Category: Calcium/Bone Disorders

Monitor: 29

29 - ETIOLOGY OF LOW BONE MASS IN PATIENTS WITH T SCORE BELOW -4 ON BONE DENSITOMETRY

Thursday, Apr 25
1:00 PM – 1:30 PM

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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Kristen Nguyen

Endocrinology Fellow
University of California, San Diego
San Diego, California

Dr. Kristen Nguyen is a southern California native. She completed her Neuroscience degree at UC Riverside and received her MD from UCLA David Geffen School of Medicine. She completed her internal medicine residency at Kaiser Permanente in Fontana, California. She is currently a fellow at the UCSD Endocrinology and Metabolism Fellowship program.

Gina Woods

Associate Clinical Professor
University of California, San Diego
San Diego, California

My overarching career goal is to find clinically meaningful solutions for patients at risk for or affected by osteoporosis and other metabolic bone diseases. I treat patients in the osteoporosis clinic, and am actively involved in medical education at UCSD. My research interests in bone health began with my work on the effects of sex-hormones on age-related kyphosis. I published findings in men from the Osteoporotic Fractures in Men (MrOS) study, and in women from the Study of Osteoporotic Fractures (SOF). My current research focuses on understanding the effects of bone marrow adipose tissue on age-related bone loss. Using data from the AGES-Reykjavik cohort, I have presented findings annually at the Bone Marrow Adiposity Meeting in 2016, 2017 and 2018, and have published manuscripts looking at the associations between bone marrow adiposity and sex hormones, and with chronic kidney disease.

Heather Hofflich

Professor of medicine
UC San Diego, California

Dr. Heather Hofflich is a Professor of clinical medicine practicing Internal Medicine and Endocrinology at UC 
San Diego Health System since 2008. Board-certified in endocrinology and internal medicine, Dr. Hofflich is a leading San Diego expert in the prevention, diagnosis and treatment of osteoporosis. Her research interests include new therapies for the treatment of osteoporosis and she is currently conducting a phase II clinical trial at UCSD in this area. Dr. Hofflich was recently appointed to Clinical Medical Director of the La Jolla Internal Medicine Clinic in July 2018
Dr. Hofflich completed an internship in internal medicine at the Pennsylvania Hospital of the University of Pennsylvania Health System, residency at Beth Israel Medical Center in New York City, and an endocrinology fellowship at University of California, Irvine. She earned her Doctor of Osteopathy at Philadelphia College of Osteopathic Medicine in 2001 and received her BA at Cornell University in 1997.
Dr. Hofflich is a fellow of the American College of Endocrinology and an International Society for Clinical Densitometry (ISCD)-Certified Clinical Densitometrist (CCD). From 2012-2015, 2017-2018, she was named a “Top Doctor” by the San Diego County Medical Society.
Outside of the clinic, Dr. Hofflich enjoys spending time with her family, as well as hiking, reading, running and swimming.

Karen McCowen

Associate Professor of Medicine
University of California, San Diego
La Jolla, California

Medical School-- Trinity College, Dublin, Ireland ; Residency-- The Mayo Clinic, Rochester, MN; Endocrinology fellowship- Harvard Medical School Longwood Program; Current position, Associate Clinical Professor, University of California San Diego

Kristen Nguyen

Endocrinology Fellow
University of California, San Diego
San Diego, California

Dr. Kristen Nguyen is a southern California native. She completed her Neuroscience degree at UC Riverside and received her MD from UCLA David Geffen School of Medicine. She completed her internal medicine residency at Kaiser Permanente in Fontana, California. She is currently a fellow at the UCSD Endocrinology and Metabolism Fellowship program.