may occur with oral bisphosphonates; correct administration technique is important
• Hypocalcemia may develop in patients on denosumab; vitamin D deficiency must be corrected beforehand
• Failure to start or discontinuation of treatment significantly increases the risk of hip and vertebral fractures in older age
• Inadequately corrected vitamin D deficiency or untreated secondary causes reduce treatment response

FAQ

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