Bone density test is recommended in all women over the age of 65; women with any of the following risk factors should be screened at an earlier age: For patients who are likely to be on prednisone 5 mg qd or more for > 3 months, anticipate bone loss. Give a bisphosphonate plus calcium and D.

HPHC offers the following risk factors (which warrant DEXA bone density scan between ages 47 and 64):

Changes in BMD of < 4% in the vertebrae and 3-6% in the hip are within the range of the inherent measurement error of the DEXA scanners. Alendronate and residronate increase LS BMD by 5-7% and hip BMD by 3-6% when used for about 3 years. Alendronate use for 10 years has been associated with an increased BMD of 14% in the LS spine and 7% in the hip (5.4% in femoral neck). The frequency of testing BMD should be no more than every 2-3 years. Whether it is useful to test patients currently on therapy with a bisphosphonate is unclear.

Who should be treated?: The National Osteoporosis Foundation recommends initiating therapy in women with T-score of <= -2.0 by hip DEXA and no risk factors OR those with a history of low-trauma hip or spine fractures. Women with one or more risk factors should be treated if they have a T-score < -1.5.
WHO criteria should not be applied in the diagnosis of osteoporosis in premenopausal women, and the Z-scores rather than T-scores should be used. The International Society for Clinicial Densitometry states that the diagnosis of osteoporosis in this group requires low BMDs and a secondary cause (diagnosis should never by based on BMD scores alone).
Monitoring treatment: There is some controversy about monitoring, as it is quite unclear what to do with a woman whose bone density is falling in spite of bisphosphonate treatment. If we don't know what to do, why bother checking FU DEXA scans? This is the current debate (as of 12/05 - see Johns Hopkins Advanced Studies in Medicine 5:547, editorial by Rosenfeld in 11/05).

Evaluation of patients with osteoporosis:
Basic testing in most patients with osteoporosis includes a chemistry profile (including electrolytes, blood urea nitrogen, creatinine, calcium, magnesium, phosphorus, alkaline phosphatase, protein and albumin), complete blood count, and serum thyrotropin (TSH) measurement. Measurements of markers of bone turnover for diagnostic purposes are not recommmended.

There are patients in whom the history, physical examination, or initial laboratory data reveal features suggestive of other contributing diseases: