Carter Lurk

Background: Osteoporosis is loss of Bone Mineral Density (BMD) leading to an increased risk of fractures¹. In the US, osteoporosis impacts 10.2 million adults aged over 50 with 43.1% experiencing a prevalence of low bone mass¹. Osteoporosis is often diagnosed via Dual Energy X-Ray Absorptiometry (DEXA) measuring BMD, fracture risk is assessed via the Fracture Risk Assessment Tool (FRAX), and treatment monitored via Bone Turnover Biomarkers (BTMs). DEXA diagnosed osteoporosis occurs when BMD is ≥2.5 standard deviations below peak bone mass². The FRAX considers validated clinical risk factors to predict 10-year probabilities of major osteoporotic fractures and determines therapeutic intervention recommendations³. BTMs are byproducts produced during the bone remodeling process that are reflective of systemic bone turnover^4,5. The loss of BMD and microarchitectural deterioration leads to increased risk of fragility fractures which are associated with an 8-36% excess mortality within 1 year and annual fracture-related costs expected to reach $95 billion by 2040^2,3.

Methods: PubMed searches including the terms: “Osteoporosis Diagnosis”, “Osteoporosis Biomarkers”, and “FRAX and DEXA”

Results: The diagnosis and management of osteoporosis is made through the DEXA defined BMD measurement, however, 47% of patients experiencing fragility fractures do not have a T-score indicating osteoporotic bone density⁴. Therefore, DEXA defined BMD is insufficient for evaluating bone strength and osteoporosis-associated fragility fractures⁴. The FRAX algorithm severely underestimates the risk to patients under 65 with scores below the threshold for treatment in 68% of patients at the time of a fragility fracture⁶. BTMs have significance in monitoring treatment response but currently have limited utility in diagnosing osteoporosis or predicting fragility fractures^4,5. However, they represent the largest area of potential breakthrough to improve osteoporosis diagnosis and fracture prediction. Further research is required to improve the diagnostic potential of BTMs as well as implementation into the FRAX algorithm to enhance fracture prediction.

Conclusion: Currently, patients often experience a fragility fracture before reaching the T-score threshold for osteoporosis diagnosis. They are defined as below threshold for treatment according to the FRAX assessment despite suffering a fragility fracture. Additionally, the lack of BTMs further complicates accurate diagnosis and prediction of osteoporosis and fractures. These shortcomings exemplify the inadequacy of the current definition and assessment of osteoporosis, suggesting a need for adjustments that prioritize patient needs. Rather than continuing with the current ineffective and reactive standards, it is crucial to adapt treatments to better serve patients in a proactive manner that does not fit the conventional criteria.

Works Cited:

1. CDC. Products – Data Briefs – Number 405 – March 2021. www.cdc.gov. Published March 26, 2021. https://www.cdc.gov/nchs/products/databriefs/db405.htm
2. Pouresmaeili F, Kamali Dehghan B, Kamarehei M, Yong Meng G. A comprehensive overview on osteoporosis and its risk factors. Therapeutics and Clinical Risk Management. 2018;14(1):2029-2049. doi:https://doi.org/10.2147/tcrm.s138000
3. LeBoff MS;Greenspan SL;Insogna KL;Lewiecki EM;Saag KG;Singer AJ;Siris ES; (n.d.). The Clinician’s Guide to Prevention and treatment of osteoporosis. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. https://pubmed.ncbi.nlm.nih.gov/35478046/
4. Williams, C. (2023, May 1). Osteoporosis markers. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK559306/
5. Lorentzon, M., Branco, J., Brandi, M. L., Bruyère, O., Chapurlat, R., Cooper, C., Cortet, B., Diez-Perez, A., Ferrari, S., Gasparik, A., Herrmann, M., Jorgensen, N. R., Kanis, J., Kaufman, J.-M., Laslop, A., Locquet, M., Matijevic, R., McCloskey, E., Minisola, S., … Cavalier, E. (2019a, August 22). Algorithm for the use of biochemical markers of bone turnover in the diagnosis, assessment and follow-up of treatment for osteoporosis – advances in therapy. SpringerLink. https://link.springer.com/article/10.1007/s12325-019-01063-9
6. Roux, S., Cabana, F., Carrier, N., Beaulieu, M., April, P.-M., Beaulieu, M.-C., & Boire, G. (2014, July 1). The World Health Organization Fracture Risk Assessment Tool (FRAX) underestimates incident and recurrent fractures in consecutive patients with fragility fractures. OUP Academic. https://academic.oup.com/jcem/article/99/7/2400/2537750