Osteoporosis

Question 1

A 67-year-old woman went to see her GP because she was experiencing a headache that started 1 week ago and was different to her usual headaches. She also mentions getting pain in her jaw when eating food, which has also been affecting her for the past week. The GP suspects that she has giant cell arteritis and commences her on high-dose prednisolone and refers her to ambulatory emergency care for specialist assessment. She is concerned about taking these high-dose steroids as she has heard it can affect her bone health. What is the most appropriate action to take? A) Arrange a bone density scan B) Reassure the patient C) Start the patient on Vit D and supplements D) Start the patient on alendronic acid E) Use NSAID treatment instead of steroids

Answer 1

D) Start the patient on alendronic acid RCP guidelines for corticosteroid-induced osteoporosis: 1. Patients over the age of 65 years or those who’ve previously had a fragility fracture should be offered bone protection. 2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent:

Question 2

What are the indications for bisphosphonate administration to prevent osteoporosis?

Answer 2

Oral bisphosphonate

• the person is eligible for risk assessment as defined in when to assess a person depending on age and sex and
• the 10-year probability of osteoporotic fragility fracture is at least 1%.

IV bisphosphonate

• the person is eligible for risk assessment as defined in when to assess a person depending on age and sex and

the 10-year probability of osteoporotic fragility fracture is at least 10% or

• the 10-year probability of osteoporotic fragility fracture is at least 1% and the person has difficulty taking oral bisphosphonates (alendronic acid, ibandronic acid or risedronate sodium) or these drugs are contraindicated or not tolerated.

Question 3

Who should be assessed for fragility fractures?

Answer 3

• All women aged 65 years and over, and all men aged 75 years and over
• All women aged under 65, and all men aged under 75 with the following risk factors:
  
  • previous fragility fracture
  • current use or frequent recent use of oral or systemic glucocorticoids
  • history of falls
  • family history of hip fracture
  • other causes of secondary osteoporosis
  • low body mass index (BMI) (less than 18.5 kg/m²)
  • smoking
  • alcohol intake of more than 14 units per week for men and women.

Question 4

How to assess fracture risk?

Answer 4

QFracture (preferred)

FRAX

Measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor:

• i.e history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Consider measuring BMD with DXA before starting treatments that may have a rapid adverse effect on bone density

Following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value.

Question 5

When would you give bisphosphonates?

Answer 5

• Above intervention threshold for fracture risk
• Near intervention threshold but DEXA < 2.5
• People who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone 7.5 mg daily for 3 months or longer)
• Patient who has had a fragility fracture