Osteoporosis Signs and Symptoms

• Progressive, systemic skeletal disease characterized by decreased bone mass and micro-architectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures
  • Bone strength, reflecting both density and quality of the bone, is compromised thus increasing fracture risk
  • Fractures commonly occur in the hip, spine and wrist with the hip fractures having a high morbidity
• Often asymptomatic until patient presents with a fragility fracture  
  • Vertebral fracture can cause back pain, height loss and increasing kyphosis
• Primary osteoporosis refers to bone loss which happens after menopause and with aging while secondary osteoporosis is bone loss resulting from diseases or medications (eg glucocorticoids)   
• Though osteoporosis in Asia is very much underdiagnosed and undertreated, it is projected that by 2050, >50% of osteoporotic hip fractures will happen in Asia
  • In most developing countries, dual-energy X-ray absorptiometry (DXA) is expensive and is widely unavailable particularly in the rural areas
• Calcium intake in almost all Asian countries is below the FAO/WHO recommendations of 1-1.3 g/day
• Studies done in both sexes and all age groups in different Southeast Asian countries demonstrated widespread incidence of vitamin D deficiency or insufficiency

• When on oral glucocorticoid therapy, bone loss occurs in the 1st 6-12 months and fracture risk increases within 3-6 months of initiating glucocorticoids
• Intake of ≥5 mg daily of Prednisolone or its equivalent for ≥3 months is associated with osteoporosis
  • Similar risk is also shown with higher glucocorticoid dose taken for a shorter period of time
  • Strong glucocorticoids inhaled for 7 years are associated with significant bone loss
• Initial clinical fracture risk assessment is recommended in adults on ≥2.5 mg/day of glucocorticoids for >3 months, who have never had fracture risk assessment or received osteoporosis therapy

• Previous history of fracture as an adult
• History of osteoporotic hip fracture in 1st-degree relative
• Advanced age 
• Poor health/frailty
• Ethnic group
• Early natural or surgical menopause before 45 years of age or prolonged premenopausal amenorrhea >1 year
• Genetics and genetic diseases: Cystic fibrosis, osteogenesis imperfecta, Ehlers-Danlos, hemochromatosis, Marfan syndrome, thalassemia, hypophosphatasia 

• Recurrent falls
• Decreased body weight (<57.6 kg [<127 lb] or body mass index [BMI] <19 kg/m²)
• Impaired vision
• Medical conditions: Rheumatoid arthritis, celiac disease, estrogen deficiency, vitamin D deficiency due to lack of sunlight exposure or low intake, thyrotoxicosis, or prolonged Levothyroxine intake, multiple myeloma
• Cigarette smoking
• Excessive alcohol and caffeine intake (≥3 drinks/day)
• Low calcium intake, excessive salt and vitamin A intake
• Oral glucocorticoid use ≥5 mg/day of prednisone for ≥3 months
• Sedentary lifestyle (lack of physical activity)

• Non-traumatic fractures of the hip, vertebrae or wrist
• Prior osteoporotic fracture from age 50 years
• Hypogonadism, growth hormone deficiency
• Idiopathic hypercalciuria
• Hyperparathyroidism
• Rheumatoid arthritis
• Lymphoma, multiple myeloma
• Hyperthyroidism
• Oral glucocorticoid use ≥5 mg/day of Prednisone for ≥3 months
• Physical inactivity, immobilization
• Low BMI (kg/m²)
• Anticonvulsants (eg Phenytoin, Phenobarbital)
• Smoking
• Alcohol intake (≥3 drinks/day)

Factors Associated with Glucocorticoid-induced Osteoporosis or Fractures

• Low bone density
• Cumulative steroid dose
• Age >65 years
• BMI ≤20 kg/m², significant weight loss
• Smoking, excessive alcohol use
• Diseases associated with low bone density (eg rheumatoid arthritis, inflammatory bowel disease, thyroid disease, hyperparathyroidism, chronic liver disease), sex hormone deficiency, family history of osteoporosis, history of fracture and immobilization
• Family history of osteoporosis, parental history of hip fracture
• History of height loss, fall or fracture and immobilization

• Low risk of major osteoporotic fracture (<10%) and intake of ≥7.5 mg daily of Prednisolone or its equivalent for >3 months
• Moderate risk of major osteoporotic fracture (10-19%) and intake of glucocorticoid at any dose for >3 months
• High risk of major osteoporotic fracture (≥20%) and intake of glucocorticoid at any dose for any length of time