The basics - Managing osteoporosis

Patients with the highest future fracture risk should be prioritised, says Dr Pam Brown.

Fractures can result in mortality, morbidity and loss of independence (Photograph: SPL)
Fractures can result in mortality, morbidity and loss of independence (Photograph: SPL)

Osteoporosis is a progressive, skeletal disease of low bone mass and micro-architectural deterioration of bone resulting in increased fracture risk. It can be thought of as a chronic skeletal disease, with fracture as the acute exacerbation.

Fragility fractures can result from falls or due to minor trauma in those aged over 50 years. However, underlying osteoporosis is only treated in 10 to 14 per cent of such cases.

Fractures result in mortality, morbidity and loss of independence and cost around £1.8 billion and two million bed-days annually.

1. Identification
Prioritise those at highest future fracture risk, namely patients with previous fragility fractures. Have a high index of suspicion for vertebral fractures in those over 50 with kyphosis, height loss or acute thoracic or lumbar back pain.

Fracture liaison services identify and flag up these patients in some parts of the country, often initiating therapy. Avoid treating the low-risk, worried well, but consider identifying and assessing others at high risk:

  • Oral steroids.
  • Early menopause (<45 years).
  • Parental hip fracture.
  • Rheumatoid arthritis; Crohn's disease; ulcerative colitis; coeliac disease; hyper(para)thyroidism; gastric surgery.
  • Chronic liver or kidney disease.
  • Recurrent falls.

DXA will confirm the diagnosis and help you decide who to treat. DXA units may provide guidance on who qualifies for scanning.

2. Investigation
Many patients will require investigation. To exclude malignancy or other underlying conditions, undertake FBC, ESR, thyroid profile, a coeliac screen, and a myeloma screen (urinary Bence-Jones proteins and protein electrophoresis). In men, test early morning testosterone and cortisol.

To determine suitability for treatment, investigate renal function and bone profile. To assess for suspected vertebral fractures, request an X-ray, which can also identify any other bony lesions, for example secondaries. Those with vertebral fractures, previous malignancy and men are at high risk of underlying conditions and should always be investigated.

3. Guidelines
NICE has produced guidance which informs DXA and treatment decisions (see references), but clinicians should use their judgment to evaluate individual patients.

The UK FRAX calculator and its link to the National Osteoporosis Guideline Group (NOGG; see references) guidance also advise on who needs DXA and who may benefit from treatment. This can be used with or without femoral neck bone density from DXA.

The Royal College of Physicians (RCP) 2002 guidance on prevention and management of steroid-induced osteoporosis has not yet been superseded by the NICE guideline, still in development.

4. Management options
In cases of fragility fracture or secondary prevention:

  • Postmenopausal women (NICE TA161): treat if T-score on DXA ≤-2.5; if ≥75 years can treat without prior DXA.
  • Men and premenopausal women >50 years (FRAX score and NOGG guidance): amber and red zone need DXA; consider referral.
  • Men and premenopausal women <50 years: refer.

In cases of steroid-induced osteoporosis or those at-risk (RCP guidance):

  • Treat those ≥65 years or with previous fractures.
  • Treat those <65 years and no previous fractures if T-score on DXA

For primary prevention:

  • If there are silent/undiagnosed vertebral fractures: manage as for secondary prevention.
  • Premenopausal women with proven osteoporosis: refer.
  • If >50 years, follow NICE TA160 or FRAX and NOGG: DXA if amber or red zone; treat or reassure.

Postmenopausal women with fracture and osteopenia are a difficult group, since they have already demonstrated bone fragility, and half of fractures will occur in people with osteopenia rather than osteoporosis. NICE does not recommend treatment, but it may be appropriate to carry out a FRAX score and consider treatment if NOGG recommends it.

5. Treatment
All patients at risk of fracture should receive lifestyle advice (for example, smoking cessation, dietary calcium, alcohol intake, weight-bearing exercise, falls assessment/gait and balance training). Those with osteoporosis should receive education about treatment benefits/risks and how to take treatments.

Drug treatments include calcium and vitamin D, alendronate, risedronate, ibandronate, strontium ranelate, denosumab, zoledronate, and parathyroid hormone.

All those requiring bone-sparing therapy and the elderly without previous fractures should receive calcium (1,000mg) and vitamin D (800IU). Consider initiating these two weeks before treatment to check tolerability.

Generic once-weekly alendronate (70mg per week) should be first-line unless there are contraindications. If the patient is intolerant, risedronate 35mg once-weekly or ibandronate 150mg monthly are options.

If there are upper GI problems or the patient is intolerant of oral bisphosphonates, consider oral therapy with strontium ranelate unless contraindicated, or referral for denosumab or zoledronate. All treatments need to be taken exactly as directed to ensure optimal absorption. If the patient does not tolerate or fails on oral treatment, refer to the local bone clinic.

People with recent fracture require pain relief and those with previous vertebral fracture may have chronic severe back pain, breathing difficulties and abdominal symptoms. Adherence and persistence with therapy is poor; only 50 per cent continue therapy at one year. However, five or more years' treatment is required for optimal fracture reduction. Check adherence three months after starting therapy and at annual medication review.

6. Referral
Consider referring those with diagnostic difficulty or who need specialist investigation or treatment. Premenopausal women and men with proven osteoporosis or fragility fractures and not on oral steroids are also best referred.

People intolerant of oral treatments or with treatment failure (further fracture after one year's full compliance) can be considered for IV bisphosphonate or denosumab; these are usually initiated in secondary care.

Those with other metabolic bone disease or abnormal bone profiles (for example, osteomalacia), Paget's disease or renal failure may be more appropriately investigated and managed in secondary care.

Key points
  • Osteoporosis is a progressive, skeletal disease resulting in increased fracture risk.
  • Patients at highest fracture risk (for example, with previous fragility fractures) should be prioritised.
  • DXA will confirm the diagnosis and can help with treatment decisions.
  • Guidelines from NICE, the RCP and FRAX/NOGG will inform DXA and treatment decisions, but clinicians should use their judgment to evaluate individual patients.
  • Treatment can range from lifestyle advice and vitamin supplements, to oral bisphosphonates and SC/IV administered drugs.
  • Adherence and persistence with drug therapy is very poor.
  • Dr Brown is a GP in Swansea
References

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