Osteoporosis: assessing risk

We worry about osteoporosis because of the increased risk of fragility fractures. So how do we assess which patients are at risk and need further investigation?

NICE produced guidelines in 2012: Osteoporosis: assessing the risk of fragility fracture. The following is based on those guidelines.

They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:

• previous fragility fracture
• current use or frequent recent use of oral or systemic glucocorticoid
• history of falls
• family history of hip fracture
• other causes of secondary osteoporosis, for example:
  • hypogonadism in either sex including low testosterone in men and premature menopause in women
  • endocrine conditions, including diabetes mellitus, Cushing's disease, hyperthyroidism
  • conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis.
  • rheumatoid arthritis and other inflammatory arthropathies.
• low body mass index (BMI) (less than 18.5 kg/m²)
• smoking
• alcohol intake of more than 14 units per week for women and more than 14 units per week for men.

Methods of risk assessment

The first step is to exclude secondary causes of osteoporosis as underlying conditions may also require treatment. Examples of secondary causes are listed above.

If a patient has had a recent fragility fracture, non-osteoporotic causes should be looked for, for example, bone metastases, myeloma and Paget's disease.

A DEXA scan should be offered without calculating the fragilty risk score in the following situations:

• 50 years of age with a history of fragility fracture

• < 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score
• before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)

Fragility fracture risk score