What are the guidelines for diagnosing Osteoporosis (bone disease characterized by decreased bone density)?

From the Guidelines

Osteoporosis diagnosis should be based on a T-score of −2.5 or lower in the lumbar spine, femoral neck, total hip, or one-third radius, as measured by dual-energy X-ray absorptiometry (DXA) scans, according to the most recent guidelines. The diagnosis of osteoporosis relies primarily on bone mineral density (BMD) testing using DXA scans 1.

Key Points for Diagnosis

• DXA BMD measurement should be performed at the lumbar spine, total hip, femoral neck, and, if indicated, one-third radius 1.
• Screening is recommended for all women at the age ≥ 65 years, men age > 70 years, and women and men age ≥ 50 years with risk factors for osteoporosis 1.
• Evaluate for prevalent vertebral fractures with VFA or standard radiography in patients ≥ 50 years with specific risk factors, or with a T-score < -1.0 in older men and women, historical height loss > 4 cm, self-reported but undocumented vertebral fracture, or long-term glucocorticoid therapy 1.

Considerations for Younger Adults

• Consider DXA in younger adults (premenopausal women and men under 50 years) with specific diseases, and/or medical drugs and/or fracture 1.
• The NHANES III reference database is recommended for T-score calculation, depending on the society based on 20–29 years aged White women or same sex-type 1.

Follow-Up and Monitoring

• Follow-up DXA should be done as indicated, depending on clinical circumstances, and ideally in the same facility with the same DXA system 1.
• The frequency of BMD testing in clinical practice may be influenced by the patient’s clinical state, national clinical guidelines, cost, and reimbursement, with suggested intervals between BMD testing typically 1–5 years after starting or changing therapy 1.

Given the most recent and highest quality evidence from 1, these guidelines provide the best approach to diagnosing osteoporosis, focusing on minimizing morbidity, mortality, and improving quality of life.

From the Research

Osteoporosis Diagnosis Guidelines

• Osteoporosis is a common condition characterized by low bone mineral density (BMD) and an increased risk of fragility fractures, affecting up to 30% of women and 12% of men at some point in their lives 2.
• The diagnosis of osteoporosis can be confirmed by DEXA, but this should only be performed in patients who have an increased risk of fracture on the basis of clinical risk factors, with a 10-year risk of major osteoporotic fracture of > 10% 2.
• BMD T-score values by DEXA at the lumbar spine, femoral neck, or total hip at or below -2.5 confirm the diagnosis of osteoporosis, while vertebral fractures are generally taken as diagnostic of osteoporosis, even if spine BMD values are not in the osteoporotic range 2.

Clinical Evaluation and Risk Factors

• The clinical evaluation of the osteoporotic patient should include a careful assessment of risk factors for low bone mass, falls, and fractures, as well as quantitation of BMD, a thorough medical history and physical examination, and targeted laboratory, radiographic, and other diagnostic studies as indicated 3.
• Common risk factors for osteoporosis include increasing age, female gender, long-term corticosteroid therapy, chronic inflammatory disease, malabsorption, and untreated premature menopause 2.
• Vitamin D deficiency is a significant and reversible cause of osteoporosis, particularly among the elderly 3.

Diagnostic Investigations

• Bone mineral density (BMD) testing, most commonly determined by dual-energy x-ray absorptiometry (DXA), is recommended for patients with risk factors, particularly women over 65 years old, and can help identify individuals at high risk of fracture 2, 4.
• Laboratory testing can detect other risk factors and provide clues to etiology, but selection of laboratory tests should be individualized, as there is no consensus regarding which tests are optimal 4.
• Biochemical markers of bone turnover have a potential role in fracture risk assessment and in gauging response to therapy, but are not widely used at present 4.

Guideline Recommendations

• The reviewed guidelines generally agree on the definition, criteria, and investigations used to diagnose osteoporosis, as well as the risk factors for osteoporosis and suggested lifestyle modifications 5.
• Referral to a bone specialist is reserved for complex cases of osteoporosis or in case of inadequate access to care, while the use of hip protectors to reduce the risk of fractures is supported for high-risk elderly patients in residential care settings 5.
• Pharmacologic agents, such as bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs, are recognized as effective treatments, but recommendations regarding monitoring of pharmacotherapy differ among guidelines 5.