Osteoporosis affects more than 10 million people in the US over age 50, and an additional 43 million have low bone mass. Globally, prevalence in adults aged 50 to 85 years exceeds 20%, with nearly nine million fractures each year. Hip fractures carry a 20% mortality rate in the first year and an 86% risk of another fracture, especially in the first two years.
A recent review summarized advances in new osteoporosis risk factors, improved assessment methods, pharmacologic and nonpharmacologic interventions, and therapy sequencing for high-risk patients.
“An individualized, goal directed care plan is necessary for a treat-to-target approach, with total hip bone mineral density being the best specific target,” wrote lead author Caroline Wei Shan Hoong, of the Division of Endocrinology at Woodlands Health, National Healthcare Group in Singapore, and Mayo Clinic, in Rochester, Minnesota, with colleagues.
Risk factors
Standard fracture risk calculators, such as FRAX, do not fully account for certain conditions. Type 2 diabetes raises nonvertebral fracture risk by about one-third despite higher bone mineral density (BMD). These patients also have higher hip fracture rates than predicted by traditional models. Sarcopenia, characterized by low muscle strength and quality, is linked to increased falls and impaired bone structure. When both osteoporosis and sarcopenia are present, the risk of frailty rises sharply.
Fracture timing is also important. A vertebral or hip fracture within the past 2 years signals a period of imminent refracture risk that requires prompt evaluation and treatment.
Assessment Methods
FRAXplus incorporates additional factors, including fracture recency, diabetes duration, number of falls, and trabecular bone score (TBS). TBS improves fracture prediction beyond BMD and benefits patients with secondary osteoporosis causes, such as glucocorticoid use. Radiofrequency echographic multi-spectrometry, an ultrasound-based technology, offers accuracy similar to dual energy x-ray absorptiometry (DXA) for spinal fracture prediction and may be valuable in settings without DXA access.
Drug Interventions
Bisphosphonates remain a first-line option for high-risk patients because they reduce vertebral fracture risk by up to 62% and hip fracture risk by 40% to 60%. Denosumab increases BMD for up to 10 years but should be followed by another antiresorptive agent upon discontinuation to prevent rapid bone loss and multiple vertebral fractures.
Non-drug Interventions
Weight-bearing, resistance, and balance training can improve BMD and reduce falls. In one trial, older adults in a year-long exercise program increased lumbar spine and hip BMD by up to 1.1% and improved muscle strength by 10% to 13%. Calcium (1000 to 1200 mg/day) and vitamin D (800 to 1000 IU/day) together are more effective for fracture prevention than either alone. For older adults, protein intake should exceed 1 g/kg/day, with higher targets for those at risk of malnutrition.
Therapy Sequencing
For very high-risk patients, anabolic agents such as teriparatide, abaloparatide, and romosozumab are recommended first, followed by antiresorptives to maintain gains. Starting with an anabolic drug generally results in greater BMD increases than starting with antiresorptives.
Only 20% to 40% of patients receive osteoporosis medication within a year after a hip fracture. Fracture liaison services improve treatment rates and reduce refracture risk.
Limitations
The findings draw on randomized trials, observational studies, and expert guidelines. Some recommendations are based on expert consensus rather than direct trial evidence. Long-term safety and effectiveness of newer agents, including romosozumab and senolytic-based approaches, require further study. Evidence on optimal exercise programs in institutionalized older adults is limited.
The authors reported no conflicts of interest.
Source: The BMJ