Risk Factors

Risk factors and prevention

Many conditions, diseases and medications have been associated with an increased risk of osteoporosis-related fracture.

Table 1. Conditions, diseases and medications that may cause or contribute to osteoporosis and fractures.1–3

Lifestyle factors    
Low calcium intake*
High caffeine intake
Alcohol (≥3 units/day)*
Smoking*
Methadone/opiates*

vitamin D insufficiency
high salt intake
sedentary lifestyle
falling

excess vitamin A
aluminium (in antacids)
immobilisation*
low body weight
Genetic factors    
Cystic fibrosis
Ehlers-Danlos
Gaucher’s disease
Glycogen storage diseases
Hemochromatosis
homocystinuria
hypophosphatasia
Idiopathic hypercalciuria
Marfan syndrome  
Menkes’s steely hair syndrome
osteogenesis imperfecta
family history of hip fracture
Porphyria
Riley-Day syndrome
Hypogonadal states    
Androgen insensitivity
Anorexia nervosa and bulimia
Early menopause*
hyperprolactinemia
panhypopituitarism
premenopausal
oligomenorrhea
Turner’s and Klinefelter’s syndromes
athletic amenorrhea
low testosterone (men only)*
Endocrine disorders    
Adrenal insufficiency*
Cushing’s syndrome 


diabetes mellitus
hyperparathyroidism

thyrotoxicosis
acromegaly
Gastrointestinal disorders    
Celiac disease
Gastric bypass
Pancreatic disease
inflammatory bowel disease
malabsorption*
primary biliary cirrhosis
gastro-intestinal surgery
Hematological disorders    
Hemophilia*
Leukemia and lymphomas
multiple myeloma  
sickle cell disease* systemic mastocytosis
thalassemia
Pulmonary diseases    
Emphysema* sarcoidosis  
Rheumatic and autoimmune diseases    
Ankylosing spondylitis systemic lupus erythematosus rheumatoid arthritis
Miscellaneous    
Low nadir CD4+ cell count*4
Alcoholism
Amyloidosis
hepatitis C infection*4
multiple sclerosis
end-stage renal disease
current protease inhibitor use*5
muscular dystrophy
parenteral nutrition
Chronic metabolic acidosis
Congestive heart failure
epilepsy
idiopathic scoliosis
post-transplant bone disease
depression
Medications    
Anticoagulants
Anticonvulsants
Aromatase inhibitors
Glucocorticoids
Excess thyroxine*
chemotherapy
cyclosporine A and tacrolimus   
  
depo-medroxyprogesterone
glitazones* 
proton pump inhibitors*
gonadotrophin-releasing hormone agonists
lithium
antiretrovirals*
barbiturates

*Particularly relevant to people living with HIV (PLWHIV).




In addition to the effects of HIV and ART, classic osteoporosis risk factors that are established in the non-HIV-infected population should be taken into consideration when predicting who will be at risk of low bone mineral density (BMD).6



Strongest risk factors for osteoporosis in the general population:7

  • female sex
  • older age
  • family history of hip fracture
  • vitamin D deficiency
  • low body mass index (BMI; ≤19 kg/m2)
  • smoking
  • sedentary lifestyle
  • long term glucocorticosteroid use (>5 mg prednisone or equivalent for ≥3 months)
  • history of low impact fracture
  • excess alcohol intake (>3 units/day)
     


Factors associated with low BMD in PLWHIV:8

  • low body weight/BMI
  • duration of HIV infection
  • older age
  • smoking
  • non-black/white ethnicity
  • stavudine exposure
  • steroid exposure
  • female sex
  • high HIV RNA level
  • tenofovir exposure
  • protease inhibitor (PI) exposure
  • duration of nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) exposure
     

Prevention

Many of the risk factors associated with osteoporosis are modifiable, and patients without low BMD can help maintain bone health by ensuring that they have an adequate intake of calcium and maximize their levels of vitamin D (either through dietary intake or regular exposure to sunlight), take regular weight-bearing and muscle-strengthening exercise, and avoid smoking and excessive alcohol intake. The risk of falling should also be minimized by ensuring vision or hearing is not impaired and that medications are not affecting balance. 




References

  1. McComsey GA, Tebas P, Shane E, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clin Infect Dis. 2010;51:937–946. 
  2. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Accessed 21 February 2011.
  3. US Department of Health and Human Services. Bone Health and Osteoporosis: A report of the Surgeon General. Chapter 3. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General, 2004.
  4. Young B, Dao CN, Buchacz K, et al. Increased rates of bone fracture among HIV-infected persons in the HIV outpatient study (HOPS) compared with the US general population, 2000–2006. Clin Infect Dis. 2011;52(8):1061–1068.
  5. Womack JA, Goulet JL, Gibert C, et al. Increased risk of fragility fractures among HIV-infected compared to -uninfected male veterans. PLoS One. 2011;6:e17217. 
  6. Yin M, Dobkin J, Brudney K, et al. Bone mass and mineral metabolism in HIV+ postmenopausal women. Osteoporos Int. 2005;16:1345–1352. 
  7. European AIDS Clinical Society (EACS). Guidelines. Version 8.2. Accessed 17 April 2017.
  8. Mallon PW. HIV and bone mineral density. Curr Opin Infect Dis. 2010;23:1–8.