Osteoporosis

Most patients with osteoporosis can be managed in primary care but if specialist input is required referrals should be made to rheumatology and marked for the attention of the Osteoporosis Service.  

The most common indications for referral are:  

• Women with severe osteoporosis (T-score <-4.0 or below) of the spine (these patients will normally be referred directly to clinic by medical physics staff) 
• Women with vertebral fractures or T-score <-3.5 (these patients will normally be referred directly to clinic by medical physics staff) 
• Intolerant of both alendronate and risedronate  
• Bone loss of >4% at any site despite adhering to oral bisphosphonate treatment 
• Unexplained osteoporosis in a patient aged <50 

Investigations 

Consider the following investigations in patients with DEXA proven osteoporosis 

• Calcium, Albumin, LFT, U&E 
• FBC, ESR, Protein electrophoresis, urine Bence Jones Protein 
• TFT, TTG 
• Gonadotrophins and testosterone (only indicated in men with osteoporosis) 

When to commence drug treatment 

There is a strong evidence base for treating patients with DEXA proven osteoporosis (BMD T-score or -2.5 or less at any site) and/or those with low trauma vertebral fractures.  

Patients with glucocorticoid induced osteoporosis (prednisolone >7.5mg daily for >3 months) should be offered treatment if T-score at any site is <-1.5.  

There is evidence that zoledronic acid is effective at preventing fractures in postmenopausal women >65 years with osteopenia. Zoledronic acid is normally reserved for patients who have intolerance or contraindications to oral therapy.   

We do not recommend starting osteoporosis treatment in patients who have a high fracture risk alone without information from DEXA since the efficacy of treatment in these individuals is uncertain.  

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. 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 approximately 40% of the 10-year value.   

Recommended treatments 

The first-choice treatments are either alendronic acid 70mg once a week or risedronate 35mg once a week.  

The most common adverse effect is upper GI upset. If this occurs with one of the oral bisphosphonates it is worth trying the other since for some reason about 20% of people who have GI upset with one oral bisphosphonate tolerate the other perfectly well. There is a liquid formulation of oral alendronic acid that can also be tried in patients who don’t like swallowing tablets or have GI upset.   

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 below). There is no need to request DEXA scans during the intervening period.  

Indications for a repeat DEXA scan during treatment would be if the patient has experienced a low trauma fracture while on treatment provided and at least two years have elapsed since starting therapy. In this case a repeat DEXA can help to assess if the patient is responding to treatment with stabilisation of BMD or an increase in BMD. Please review the algorithm for the management of patients who fracture on treatment for more details. 

If the patient’s dietary calcium is less than 700mg daily a calcium and vitamin D supplement is indicated. The first choice in LJF currently is Accrete D3 one daily 

If the patient’s dietary calcium is greater than 700mg daily, then a standalone vitamin D supplement may be considered. Typical choices include cholecalciferol 800 units daily or 5600 units once a week.    

Treatment review at 5 years  

Oral bisphosphonate treatment should be given for 5 years in the first instance and the need for continued therapy assessed by repeat DEXA at that point in time. The suggested course of action for the following scenarios is shown below 

• Treatment holiday. This should be considered if there have been no new fractures over the 5-year treatment spell and BMD T-score is -2.5 or better.  

In this case, stop treatment for 5 years if the patient has been on alendronic acid and 3 years if the patient has been on risedronate. Re-organise DEXA after the holiday and consider restarting for another 5 years if BMD has fallen by below -2.5 at any site. 

• Extended treatment. Continuation of treatment to 10 years should be considered if the patient has experienced a vertebral fracture during treatment and/or the T-score is below -2.5 continue to 10 years. 

Treatment review at 10 years. 

A DEXA scan should be organised at 10 years and the patient reviewed. Treatment should generally be stopped after 10 years even if they remain osteoporotic, unless the repeat BMD has showed bone loss of >4% at any site. This would suggest that the treatment hasn’t been absorbed or taken properly. These patients will usually be offered an appointment at the osteoporosis clinic direct from medical physics.  

For patients who have completed 10 years and where BMD is stable, we recommend a treatment holiday of 5 years for alendronic acid and 3 years for risedronate followed by another DEXA. If BMD has fallen by more than 4% at any site after the treatment holiday, another 5-year spell of treatment should be considered.  

The National Osteoporosis Society (nos.org.uk)