History
- Low trauma fracture of any site age >50
- Back pain
- Height loss >2.5cm
- Patients are often asymptomatic until a fracture has occurred.
Examination
- Kyphosis in patients with multiple vertebral fractures
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 considered to have osteoporosis of the spine irrespective of the results of DEXA since spine measurements in older people are often confounded by the presence of osteoarthritis, the fractures themselves or aortic calcification.
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
- Thyroid function tests
- TTG
- Serum protein electrophoresis
- Spot urine for Bence-Jones protein
M.A & S.R/H.B. 25-01-24
The main indications for referral to secondary care are:
- Severe spinal osteoporosis (T-score <-4.0 or below)
- Postmenopausal women with at least one severe or two moderate vertebral fractures and a T-score at any site of <-1.5 .
- 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, new fractures or worsening vertebral fracture ) 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 40% 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 below). 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 page on management of patients who fracture on treatment for more details.
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 for 3 years, re-organise DEXA after the treatment holiday and consider restarting for another 5 years if BMD has fallen 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 and or the T-score remains below -2.5 at any site. These patients should be treated for 10 years, and a repeat DEXA performed. 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. 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.
Most patients with osteoporosis can be managed in primary care.
Standard treatment
Standard treatment consists of alendronic acid tablets 70mg once a week accompanied by cholecalciferol 800 units daily. A combined calcium and vitamin D supplement (Accrete D3, 1000/880) is 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.
If the patient has GI intolerance with oral alendronate tablets, Risedronate 35mg once a week or liquid buffered alendronate (Binosto, 70mg weekly) can be tried instead.
Non-standard treatments
Hormone replacement therapy is an option in younger women (aged <60) with osteoporosis especially when menopausal symptoms are present and as a preventative therapy for women with premature menopause. Raloxifene 60mg daily is a potential option for younger women with low BMD at the spine but has no efficacy at preventing non-vertebral fractures. 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 is an effective treatment but it should not be initiated in primary care as if it needs to be stopped for any reason, there is a rebound increase in bone remodelling sometimes accompanied by multiple vertebral fractures. This can be partly but not completely mitigated by zoledronic acid. Anabolic therapies include teriparatide (20mcg daily by subcutaneous injection for 24 months and Romosozumab 210mg monthly by subcutaneous injection for 12 months. These medicines are prescribed in secondary care but are followed up by bisphosphonate therapy to maintain the increase in BMD.
The recommended treatment course is 5 years with review by repeat DEXA. If the 5-year DEXA reveals that T-scores have increased to lie above the osteoporotic range (T >-2.5) a treatment holiday of 3 years can be considered provided the patient does not have pre-existing vertebral fractures. In patients with pre-existing vertebral fractures and those in whom T-scores are below -2.5 treatment should be continued for 10 years with review by a further DEXA. Treatment should be stopped at this point for unless there has been bone loss of >4% in which case, referral to the osteoporosis service 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
