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The case
A 73-year-old woman with controlled hypertension sees you for a routine visit. Five months ago, she broke her humerus after tripping over a bag of groceries. She has completely recovered. Although she fell 4 times in the last year, this was her first fracture. She does not smoke, drinks alcohol occasionally and enjoys line-dancing twice weekly. Her medications include a calcium-channel blocker and a thiazide diuretic. She has never taken corticosteroids. Her weight is 67 kg, height 165 cm and body mass index 25. Her blood pressure is 135/80 mm Hg, with no evidence of orthostatic drop. Measurement of bone mineral density with the use of dual-energy x-ray absorptiometry reveals T scores of -2.2 at the lumbar spine and -2.1 at the femoral neck. What would your approach be to the management of this patient?
Osteoporosis is a common disorder characterized by deterioration of bone microarchitecture, skeletal fragility and increased risk of fracture.1 The prevalence of osteoporosis increases with age, from 6% at 50 years to 50% after the age of 80.2 An estimated 50% of women and 20% of men over the age of 50 will have an osteoporosis-related fracture.1 Osteoporosis is responsible for lasting disability, impaired quality of life and increased mortality.1,3 Individuals who have an osteoporosis-related fracture are at high risk of recurrent fractures.4-6
In this review, we will address the approach to managing osteoporosis in postmenopausal women and older men. Although the prevention of falls should not be ignored, its evaluation is beyond the scope of this article and we refer readers to recent systematic reviews.7,8
How should osteoporosis be diagnosed?
Osteoporosis may be diagnosed in postmenopausal women and in men aged 50 years and older if the measurement of bone mineral density in the lumbar spine, total hip or femoral neck is at least 2.5 standard deviations below that of a young control (T score -2.5 or less).9 Each decrease in standard deviation is associated with a 2-fold increase in the relative risk of osteoporosis-related fractures.1
The measurement of bone mineral density, however, identifies only a small component of the risk of fracture.10 There is an emerging consensus based on results from clinical trials and observational studies that individuals at high risk of osteoporosis-related fractures are best identified...