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Osteoporosis
General Practitioner, The Ridgeway Surgery, Worcestershire
E-mail: bleeprldavies{at}hotmail.com
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Abstract |
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Abstract
The GP curriculum and...Osteoporosis occurs mostly in postmenopausal women and patients taking long-term corticosteroids. In women, the lifetime risk is 40% and men have a much lower but still significant risk of 13%. The survival rates after hip fracture vary with the patient's age, for women between the ages of 65–69 years 1-year survival is 11%, while for men over 90 the figure is 67%. Hip fractures and other osteoporotic fractures can have an enormous impact on a patient's mobility and quality of life, leading to increase use of social care services and informal carers. The cost of osteoporosis and fractures is immense, this cost not only relates to the initial hospital care but also ongoing social care costs. Each admission from fractured hip can cost the NHS over £8,000. The main aim of treatment is to prevent fractures and to reduce the both morbidity and mortality.
Osteoporosis is listed as an important condition in the knowledge base for section 15.9 of the GP curriculum (Rheumatology, musculoskeletal & trauma). This section outlines the skills and attitudes needed to treat osteoporosis in primary care. It covers primary care management, person-centred care, problem solving skills, community and holistic approaches to osteoporosis.In particular it requires GPs to be able to:
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Definition |
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Osteoporotic bone is defined as bone with a bone mineral density (BMD) of >2.5 standard deviations (SDs) below the young adult mean (T-score of –2.5 or lower). There is a two- to three-fold increase in the relative risk of fracture for each SD reduction in BMD. X-rays may suggest ‘osteopoenia’ but should not be relied upon for diagnosis; these patients should be referred on for dual energy X-ray absorptiometry (DEXA) scanning (Fig 1).
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Risk factors for osteoporosis |
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Increasing age is a risk factor for osteoporosis and there are a number of age-independent risk factors (Box 2). For patients taking glucocorticoid medication, make sure the lowest dose necessary to control the original condition is used for the shortest possible time. The rate of bone loss is greatest in the first few months of steroid use, so it is important to start treatment early. Advise all patients taking any dose of oral steroids to take calcium and vitamin D supplements. In addition for patients taking oral (equivalent of prednisolone 7.5 mg or more each day) or high-dose inhaled steroids for over 3 months add in a bisphosphonate for patients over 65 years. For patients under 65, refer for a DEXA scan and add in treatment if T-score is
–1.5. | Box 1. Major age-independent risk factors for osteoporosis Glucocorticoid use Previous fragility fracture (this includes vertebral collapse) Low body mass index (BMI) <19 kg/m2) Family history of maternal hip fracture aged <75 years Untreated premature menopause, prolonged amenorrhoea or male hypogonadism Conditions associated with prolonged immobility Medical disorder independently associated with bone loss
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| Box 2. Falls prevention Falls are one of the biggest risk factors for fracture. Tendency to fall increases with age. Measures to decrease the risk of falls and damage from falling include.
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History and examination |
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Presentation is usually as a fractured bone caused by minimal trauma. With a fragility fracture, the fall causing the break is from less than standing height. Common fracture sites include the hip, wrist and spine. Other patients present with back pain associated with crush fracture, height loss and thoracic spine osteoporotic kyphosis (known as Dowager's hump). Osteoporotic vertebral collapse may cause severe pain. The pain can take from 3–6 months to resolve and strong analgesia is often needed to control the pain.
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Diagnosis: DEXA scans |
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Radiological osteopoenia may suggest thin bones but cannot be used to make a definite diagnosis of osteoporosis. BMD is assessed at the hip and lumbar spine by a DEXA scan. Local referral guidelines for DEXA scanning apply. Generally, treatment is started if the T-score is
–2.5. National guidance is expected in the near future from NICE, and this should contain information on referral criteria for DEXA scanning, fracture risk, osteoporosis management and time interval for rechecking BMD.
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Fragility fracture |
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For any patient with a confirmed fragility fracture, it is important to exclude other causes of pathological fracture, such as fracture due to malignancy, ostomalacia or hyperparathyroidism. Check fullblood count, ESR, thyroid function, creatinine, bone and liver function tests - all should be normal. In addition, consider checking serum paraproteins and urine Bence Jones protein, an isotope bone scan particularly if past history of malignancy, and follicle stimulating hormone, luteinizing hormone, and for men serum testosterone, if hormonal status is unclear. Once other causes of fragility fracture have been excluded, treat patients over the age of 75 for osteoporosis without obtaining a DEXA scan. For patients under the age of 75, refer for a DEXA scan. Treat for osteoporosis only if:- aged 65-74 years and DEXA confirms osteoporosis (T-score £ 2.5)- aged under 65 years and very low BMD (T score £ -3) or if T score is £ -2.5 and the patient has one or more additional risk factors for osteoporosis apart from age.
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Non-pharmacological management |
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It is important to offer lifestyle advice to patients at risk of osteoporosis, as well as to patients with confirmed reduction in BMD. NICE published advice for secondary prevention of osteoporosis in 2005, it suggested if clinicians are confident patients have adequate calcium and vitamin D intake supplements, are not needed. However, the research studies used to develop the NICE guidance all gave supplements, and in practice they are prescribed to most patients. If patients cannot tolerate supplements, it is important to ensure the patient's diet contains adequate levels of calcium and vitamin D (Tables 1 and 2).
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Regular weight-bearing exercise lasting longer than 30 minutes a day can reduce the fracture rate and it is important to highlight the risks of being underweight (BMI < 19 kg/m2).
Stopping smoking is another important area to cover with the patient, stopping smoking; premenopause leads to a 25% reduction in fracture rate postmenopause. Alcohol consumption should also be limited to less than 21 units a week for men and 14 units a week for women. Measures should be taken to reduce the risk of falls and to reduce the damage from falls (Box 2).
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Pharmacological management |
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Calcium (0.5–1 g/day) and vitamin D (800 IU/day) supplements are given alongside other treatments routinely. On their own, supplements can be given to postmenopausal women with dietary deficiency, patients on long-term steroids, or who are over 80 years of age, housebound or institutionalized.
Bisphosphonates are adsorbed onto bone and slow its turnover. They are the mainstay of treatment and prevention of osteoporosis. Alendronate and risedronate reduce vertebral and non-vertebral fractures. Osteonecrosis of the jaw had been seen after intravenous bisphosphonates and rarely after oral preparations. Patients should be advised to have dental work carried out before starting oral treatment. Patients are advised to take bisphosphonates with a glass of water first thing in the morning on an empty stomach. Some patients suffer gastrointestinal side effects despite following this advice.
Strontium ranelate 2 g/day in water increases formation and decreases resorption of bone. It is used for postmenopausal osteoporosis particularly when bisphosphonates are contraindicated or not tolerated. In postmenopausal women, it has been shown to reduce both vertebral and non-vertebral fractures.
Selective oestrogen receptor modulators, for example raloxifene 60 mg once a day are another option. They have been shown to reduce vertebral fractures but can increase the patient's risk of thromboembolism.
Hormone replacement therapy (HRT) postpones postmenopausal bone loss and decreases fractures. The optimum duration of use is uncertain but benefits disappear within 5 years of stopping. Higher rates of breast cancer and cardiovascular problems limits use. For patients with premature menopause, HRT is recommended for the prevention of osteoporosis until women reach 51 years. Above 51 years, HRT should not be considered first-line therapy for long-term prevention of osteoporosis. HRT remains an option where other therapies are contraindicated, cannot be tolerated or if there is a lack of response. Risks and benefits should carefully be assessed. Supplemental testosterone is used in male patients with hypogonadism-associated osteoporosis.
Recombinant parathyroid hormone and teriparatide (a recombinant fragment of parathyroid hormone) are sometimes initiated by specialists for the treatment of postmenopausal osteoporosis. Both are administered by daily subcutaneous injection, in most cases by the patient themselves after suitable education. They are usually used in patients with extremely low BMD or in patients with multiple fractures and other risk factors for osteoporosis.
Calcitonin is involved in bone turnover and can be used in the prevention and treatment of postmenopausal osteoporosis. It is administered intranasally and given alongside calcium and vitamin D supplementation.
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Referral |
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Routinely refer to endocrine or menopause clinic if premature menopause (under the age of 40) to determine the possible cause and discuss fertility issues. Also consider referral if the cause of osteoporosis is not clear, if the patient is male or if there are problems with management in primary care.
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Patient information |
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There is a lot of information for the patient to take in, not least in relation to lifestyle and medication issues. Printed information is helpful and there are many other sources of information available via the Internet (Box 3).
| Box 3. Advice for patients Frequently asked questions about osteoporosis: What is osteoporosis? Everybody loses bone as they get older. The amount of body lost varies from person to person. Some people lose so much bone that their bones become fragile and break more easily. Those people have osteoporosis. Osteoporosis is far more common in women than men and usually comes on after the menopause. Who is at risk of developing osteoporosis? Everyone is at risk of developing osteoporosis as they get older. Some factors make you more at risk. These include having an early menopause or having a period of time when your periods stopped due to an eating disorder, heavy exercise or illness; having a family history of osteoporosis; having a medical history of certain conditions such as an overactive thyroid or taking steroid tablets for other medical conditions. Your lifestyle can also put you at risk. You can lower your risk of having thin bones by eating foods which contain calcium and vitamin D or taking supplements, taking plenty of exercise, stopping smoking and cutting down on your alcohol intake. How is osteoporosis diagnosed? Special X-ray machines do a DEXA scan which can check your bone density (thickness) and confirm osteoporosis. However, osteoporosis is often first diagnosed when you break a bone. What are the symptoms and problems of osteoporosis? Osteoporosis usually develops slowly over several years without any symptoms. The major problem associated with osteoporosis is the increased risk of breaking a bone, even after a minor fall. A fractured bone in an older person can be serious. For example, about half the people who have a hip fracture are unable to live independently afterwards. What are the treatments for osteoporosis? There are a number of medicines which can be prescribed to prevent your osteoporosis getting worse. The most commonly used drugs are the bisphosphonates which include alendronate, risedronate and etidronate. You can also take measures to help prevent you from falling. This can reduce the chance of you breaking a bone. Check your home for hazards, such as loose rugs, slippery floors and objects you could trip on, and be careful outside in bad conditions, for example if it is wet or icy. If your medicine makes you drowsy, talk to your doctor to see if it can be changed and keep active. If you have had a fall, see your doctor as a ‘falls assessment’ may help prevent further falls. Information and support for patients Arthritis Research Campaign, Tel: 0870 850 5000, www.arc.org.uk National Osteoporosis Society, Tel: 0845 450 0230, www.nos.org.uk
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Key points
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References |
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Black D, Cummings S, Karpf D, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet (1996) 348:1535–41.[CrossRef][Web of Science][Medline]
British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary (2008) London: BMA, RPS. (no. 54).
Committee on Saftey of Medicine. Further advice on safety of HRT: risk: benefit unfavourable for first-line use in prevention of osteoporosis. (2003) Accessed via www.mhra.gov.uk.
Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomised clinical trial. The Journal of the American Medical Association (1999) 282:637–45.
Harris ST, Watts NB, Genant HK, et al. Effect of risedronate treatment on vertebral and non vertebral fractures in women with postmenopausal osteoporosis. A randomised controlled trial. The Journal of the American Medical Association (1999) 282:1344–52.
Meunier PJ, Roux C, Seeman E, et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. The New England Journal of Medicine (2004) 350:459–68.
National Institute for Health and Clinical Excellence. Osteoporosis: assessment of fracture risk and the prevention of osteoporotic fractures in individuals at high risk. Accessed via www.nice.org.uk.
National Institute for Health and Clinical Excellence. Osteoporosis—secondary prevention. (2005) Accessed via www.nice.org.uk/TA087 [date last accessed 06.10.2008].
RCGP Curriculum statement 15.9: Rheumatology & conditions of the musculoskeletal system (including trauma). Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15.9_Rheumatology_and_Musculoskeletal_System2.pdf [date last accessed 12.12.2008].
Reginster JY, Seeman E, De Vernejoul MC, et al. Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: treatment of peripheral osteoporosis (TROPOS) study. The Journal of Clinical Endocrinology and Metabolism (2005) 90:2816–22.
Roberts SE, Goldacre MJ. Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study. British Medical Journal (2003) 327:771–5.
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