Osteoporosis natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

If left untreated, most of the patients with osteoporosis develop fractures. With the appropriate and timely usage of medications along with calcium and/or vitamin D supplementation, the outcome of osteoporosis is usually good. Apart from the risk of death and other complications, osteoporotic fractures are associated with deep venous thrombosis, kyphosis, and a reduced quality of life due to immobility.

Natural History, Complications, and Prognosis

Natural history

• Symptoms of osteoporosis typically develop in the sixth decade of life.
• The risk of osteoporosis increases proportionately with age.
• Another major factor that directly affects BMD is body weight. Women with increased body weight and body mass index (BMI) have more changes in their BMD in both hip and lumbar spine as they age.
• Bone site is an important factor to determine the measure of bone loss. The magnitude of bone density loss is higher at the spine (-3.12% annually) compared to the femoral neck (1.67% annually). The main proposed theory for the phenomenon is "different effect of estrogen deficiency on different bone sites".

• With the appropriate and timely usage of medications along with calcium and/or vitamin D supplementation, the outcome of osteoporosis is usually good. But if the disease is left untreated, or not treated optimally, osteoporosis results in fracture leading to increased morbidity and mortality.
• Vertebral fractures are more common and affect the quality of life more significantly.

Complications

The major complications of osteoporosis include:

• Fractures: hip and lumbar spine are among the most frequent sites of fracture.
• Deep venous thrombosis (DVT): It can be caused by prolonged immobility.
• Kyphosis (Dowager's hump): Due to decreased height of anterior aspect of cervical vertebrae body (wedge shape).
• Restrictive lung disease: Due to decreased thoracic space, due to vertebral compression.

• Apart from the risk of death and other complications, osteoporotic fractures are associated with a reduced quality of life due to immobility and other emotional problems resulting from osteoporosis.

Fracture risk

Fracture risk categories in glucocorticoid-treated patients are listed in the table below.

	Adults ≥ 40 years of age	Adults <40 years of age
High fracture risk	Prior osteoporotic fracture(s) Hip or spine bone mineral density T score ≤ -2.5, in men age ≥50 years and postmenopausal women FRAX 10-year risk of major osteoporotic fracture ≥ 20% FRAX 10-year risk of hip fracture ≥ 3%	Prior osteoporotic fracture(s)
Moderate fracture risk	FRAX 10-year risk of major osteoporotic fracture 10–19% FRAX 10-year risk of hip fracture >1% and <3%	Hip or spine bone mineral density Z score <-3 or Rapid bone loss (≥10% at the hip or spine over 1 year) and Continuing glucocorticoid treatment at ≥7.5 mg/day for ≥6 months
Low fracture risk	FRAX 10-year risk of major osteoporotic fracture <10% FRAX 10-year risk of hip fracture ≤1%	None of above risk factors other than glucocorticoid treatment

Prognosis

• Early identification of the bone mass density loss and appropriate treatment results in a good prognosis of osteoporosis.
• Osteoporotic fractures are increased by:
  • Advancing age
  • Low BMD

• The lifetime fracture at age 60 adjusted with the death rate may be as high as 44% for women and 25% for men.
• The lifetime fracture risk for hip is 9% in women and 4% in men.
• Similarly, fracture risk of hip and vertebrae in men (15%) is totally noticeable along with their prostate cancer risk.
• Most children with idiopathic juvenile osteoporosis (IJO) experience a complete recovery of bone tissue. Although growth may be somewhat impaired during the acute phase of the disorder, normal growth resumes and catch-up growth often occurs afterwards.
• In some cases, IJO can result in permanent disability such as kyphoscoliosis or collapse of the rib cage.

Monitoring

Suggested follow-up:

• Normal (T score, −1.00 or higher)- 15 years
• Mild osteopenia (T score, −1.01 to −1.49) - 15 years
• Moderate osteopenia (T score, −1.50 to −1.99) - 5 years
• Advanced osteopenia (T score, -2.00 to −2.49) - 1 year

References

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