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Osteopenia, preferably known as "low bone mass" or "low bone density", is a condition in which bone mineral density is low. Because their bones are weaker, people with osteopenia may have a higher risk of fractures,[1] and some people may go on to develop osteoporosis. In 2010, 43 million older adults had osteopenia.[2]

Osteopenia
Other nameslow bone mass, low bone density
SpecialtyRheumatology, Endocrinology
Complicationsdevelopment into osteoporosis
Osteopenia exists on a spectrum of normal to dangerously low bone density (osteoporosis).

Risk factorsEdit

Many divide risk factors for osteopenia into fixed (non-changeable) and modifiable factors. Osteopenia can also be secondary to other diseases. An incomplete list of risk factors:[3][4][5]

 
Bone density peaks at 35 and then decreases with age.

FixedEdit

  • Age: bone density peaks at age 35, and then decreases. Bone density loss occurs in both men and women[6]
  • Race: Caucasian and Asian people have increased risk
  • Sex: women are at higher risk, particularly those with early menopause
  • Family history: low bone mass in the family increases risk

Modifiable / behavioralEdit

  • Tobacco use
  • Alcohol use
  • Inactivity - particularly lack of weight-bearing or resistance activities [7][8][9]
  • Insufficient caloric intake - osteopenia can be connected to female athlete triad syndrome[10]
  • Low nutrient diet (particularly calcium, Vitamin D)

Other diseasesEdit

  • Celiac disease, via poor absorption of calcium and vitamin D[11][12]
  • Hyperthyroidism
  • Anorexia nervosa[13]

MedicationsEdit

  • Steroids
  • Anticonvulsants

Screening and diagnosisEdit

The ISCD (International Society for Clinical Densitometry) and the National Osteoporosis Foundation recommend that older adults (women over 65 and men over 70) and adults with risk factors for low bone mass, or previous fragility fractures, undergo DXA testing.[14] The United States Preventive Task Force recommends osteoporosis screening for women with increased risk over 65, and states there is insufficient evidence to support screening men.[15] The main purpose of screening is to prevent fractures. Of note, USPTF screening guidelines are for osteoporosis, not specifically osteopenia.

A common test for bone mineral density is the DXA (dual X-ray absorptiometry) scan. DXA uses a form of X-ray technology, and offers accurate bone mineral density results with low radiation exposure.[16][17]

 
A DXA scanner in use.

The National Osteoporosis Foundation recommends use of central (hip and spine) DXA testing for accurate measure of bone density, emphasizing that peripheral or "screening" scanners should not be used to make clinically meaningful diagnoses, and that peripheral and central DXA scans cannot be compared to each other.[18]

DXA scanners can be used to diagnose osteopenia or osteoporosis as well as to measure bone density over time as people age or undergo medical treatment or lifestyle changes.

The DXA scanner evaluates bone mineral density: comparison of a patient's density to the bone density of a healthy young person creates a bone mineral density T-score. Bone density between 1 and 2.5 standard deviations below the reference, or a T-score between −1.0 and −2.5,[19][20] indicates osteopenia (a T-score greater than or equal to -2.5 indicates osteoporosis). Calculation of the T-score itself may not be standardized. The ISCD recommends using Caucasian women between 20 and 29 years old as the baseline for bone density for ALL patients, but not all facilities follow this recommendation[21][14]

The ISCD recommends that Z-scores, not T-scores, be used to classify bone density in premenopausal women and men under 50.[22]

PreventionEdit

Prevention of low bone density can start early in life by maximizing peak bone density. One a person loses bone density, the loss is usually irreversible, so preventing (greater than normal) bone loss is important.[23]

Actions to maximize bone density and stabilize loss include:[24][25][26][27]

  • Exercise, particularly weight-bearing exercise and resistance exercises
  • Adequate caloric intake
  • Sufficient calcium in diet: older adults may have increased calcium needs[25]—of note, medical conditions can affect absorption of calcium
  • Sufficient Vitamin D in diet
  • Estrogen replacement
  • Avoidance of steroid medications
  • Limit alcohol use and smoking

Pharmaceutical treatmentEdit

The pharmaceutical treatment of osteopenia is controversial[28][29] and more nuanced than well-supported recommendations for improved nutrition and weight-bearing exercise.[5] The diagnosis of osteopenia in and of itself does not always warrant pharmaceutical treatment.[30][31]

Risk of fracture guides clinical treatment decisions: the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) estimates the probability of hip fracture and the probability of a major osteoporotic fracture (MOF), which could occur in a bone other than the hip.[32][33] In addition to bone density (T-score), calculation of the FRAX score involves age, body characteristics, health behaviors, and other medical history.[34]

As of 2014, The National Osteoporosis Foundation (NOF) recommends pharmaceutical treatment for osteopenic postmenopausal women and men over 50 with FRAX hip fracture probability of >3% or FRAX MOF probability >20%.[35] As of 2016, the American Association of Clinical Endocrinologists and the American College of Endocrinology agree.[36] In 2017, the American College of Physicians recommended that clinicians use individual judgment and knowledge of patients' particular risk factors for fractures, as well as patient preferences, to decide whether to pursue pharmaceutical treatment for women with osteopenia over 65.[37]

Pharmaceutical treatment for low bone density includes a range of medications. Commonly used drugs include bisphosphonates (alendronate, risedronate, and ibandronate) - some studies show that decreased fracture risk and increased bone density after bisphosphonate treatment for osteopenia.[38] Other medications includeselective estrogen receptor modulators (SERMs) (raloxifene; estrogen; calcitonin; and teriparatide).[39]

These drugs are not without risks.[40][41] In this complex landscape, many posit that clinicians must consider a patient's individual risk of fracture, not simply treating those with osteopenia as equally at risk. A 2005 editorial in the Annals of Internal Medicine states "The objective of using osteoporosis drugs is to prevent fractures. This can be accomplished only by treating patients who are likely to have a fracture, not by simply treating T-scores."[42]

History of osteopeniaEdit

Osteopenia, from Greek ὀστέον (ostéon), "bone" and πενία (penía), "poverty", is a condition of sub-normally mineralized bone, usually the result of a rate of bone lysis that exceeds the rate of bone matrix synthesis. See also osteoporosis.

In June 1992, the World Health Organization defined osteopenia.[43][29] An osteoporosis epidemiologist at the Mayo Clinic who participated in setting the criterion in 1992 said "It was just meant to indicate the emergence of a problem", and noted that "It didn't have any particular diagnostic or therapeutic significance. It was just meant to show a huge group who looked like they might be at risk."[44]

See alsoEdit

ReferencesEdit

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  2. ^ Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B (November 2014). "The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine". Journal of Bone and Mineral Research. 29 (11): 2520–6. doi:10.1002/jbmr.2269. PMC 4757905. PMID 24771492.
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External linksEdit