By Dr. Vivek Sinha
As a primary care physician, one of our main goals during a routine physical is prevention. How can we prevent disease? How can we prevent the need for more and more medications? How can we prevent injury? This idea of prevention is extremely important when we are thinking about what sort of tests to order for patients. When we think about screening tests, we often look at a patient’s age, gender, medical history, family history and acquired risk factors and then decide what tests will give us the best information. One extremely common condition that we screen for is osteoporosis.
What is osteoporosis? Who does it affect? Why are physicians so concerned about diagnosing it? Like most things in medicine, we must first understand the condition before we can determine how to prevent or treat the condition.
Osteoporosis occurs when there is decreased bone mass, bone matrix disruption and weakness in the skeletal system. A patient with osteoporosis is at a significantly higher risk of fracture in his or her lifetime. The hip and spine are two areas of the body that are particularly susceptible to injury and fracture. Fractures may occur after a fall from standing height with little or no further trauma.
Fractures of the hip can be severe and the treatment often involves surgery. After a fracture, the patient may find themselves in some level of pain for the rest of their life. Currently, it is estimated that 55 percent of the U.S. population above age 50 has osteoporosis, and as a result, there are approximately two million fractures in the U.S. per year due to osteoporosis.
There are many factors that can lead to low bone density. Advancing age, history of previous fractures, chronic steroid therapy, family history of hip fractures, low body weight, current cigarette smoking, excessive alcohol consumption and rheumatoid arthritis are some of the factors that may put an individual at higher risk of having low bone density. Therefore, patients who have these conditions may often be screened for osteoporosis earlier than those individuals who don’t.
So how do we check for osteoporosis? There are several screening tools that have been developed to assess a person’s risk factors. They are usually in the form of screening questionnaires. They take into account a person’s age, gender, weight and absence or presence of additional risk factors and calculate a 10-year probability of fracture. While screening questionnaires are quick and inexpensive, they do not give very specific advice about the state of a person’s bone mineral density. However, they are often an ideal first starting point when deciding on who should receive further testing.
Since assessing a person’s current bone mineral density is one of the most important factors in determining their fracture prediction, the most accurate way is to use an imaging study called a DXA Scan. DXA stands for Dual-Energy-X-Ray Absorptiometry test.
These tests are often done in outpatient radiology centers and hospital radiology departments. The patient lies on a padded table and photon beams are used to quantify bone mineral density. The exposure of radiation is minimal and similar to daily environmental background radiation. As an example of how little the exposed radiation is, the technician performing the test does not need to be shielded or protected as is done during otherwise normal X-ray studies.
Once the test is performed, a scoring system is used to classify the person’s bone mineral density. The results can be generalized into three main categories: normal, osteopenia (abnormal) and osteoporosis (abnormal).
Osteopenia is abnormal and can be thought of as the “midpoint” between normal and full-blown osteoporosis. Once osteopenia is diagnosed, there are prescription medications that are usually prescribed, along with an increased frequency of testing. If the DXA Scan shows osteoporosis, then the patient is at a significantly increased risk of fractures. At this point, very specific medication that is designed to help rebuild the bone matrix is usually prescribed.
The most commonly used first-line agent is a category of drugs called bisphosphonates. These medications can be given via oral pills or via IV Infusion. They are generally effective; however, they are not without side effects in certain patients. There are several other categories of medication that are available. Some of them are not considered first line agents due to their side effect profile. However, for certain patients, they may be the best option. Drug treatment for osteoporosis must be based on an individualized approach.
While extremely important, medications are but one aspect of the treatment regimen for osteopenia and osteoporosis. Lifestyle changes should also be initiated to help reduce bone loss. Diet is an extremely important aspect for bone mineral density levels. Adequate amounts of vitamin D and calcium should be taken every day. Cigarette smoking accelerates bone loss; therefore, smoking cessation is an important step for women to consider when dealing with osteopenia/osteoporosis. Exercising for 30 minutes three times a week is a critical factor when trying to improve bone health. Lifestyle modifications should absolutely be included in any treatment discussion for osteopenia/osteoporosis, but since preventing osteoporosis is the best approach, these lifestyle changes should be initiated as early as possible.
One aspect of screening for osteoporosis that has become more commonplace in recent years is screening in men. There are various guidelines that advise using screening tools to determine bone mineral density and there are other studies that show DXA scans should be performed in anyone, male or female, if they have risk factors for decreased bone mass. The take-home message is that screening for osteoporosis is a discussion that should take place and a decision should be made based on risk factors, medical conditions and family history.
Unfortunately, osteoporosis has no symptoms until there is a fracture, which is why getting tested for it is so important. The fracture can be significant and greatly affect one’s quality of life. Getting screened based on these guidelines is critically important in diagnosing this condition early. Talk to your doctor. The best treatment for osteoporosis is prevention and that can only occur with early screening.
Dr. Vivek Sinha is the chief medical officer of Belleview Medical Partners, an office and house call based practice in Old Town.