Ten tips on osteoporosis
Musculoskeletal GPSI Dr Louise Warburton’s management tips based on latest NICE guidance, published earlier this month
Musculoskeletal GPSI Dr Louise Warburton's management tips based on latest NICE guidance, published earlier this month
1. Decide which patients are at highest risk of having osteoporosis.
Use the following criteria:
• those committed to at least three months of any dose of oral steroid
• those with a recent or previous low trauma fracture (a fracture sustained by a fall from standing height or less, after the age of 50)
• the frail, housebound elderly or those in care homes.
2. Osteoporosis is diagnosed by dual energy X-ray absorptiometry (DXA) scanning and scan reports should guide treatment. DXA scans are reported as T-scores, comparing the patient's BMD with that of a fit, healthy young adult. Osteopenia is defined as a T-score of -1 to -2.5 SD and osteoporosis as less than -2.5 SD.
3. It is not cost-effective to screen the whole population but we should identify which patients need a DXA scan. Indications are:
• low-trauma fracture or vertebral deformity, age under 75
• oral steroid therapy, age under 65, no low trauma fracture
• men and women with primary hypogonadism
• premature menopause (under the age of 45) or prolonged amenorrhoea
• radiographic evidence of osteopenia
• chronic disease associated with osteoporosis
– anorexia nervosa
– primary hyperparathyroidism
– chronic renal failure
– prolonged immobilisation
– Cushing's syndrome
– rheumatoid arthritis
• postmenopausal women with maternal hip fracture or BMI <19 kg/m2.
4. Sometimes bone-sparing medication can be started without a DXA scan. NICE recommends women over 75 with a low-trauma fracture should receive bone-sparing treatment without a scan.
5. Patients diagnosed with osteoporosis and low-trauma fractures should have the following:
• FBC, ESR or CRP
• renal and liver profile
• bone profile
• thyroid profile
• urinary Bence-Jones protein or serum immunoglobulin electrophoresis
• testosterone/androgen screen for men.
It is also useful to check vitamin D levels. Female Asian patients who do not expose themselves to sunlight because of their dress code are often vitamin D deficient. This can cause osteomalacia and also needs to be addressed.
6. Hyperparathyroidism is a cause of osteoporosis in many elderly patients. Primary hyperparathyroidism results from excessive release of PTH and manifests as hypercalcaemia. Patients with hypercalcaemia who have normal renal function and no malignancy must be tested for elevated PTH levels. Hyperparathyroidism is often discovered during routine laboratory testing when hypercalcaemia is noted.
Most patients can be monitored by watchful waiting once the cause has been established as primary hyperparathyroidism, but MUST be referred for DXA scanning.
7. Encourage patients to engage in primary prevention. All patients at risk should be encouraged to stop smoking, eat a well-balanced diet containing at least 700mg daily calcium, and aim for 20 minutes' sun exposure to face and arms daily during summer months. Patients already diagnosed with osteoporosis should aim for 1,200mg daily calcium intake. Those with low fracture risk should be encouraged to undertake vigorous weight-bearing exercise, or resistance exercise (slow lifting of moderate weights) to maintain or improve BMD, while t'ai chi and balance work may reduce risk of falls in the elderly. Those at risk of vertebral fractures should avoid heavy lifting or forced flexion activities.
NICE released a final appraisal on primary prevention earlier this month.
Alendronate is recommended in women aged 70 and over who have an independent risk factor for osteoporosis or an indicator of low BMI.
In a woman over 75 a DXA scan is not required if she has two or more clinical indicators of an increased fracture risk or low BMD.
Etidronate and risedronate can be used if the woman is intolerant of alendronate.
Strontium ranelate is recommended if the woman is intolerant of bisphosphonates. NICE has produced guidance based on a combination of risk factors and bone density. Raloxifene is not recommended for primary prevention.
8. Bisphosphonates are first line for established osteoporosis. Alendronate, etidronate and risedronate are recommended in postmenopausal women:
• 75 and older, without the need for a DXA scan
• between 65 and 74, if osteoporosis is confirmed with a scan
• under 65, if their T-score is –3 SD or below, or if they have a confirmed diagnosis of osteoporosis and one or more of the following:
– they are very underweight
– their mother had a hip fracture before age 75
– they had an early menopause that was untreated
– they have a condition that increases the risk of osteoporosis, such as RA, IBD or hyperthyroidism
– they have a medical condition that has immobilised them.
9. Consider the alternatives if the patient cannot tolerate bisphosphonates or they do not work. Alternative treatments are raloxifene and teriparatide. Strontium ranelate is still being considered by NICE as a technology appraisal.
10. Carry out a practice audit. Search practice records for those over 65 who have had a fracture, are using bisphosphonates, raloxifene, teriparatide, strontium ranelate or high-dose calcium and vitamin D. Suggestions for audit:
• All postmenopausal women who have had
a low trauma fracture should be managed as recommended in NICE Technology Appraisal 87. Standard: 80%.
• Patients on oral steroids for more than three months should be managed according to Royal College of Physicians 2002 guidelines. Standard: 80%.
• Frail elderly in care homes who have no previous low trauma fractures should be treated with high-dose calcium/vitamin D. Standard: 90%.
Dr Louise Warburton is a GPSI in musculoskeletal medicine in Ironbridge, Shropshire
Competing interests None declaredWomen over 75 with a low trauma fracture can start treatment without a DEXA scan Women over 75 with a low trauma fracture can start treatment without a DEXA scan