Osteopenia: what is it, symptoms, treatment, prognosis

What is osteopenia?

Osteopenia Is a clinical term used to describe a decrease in bone mineral density (BMD) below normal control values ​​but not low enough to meet diagnostic criteria to be considered osteoporosis. BMD is diagnosed using dual energy X-ray bone absorptiometry. The decline in BMD values ​​reflects an underlying disorder of bone microarchitecture and osteopenia, and osteoporosis is considered a quantitative rather than qualitative disorder in bone mineralization.

Signs and symptoms

Osteopenia is usually asymptomatic. This means that osteopenia is often undetectable if a person has not been tested for bone density. When osteopenia does cause symptoms (with fractures), localized pain and weakness may occur in the area of ​​the bone fracture. Interestingly, sometimes even a bone fracture can proceed without causing pain.

Causes and risk factors

The acquisition of bone minerals from birth to adulthood follows a predictable trend based on a person's age and gender. With the onset of puberty, bone mineral gain increases to a maximum level shortly after peak growth is reached in adolescence. Bone mineral gain remains highest in men and women for about four years after reaching the maximum rate of growth, and 95% of the bone mass of an adult is usually achieved by 17 years in women and 21 years in men. Thus, peak bone mass is usually reached by the third decade of life. Failure to reach peak bone mass at a young age leads to the early development of conditions with low bone mass (osteopenia or 

osteoporosis) and an increased risk of fractures, even during adolescence and adolescence. After 30 years, there is a gradual and natural decrease in bone mass, which occurs over the next decades.

Although it is believed that inherited factors determine up to 80% of our ability to achieve and maintain optimal levels bone mineralization, modifiable factors attributed to the rate of natural bone loss in adulthood, include weight bearing exercise, nutritional status (adequate daily intake of calcium and vitamin D), body weight, and hormonal background.

Natural bone loss, which occurs gradually in adulthood, is thought to be the cause of primary forms of osteopenia and osteoporosis. Secondary causes serve to accelerate this process and include factors related to the image life, such as alcohol abuse, smoking, sedentary lifestyle, body weight (BMI below 18.5 kg / m2). White and Asian races are also common risk factors.

General medical conditions and some medications are also considered secondary causes. Medical conditions include:

• hyperparathyroidism;
• anorexia;
• malabsorption syndromes;
• hyperthyroidism;
• chronic renal failure;
• hypogonadism;
• amenorrhea/олигоменорею;
• early onset of menopause;
• chronic conditions leading to calcium and / or vitamin D deficiency

Medicines involved in the disease process include:

• Excessive glucocorticoid / prolonged use of steroids;
• valproic acid;
• proton pump inhibitors;
• antiepileptic and chemotherapeutic agents.

Epidemiology

According to the National Medical Research Center of Traumatology and Orthopedics named after R.R. Harmful, osteoporosis is recorded in every third woman and every fourth man at the age of 50 and older. Every minute in the country there are 7 vertebral fractures, and every 5 minutes - a fracture of the proximal femur. By 2035 the total number of major osteoporotic fractures will increase from 590 thousand to up to 730 thous. cases per year. Osteoporosis is costly for health care due to the high cost of fracture treatment, which is also accompanied by a significant decrease in the quality of life, patient disability and mortality. Epidemiological studies have shown that due to the high risk of fractures, 31% of women and 4% of men over 50 need treatment for osteoporosis.

Pathophysiology

Osteopenia occurs against the background of dissociation of the activity of osteoclasts and osteoblasts, which leads to a quantitative decrease in bone mass. Peak bone mass is usually reached in men and women shortly before or early in the third decade of life. After age 30, bone resorption gradually becomes preferred as dynamic bone remodeling continues into the later decades of life.

Diagnostics

A detailed history and physical examination is required, including identification of potential risk factors associated with secondary bone loss. A thorough social history should also be obtained, with attention to smoking and chronic alcohol use. A family history of osteoporosis should also be noted. The patient should be asked about any previous fractures, with particular attention to low energy fall mechanisms from the ground and any fractures after age 40.

The physical examination is often normal, with the exception of some advanced medical conditions (such as osteoporosis). In healthy people without risk factors, most clinicians recommend women approaching menopause (or not later than 65 years old), and men aged 70 years old undergo a dual energy X-ray absorptiometry examination (DEXA).

Women with normal DEXA scan results do not require a follow-up scan, since studies have shown that most women with normal scores do not have osteoporosis is progressing. Some experts may advocate post-treatment rescanning, but this method remains controversial. as the literature suggests that subsequent DEXA scans rarely lead to interventions or adjustments treatment.

Treatment

The main treatment options for patients with osteopenia include early education on how to achieve and maintain healthy bone levels, as well as comprehensive training and counseling on relevant social, environmental and lifestyle risk factors that endanger health bones.

- Lifestyle changes.

All patients can benefit from lifestyle changes. Chronic alcohol use has been found to be a significant risk factor for a decrease in BMD. Clinicians should also regularly encourage smoking cessation and promote regular exercise. Yoga and tai chi help reduce stress, improve balance and dexterity.

Patients should be informed about the recommended daily intake of calcium and vitamin D. The National Osteoporosis Foundation recommends 1,200 to 1,500 mg of calcium per day and 800 to 1,000 IU of vitamin D per day for adults over 50.

- Fall prevention.

Falls, mostly at home, account for more than 90% of hip fractures and all fractures of the distal radius. While the role of exercise programs and physiotherapy interventions for the elderly has been reported with mixed results in reducing falling and lower incidence of subsequent hip fractures and other brittle fractures, some studies recommend multimodal combinations in favor of the elderly of people. Regular exercise combined with preventive measures to remove loose carpets, reduce the use of sleeping pills and other tranquilizers and the treatment of visual impairment in the elderly, lead to a decrease the number of falls.

- Pharmaceutical treatment.

Pharmacotherapy agents act as both antiresorptive and anabolic agents. Bisphosphonates are the most commonly prescribed class of drugs. These drugs are divided into non-nitrogen and nitrogen-containing compounds. The latter are considered first line therapy. Nitrogen-containing compounds inhibit farnesyl pyrophosphate synthase and ultimately inhibit osteoclast resorption and cause apoptosis osteocytes. Common agents include:

• Alendronate can reduce the incidence of hip, spine and wrist fractures by 50%.
• Risedronate can reduce the number of vertebral fractures by 40% over three years.
• Intravenous zoledronic acid reduces the incidence of spinal fractures by 70% and hip fractures by 40% over three years.

Other classes of drugs:

• Conjugated estrogen-progestin hormone replacement therapy.
• Replacement therapy with estrogen only.
• Salmon calcitonin.
• Selective estrogen receptor modulators (Raloxifene) - Raloxifene is an agonist of estrogen receptors in bones and reduces osteoclast resorption.
• Anabolic - Teriparatide is a recombinant form of parathyroid hormone (PTH) that stimulates osteoblasts to produce more bone. Teriparatide is approved by the FDA for the treatment of osteoporosis in men and women.
• RANKL inhibitors (Denosumab) - Denosumab is a monoclonal Ig2 that targets RANKL and suppresses its ability to bind to RANK, resulting in inhibition of osteoclast activation.

- Recommendations for treatment and follow-up.

The duration of treatment varies depending on the class of drugs used. Agents such as teriparatide and hormone therapy require immediate follow-up treatment with another agent after the drug is discontinued; otherwise, bone mass is quickly lost. Clinicians should also exercise caution with prolonged use of continuous bisphosphonate therapy after a 3-5 year period. Patients should also be aware of these potentially painful side effects and should advise to immediately seek help if they experience any symptoms of discomfort in thighs.

Any patient who has been taking bisphosphonates for any length of time and who has mild hip discomfort should undergo the following medical evaluation:

• Be aware of the risks and immediately stop all activities related to weight transfer.
• Obtain a full-length radiograph of the hip and hip joint. Hip pain may indicate an impending pathological, atypical hip fracture. Attention should be paid to the subtrochanteric and diaphyseal regions of the femoral cortex, especially the lateral cortex, which often shows signs of a periosteal reaction.
• Stop using bisphosphonate immediately.
• Get a referral to an orthopedic surgeon for prophylactic surgical fixation.

Forecast

The prognosis for patients with osteopenia is good if diet and exercise recommendations are followed. Bone density can be stabilized and the risk of fractures can be further reduced with supplements and medications.