The challenges of diagnosing osteoporosis and the limitations of currently available tools

Abstract

Dual-energy X-ray absorptiometry (DXA) was the first imaging tool widely utilized by clinicians to assess fracture risk, especially in postmenopausal women. The development of DXA nearly coincided with the availability of effective osteoporosis medications. Although osteoporosis in adults is diagnosed based on a T-score equal to or below − 2.5 SD, most individuals who sustain fragility fractures are above this arbitrary cutoff. This incongruity poses a challenge to clinicians to identify patients who may benefit from osteoporosis treatments. DXA scanners generate 2 dimensional images of complex 3 dimensional structures, and report bone density as the quotient of the bone mineral content divided by the bone area. An obvious pitfall of this method is that a larger bone will convey superior strength, but may in fact have the same bone density as a smaller bone. Other imaging modalities are available such as peripheral quantitative CT, but are largely research tools. Current osteoporosis medications increase bone density and reduce fracture risk but the mechanisms of these actions vary. Anti-resorptive medications (bisphosphonates and denosumab) primarily increase endocortical bone by bolstering mineralization of endosteal resorption pits and thereby increase cortical thickness and reduce cortical porosity. Anabolic medications (teriparatide and abaloparatide) increase the periosteal and endosteal perimeters without large changes in cortical thickness resulting in a larger more structurally sound bone. Because of the differences in the mechanisms of the various drugs, there are likely benefits of selecting a treatment based on a patient’s unique bone structure and pattern of bone loss. This review retreats to basic principles in order to advance clinical management of fragility fractures by examining how skeletal biomechanics, size, shape, and ultra-structural properties are the ultimate predictors of bone strength. Accurate measurement of these skeletal parameters through the development of better imaging scanners is critical to advancing fracture risk assessment and informing clinicians on the best treatment strategy. With this information, a “treat to target” approach could be employed to tailor current and future therapies to each patient’s unique skeletal characteristics.

The Prevalence of Osteoporosis in China, a Nationwide, Multicenter DXA Survey

“…Generally, the population from North China had higher BMD values than the population from South China. This is associated with region‐related factors, such as sunlight, climate, food, and lifestyle …”

Lipid Peroxidation-Derived Aldehydes, 4-Hydroxynonenal and Malondialdehyde in Aging-Related Disorders

“…The current National Osteoporosis Foundation guidelines for the USA, coupled with the most recently available population data from the National Health and Nutrition Survey, show that the eligibility for osteoporosis treatment increases exponentially with age; roughly 10% of both men and women meet criteria for treatment at age 50 years, whereas 48% of men and 79% of women over 80 years meet treatment guidelines [ 19 ]. Current treatments for osteoporosis, which increase bone density and reduce fracture risk, include anti-resorptive medications (bisphosphonates and denosumab), which primarily increase endocortical bone and cortical thickness, and anabolic medications (teriparatide and abaloparatide), which increase the periosteal and endosteal perimeters, without causing large changes in cortical thickness [ 20 ].…”

Association Between Diet, Physical Activity and Body Mass Index, Fat Mass Index and Bone Mineral Density of Soldiers of the Polish Air Cavalry Units

“…We agree that BMD measured on the hip, spine, or total body are more highly recommended and more precise. However, there are other studies that use a forearm bone BMD [40,50,56,57] and the forearm is still one of the standard locations for DXA measurements [58]. Moreover, we conducted our study in the military unit; thus, we had the possibility to use only small-sized devices.…”