Drug-induced Osteoporosis in the Older Adult

Mary Beth O'Connell; Laura M Borgelt; Susan K Bowles; Sheryl F Vondracek

Disclosures

Aging Health. 2010;6(4):501-518. 

In This Article

Abstract and Introduction

Abstract

The elderly population is at risk for polypharmacy and, therefore, also at risk for drug-induced osteoporosis (DIOP). Epidemiologic studies provide valuable information about medications that may place patients at risk for DIOP. While glucocorticoids are the most common cause of DIOP, the use of several other therapeutic agents can place patients at risk for significant bone loss and fracture. These medications include, but are not limited to, aromatase inhibitors, gonadotropin-releasing hormone agonists, thyroid replacement therapy, antiepileptics, antidepressants, antipsychotics, lithium, gastric acid lowering agents, thiazolidinediones, loop diuretics, heparins and warfarin, vitamin A and cyclosporine. This article provides information about their mechanism of action, studies that have evaluated these agents in DIOP and prevention and treatment strategies.

Introduction

Seniors are at risk for osteoporosis as well as polypharmacy. Osteoporosis increases with aging, with estimates suggesting that approximately 52% of women 80 years of age or older have osteoporosis.[1] The incidence of osteoporotic fractures increases from 20.6 and 9.4 per 10,000 individuals for white women and men aged 65–69 years old, respectively, to 180 and 92 per 10,000 for white women and men aged 80–84 years old, respectively.[2] Many medications can lower BMD and increase fracture risk in both women and men (Table 1).[1,3–47,201] Thus, secondary causes should be explored in seniors with or at risk for osteoporosis. A concise overview of most medications that can cause drug-induced osteoporosis (DIOP) is provided.

Most data regarding the mechanism of action for medications known to alter BMD come from animal or in vitro bone cell culture studies. The magnitude of risk for DIOP and fragility fractures is drawn predominantly from epidemiology studies that identify associations rather than establish causality. These epidemiologic studies vary greatly in size, patient selection, prospective versus retrospective data collection, risk factors for osteoporosis and, especially important for this topic, quantification of medication use (e.g., reason for use, dose, duration and adherence). Fractures can also be underestimated in these observational studies, especially vertebral fractures, because the majority of these fractures tend to be silent and are often detected by lumbar spine films. Furthermore, some studies include trauma-related and/or non-osteoporotic fractures. Meta-analyses include studies with primary and secondary data analysis of DIOP.

Prevention and treatment strategies for medication-related osteoporosis are largely extrapolated from the medical and pharmacotherapeutic principles of primary osteoporosis. Clinical trials data and guidelines or recommendations exist for some hormonal medications causing osteoporosis.

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