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Gina Woods, MD – Associate Clinical Professor, University of California, San Diego

Heather Hofflich, DO – Professor of medicine, UC San Diego

Kristen Nguyen, MD – Endocrinology Fellow, University of California, San Diego

Karen McCowen, MD MRCPI – Associate Professor of Medicine, University of California, San Diego

Kristen Nguyen, MD – Endocrinology Fellow, University of California, San Diego


Objective : We investigated underlying etiologies of low bone mass in patients with extremely low T score (below -4). Our hypothesis was that this population would be enriched in patients with identifiable causes of osteoporosis.  The goal was to determine whether investigation revealed specific secondary causes, and whether treatment was initiated in this population at high fracture risk.

Methods : With IRB approval, we generated a list of patients seen at our university over a 4 year span with T score below -4 at any site. Patients who received care for at least 1 year after the bone density test were included. The medical record was reviewed, and chart data extracted. We considered a minimum appropriate work up to include measurement of Vitamin D, PTH, chemistry panel, 24 hour urine calcium/ creatinine, and testosterone (males).

Results :

150 patients (mean age 75 years) were identified with T score below -4 at any site on bone densitometry. Of the 70 charts reviewed to this point (all women), 30% of the patients were Asian (much higher than our university practice prevalence of 8%). Average BMI was 21.5 kg/m2; underweight prevalence was 47% (BMI below 20 kg/m2). A clearly identifiable cause for osteoporosis was found in 34% of the population (prolonged immobilization (7%), rheumatoid arthritis/ or chronic inflammatory disorder (17%), extensive glucocorticoid exposure (12%), alcoholism (4%), and other (5%).  Of the remainder, appropriate work up was performed only in 7%. Among secondary causes, the only treatable new cause identified was primary hyperparathyroidism (2 cases). Fracture prevalence in the population was 53%. Despite this, 29% did not receive any treatment with anabolic or anti-resorptive therapy.

Discussion :

Fragility fractures, extreme leanness and Asian race were common in this group of patients with very low T score. However, few new underlying causes were identified, as workup was incomplete in the majority of cases in this academic medical center. In addition, rates of treatment following diagnosis of osteoporosis were suboptimal.

Conclusion :

Even well-informed clinicians at an academic medical center failed to investigate secondary causes of osteoporosis in this population with extremely low bone density. Underlying etiology of the low bone mass was either immediately evident or inadequately studied. Rates of treatment were low, especially considering high fracture rates.

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