Osteoporosis

Disease Description (Causes and Symptoms)

• Definition: Osteoporosis is a disease in which bone strength decreases and the risk of fractures increases because bone mass (the amount of bone) and bone quality (the structural integrity of bone) decrease.
• Main pathophysiology: Bone loss progresses due to an imbalance between bone resorption and formation (bone resorption > bone formation). Causes include decreased estrogen after menopause, reduced bone formation with aging, vitamin D deficiency·impaired calcium absorption, medications (such as glucocorticoids), and endocrine diseases (such as hyperthyroidism and hyperparathyroidism).
• Main symptoms: Often asymptomatic in the early stages. As it progresses, symptoms may include loss of height, kyphosis (hunched back), chronic lower back pain, and vertebral compression fractures, hip fractures, or wrist fractures that occur without trauma.

Treatment Methods and Precautions

• Diagnostic criteria (general): Bone mineral density testing (DXA) T-score ≤ -2.5 → osteoporosis. T-score -1.0 ~ -2.5 → osteopenia (pre-osteoporosis). A history of fracture is an indication for medication treatment.
• Non-pharmacological treatment (lifestyle management)
  • Calcium intake: Total intake (dietary + supplements) of 1,000–1,200 mg/day for general adults (adjusted according to age and health status).
  • Vitamin D: Generally 800–2,000 IU/day (adjusted according to the blood 25-OH vitamin D concentration).
  • Exercise: Prevent falls through weight-bearing exercise (walking, stairs, jumping exercises, etc.), strength training, and balance training.
  • Lifestyle habits: Quit smoking, limit excessive alcohol consumption (no more than 1–2 drinks per day), limit excessive salt and caffeine intake, and consume an appropriate amount of protein.
  • Fall prevention: Improve the home environment (slip prevention, improved lighting, etc.).
• Pharmacological treatment (standard options·precautions)
  • Bisphosphonates (bone resorption inhibitors)
    • Oral: Alendronate (e.g., 70 mg once weekly or 10 mg daily), risedronate, etc. Take while fasting with plenty of water and do not lie down for 30–60 minutes after taking it (risk of esophageal irritation·reflux).
    • Intravenous: Zoledronic acid 5 mg IV at 1-year intervals. Caution is needed with kidney function and acute-phase reactions; rarely, there is a risk of osteonecrosis (of the jaw).
  • Denosumab (monoclonal antibody): 60 mg subcutaneously every 6 months. When discontinued, there is a risk of rapid bone mineral density loss and rebound vertebral fractures (appropriate alternative treatment is needed after discontinuation). Caution is needed regarding hypocalcemia — correct calcium·vitamin D deficiency before treatment.
  • Bone-forming agents (anabolic agents)
    • Teriparatide 20 μg SC daily; the usual maximum treatment duration is 2 years. Temporary hypercalcemia may occur.
    • Abaloparatide is similar.
  • Romosozumab: Subcutaneous injection once a month (limited to 12 months); cardiovascular risk assessment is required.
  • Selective estrogen receptor modulators (SERMs): Raloxifene, etc. (prevention of vertebral fractures, increased risk of venous thromboembolism).
  • Hormone replacement therapy (women during menopause): Use after considering symptoms and risk level (risk of breast cancer·thrombosis).
  • Calcitonin: Limited use for the purpose of relieving bone pain.
• Complications and precautions during treatment
  • The side effects of each medication (esophageal irritation·gastrointestinal problems, hypocalcemia, acute bone pain·fever, jaw osteonecrosis, and, rarely, atypical femoral fractures, etc.) should be discussed, and risk factors should be assessed.
  • A dental examination is recommended before starting IV bisphosphonates or denosumab (to prevent osteonecrosis of the jaw).
  • Before starting medication, secondary causes should be evaluated and corrected based on calcium·vitamin D status, kidney function, PTH, etc.
  • Because the risk of fractures increases when denosumab is discontinued, a strategy to switch to another medication is needed when planning discontinuation.

Checklist Before an Outpatient Visit (Items to Bring·Information to Provide and Sample Questions)

• Items to bring/information to provide
  • List of currently taken medications·supplements (dose, duration of use) — especially steroids, anticonvulsants, thyroid hormones, etc.
  • Existing test results: Previous DXA (bone mineral density) test results (date of measurement·T-score), fracture history, and imaging (X-ray, CT, MRI).
  • Medical·surgical history (e.g., gastrectomy, intestinal surgery), chronic diseases (liver·kidney·gastrointestinal diseases), and family history (fracture or osteoporosis in the mother).
  • Lifestyle information: Smoking·alcohol consumption·amount of exercise·nutritional intake (calcium·protein), and fall risk factors.
• Checklist before an outpatient visit
  • Record changes in height and weight (loss of height), whether you have experienced any recent fractures, and whether you have lower back pain or any new pain.
  • Recent blood tests (if available) — calcium, 25-OH vitamin D, creatinine, and TSH are recommended.

Examples of General Questions to Ask the Doctor

• "Based on my T-score and FRAX results, do I need medication treatment?"
• "What are the long-term benefits and major side effects of the medication you recommend?"
• "What additional tests (blood tests·imaging) should be performed before starting treatment?"
• "How often will monitoring be performed during medication treatment, and what is the plan if treatment is discontinued or changed?"
• "What more should I do at home to reduce my risk of fractures?"

Examples of Disease-Specific Questions

• "I have a history of gastroesophageal reflux or esophagitis. Is it safe for me to take oral bisphosphonates? What alternative medications are available?"
• "I have heard that the risk of fractures increases if denosumab is discontinued. What transition strategy do you recommend if long-term treatment is discontinued?"

(If needed, if you provide your diagnostic results or the medications you are currently taking, we can organize more specific consultation points and recommended tests·treatment plans.)