History
- Low trauma fracture of any site age >50
- Back pain
- Height loss >2.5cm
- Patients are often asymptomatic until a fracture has occurred.
- Androgen deprivation therapy for prostate cancer.
Examination
- Kyphosis in men with multiple vertebral fractures
- Signs of hypogonadism
Investigations
Dual x-ray absorptiometry
The diagnosis can be confirmed by Dual Energy X-ray absorptiometry (DEXA). Please refer to the DEXA page for referral criteria. Patients with low trauma vertebral fractures are generally considered to have osteoporosis of the spine irrespective of the results of DEXA since DEXA measurements at the spine can be confounded by the presence of osteoarthritis, the fractures themselves or aortic calcification, especially in older people.
X-rays
Thoracic and lumbar spine x-rays are indicated in patients with back pain, kyphosis or height loss to confirm or 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
- Serum testosterone and gonadotrophins (testosterone may be reduced in patients taking opiates)
M.A & S.R/H.B. 04-12-24
The main indications for referral to secondary care are:
- Severe spinal osteoporosis (T-score <-4.0 or 2 new moderate to severe 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
- Progression of vertebral osteoporosis (height loss or new vertebral fractures) 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 Android. 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.
We suggest that treatment be given for 5 years in first instance and the need for ongoing treatment reviewed with a repeat DEXA at that point in time (see above). There is no need to request DEXA scans during the intervening period unless another low trauma fracture has occurred (see below).
If the patient has experienced a further low trauma fracture while on treatment and at least two years have elapsed since starting therapy a repeat DEXA would be indicated to assess if the patient is responding to treatment with stabilisation of BMD or an increase in BMD. Please refer to the fractures on treatment page of RefHelp for advice on what to do.
How to refer:
SCI Gateway > Rheumatology > WGH
Standard treatment
Most patients with male osteoporosis can be managed in primary care. Standard treatment consists of alendronic acid tablets 70mg once a week accompanied by cholecalciferol 800 units daily. If the patient has GI intolerance with oral alendronate tablets, Risedronate 35mg once a week or liquid buffered alendronate (Binosto, 70mg weekly) are alternatives.
A combined calcium and vitamin D supplement (Accrete D3, 1000/880) is also indicated in patients with dietary calcium intake <700mg daily. If the patient’s dietary calcium is greater than 700mg daily, then a standalone vitamin D supplement may be considered. There are various choices including cholecalciferol 800 units daily, 5600 units once a week or 25,000 units once every 4 weeks. Dietary calcium intake is usually noted on DEXA reports but can be calculated by completion of a simple food frequency questionnaire using a dietary calcium calculator.
Non-standard treatments
Parenteral bisphosphonates such as iv Zoledronate can be considered if the patients have tried and failed at least two different types of oral bisphosphonate. Please do refer to Rheumatology via SCI store if the patient would be a suitable candidate and prepared to attend the infusion suite for yearly infusions.
Strontium ranelate 2g at night can be considered in patients where bisphosphonates are contraindicated. This treatment has been shown to reduce the risk of vertebral and non-vertebral fractures. Treatment is contraindicated in those at risk of DVT and those with a history of cardiovascular or cerebrovascular disease. Denosumab 60mg subcutaneously has efficacy similar to bisphosphonates but is not recommended routinely because if treatment needs to be stopped for any reason, there is a rebound increase in bone loss sometimes accompanied by multiple vertebral fractures. This can be partly but not completely mitigated by zoledronic acid. Denosumab may be considered as treatment with close monitoring by secondary care. Anabolic therapies can be given with teriparatide (20mcg daily by subcutaneous injection for 24 months). This medicine will be prescribed in secondary care for patients with severe spinal osteoporosis and multiple vertebral fractures. The course of teriparatide is followed up by bisphosphonate therapy to maintain the increase in BMD.
If the patient has biochemical evidence of hypogonadism, please seek advice from endocrinology.
Duration of Treatment
Oral bisphosphonate treatment should be given for 5 years in the first instance and the need for continued therapy, or a treatment holiday assessed by repeat DEXA.
Treatment holiday. This should be considered in patients without pre-existing vertebral fractures where the BMD T-score has increased to -2.5 or better. For these patients, stop treatment 3 years and then start another cycle of 5 years therapy .There is no need to repeat DEXA after a 3 year treatment holiday.
Extended treatment. Continuation of treatment to 10 years should be considered if the patient has experienced a vertebral fracture or if the T-score remains below -2.5 at any site after 5 years therapy. Treatment should generally be stopped after 10 years even if the patient remains osteoporotic unless the 10-year DXA scan has showed bone loss of >4% at any site compared with previous scans. This would suggest that the treatment hasn’t been absorbed or taken properly. Please refer these patients to the osteoporosis service. For patients where the 10-year DEXA is stable or has increased a treatment holiday of 3 years is recommended.
Royal Osteoporosis Society (www.theros.org.uk )
Management of osteoporosis and prevention of fragility fractures (SIGN 142)
Dietary calcium calculator. Calcium Calculator
Osteoporosis risk benefit calculator: ORB calculator
