Secondary Osteoporosis.

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although post-menopausal osteoporosis is most common, up to 30% of post-menopausal women, >50% of premenopausal women, and between 50-80% of men have secondary osteoporosis. Exclusion of secondary causes is important as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis with advanced investigations reserved for premenopausal women and men aged <50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤-2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual energy x-ray absorptiometry (DXA), may underestimate fracture risk in some chronic diseases including glucocorticoid-induced osteoporosis, type 2 diabetes and obesity, and may overestimate fracture risk in others (e.g. Turner syndrome). FRAX ® and TBS may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥40 years and ≥50 years, respectively. In additional FRAX ® requires adjustment in some chronic conditions e.g. glucocorticoid dose, type 2 diabetes and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.