History
- Patient requiring oral prednisolone >7.5mg/day for >3 months.
- Cumulative annual prednisolone dose of >630mg (oral or parenteral)
Examination
- Kyphosis in patients with vertebral fractures
- Signs of underlying disease
Investigations
Dual x-ray absorptiometry
X-rays
Thoracic and lumbar spine x-rays are indicated in patients with back pain, kyphosis or height loss to confirm of exclude the presence of vertebral fractures.
X-rays of other sites aren’t a reliable means of diagnosing osteoporosis but if an x-ray is performed for another reason and it is reported as showing osteopenia this can indicate underlying osteoporosis.
Biochemistry and haematology
The following tests are useful to exclude secondary causes of osteoporosis. They should be considered in patients with a confirmed diagnosis of osteoporosis.
- FBC and ESR
- Urea and Electrolytes
- Liver function tests
- Calcium and Albumin,
Serum 25(OH) D - Thyroid function tests
- TTG
- Serum protein electrophoresis
- Spot urine for Bence-Jones protein
- Testosterone and gonadotrophins in men
M.A & S.R/H.B. 25-01-24
Most patients with corticosteroid induced osteoporosis can be managed in primary care. Criteria for referrals to secondary care are:
- Postmenopausal women with at least one severe or two moderate vertebral fractures.
- Intolerant of both alendronic acid and risedronate
- Bone loss of >4% at any site on repeat DEXA despite adhering to oral bisphosphonate treatment
Counselling patients about treatment
Treatment should only be commenced following a discussion of the options with the patient, including the possibility of not having treatment given the fact that none of the treatments available can completely prevent fractures. You may wish to consider using the ORB calculator to work out the benefits of treatment for your patient with different drugs as part of this discussion. The ORB calculator is also available free as an iPhone app on Apple store and on Google Play for Androids. Note that if you are using FRAX (which only permits calculation of 10-year fracture risk), the risk of any osteoporotic fracture over 5 years is about 50% of the 10-year value.
Royal Osteoporosis Society (www.theros.org)
Management of osteoporosis and prevention of fragility fractures (SIGN 142)
Dietary calcium calculator. Calcium Calculator
Osteoporosis risk benefit calculator: ORB calculator
Endocrinology RefHelp guidance on management of patients on long term steroid therapy:
Management of long term high dose steroid therapy – RefHelp (nhslothian.scot)
