Osteoporosis

Question 1

What is Osteoporosis?

Answer 1

A condition that weakens bones, making them fragile and more likely to break. It is spongy bones.

At this stage the holes on the honeycomb structure on the trabecular bone are larger and therefore overall density is lower meaning the bone is more likely to fracture

Question 2

What kind of patients are likely to get Osteoporosis?

Answer 2

Postmenopausal women, men aged over 50 and patients who are taking long oral corticosteroids

Question 3

What are the risk factors associated with developing Osteoporosis?

Answer 3

 Female gender
 Increasing age
 Menopause
 Oral corticosteroids
 Smoking
 Alcohol
 Previous fragility fracture
 Rheumatological conditions, such as rheumatoid arthritis and other inflammatory arthropathies
 Parental history of hip fracture
 Body mass index of less than 18.5 kg/m2
.

Question 4

How is Osteoporosis diagnosed?

Answer 4

1. By calculating a 10-year fragility risk score
2. By using a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD)

Question 5

What are the exceptions in diagnosing Osteoporosis?

Answer 5

 Over 50 years of age with a history of fragility fractures — a DXA scan should be offered.

 Under 40 years of age who have a major risk factor for fragility fracture — a DXA scan should be offered, then referral to a specialist experienced in the treatment of osteoporosis depending on the BMD T-score. The T-score is the number of standard deviations below the mean BMD of young adults at their peak bone mass.

 With vertebral or hip fractures — starting treatment without undertaking DXA should be considered if this is inappropriate or impractical.

Question 6

How is Fragility fracture risk calculated? And what are the next steps after receiving results?

Answer 6

1. People at high risk should be offered a DXA scan to confirm osteoporosis.
2. People at intermediate risk whose fracture risk is close to the recommended threshold and who have risk factors that may be underestimated by FRAX®, such as people taking high doses of oral corticosteroids, should be offered a DXA scan.
3. People at low risk should not be offered treatment or a DXA scan, but given lifestyle advice.

Question 7

What does a dual-energy X-ray absorptiometry (DXA) scan do?

Answer 7

It measures the patient’s bone strength, during the scan the bones are x-rayed.

*The bone density is then compared to a healthy young adult.
*The difference is calculated as a standard deviation (SD) and is called a T-score.

Question 8

Explain the results of T-scores?

Answer 8

• Above -1 SD is normal
• Between -1 and -2.5 SD shows bone loss and is defined as osteopenia
• Below - 2.5 shows bone loss and is defined as osteoporosis

Question 9

Which patients should be given pharmacological treatments and which patients should be given non-pharmacological treatments?

Answer 9

Treatment option is based on risk of fragility and T-score.

• If the T score is –2.5 or less bone-sparing drug treatment should be offered.
• If the T-score is greater than –2.5 patients should be helped to modify risk factors.

If the fracture risk is close to the recommended threshold and they have risk fractures which may be underestimated by FRAX, a DEXA scan should be offered and if the T-score is –2.5 or less they should be offered drug treatment.

People with low fragility fracture should be offered lifestyle advice, with follow up within 5 years.

Question 10

What are the treatments for Osteoporosis?

Answer 10

If the T-score was -2.5 or less, a bisphosphonate should be given, if appropriate to postmenopausal women and men over 50 years.

Question 11

What are the choices of pharmacological treatment, and which patients can they be given to?

Answer 11

Choices include;
Alendronic Acid 10mg daily
Alendronic Acid 70mg weekly
Risedronate 5mg daily
Risedronate 35mg daily

All of the above are licensed in postmenopausal women however only alendronic acid once daily and risedronate once weekly are licensed for use in men.

Question 12

What should happen if a patient cannot tolerate bisphosphonate or is contraindicated?

Answer 12

They should be referred to a specialist and the specialist can prescribe another medication.

Question 13

What are the second-line treatments for Osetoporosis?

Answer 13

Zoledronic acid
Strontium ranelate
Raloxifene
Denosumab
Teriparatide

Question 14

Which patients can Bisphosphonate be considered in?

Answer 14

In patients who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone 7.5 mg daily for 3 months or longer).

Question 15

What monitoring should be done for Osteoporosis?

Answer 15

An assessment of calcium intake and need for vitamin D.

If the person’s calcium intake is adequate (700 mg/day):
- prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.

If calcium intake is inadequate:
- prescribe 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily.

• Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home.

Question 16

What other treatment option can be considered to prevent osteoporosis?

Answer 16

In women who have premature menopause (menopause before 40 years of age), should be offered to reduce the risk of fragility fractures and for the relief of menopausal symptoms.

Question 17

What non-pharmacological treatments can be given for Osteoporosis?

Answer 17

• Regular exercise - to improve muscle strength (especially outdoors as it increases vitamin D production)
• Eating a balanced diet - to improve bone health
• Stop smoking
• Drink alcohol within recommended limits