Osteoporosis

Question 1

Osteoporosis vs Osteopaenia

Answer 1

Osteoporosis is a condition where there is a reduction in the density of the bones.

Osteopenia refers to a LESS SEVERE reduction in bone density than osteoporosis.

Question 2

Risk factor

Answer 2

Older age
Female (particularly postmenopausal)
Reduced mobility and activity
Low BMI (<18.5 kg/m2)
Rheumatoid arthritis
Alcohol and smoking

Long term corticosteroids

Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens.

Question 3

Who should be assessed and how?

Answer 3

First step is to perform a FRAX assessment on patients at risk of osteoporosis:

Women aged > 65
Men > 75
Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids (3 months), endocrine disorders and rheumatoid arthritis.

Next step in management based on the probability of a major osteoporotic fracture from the FRAX score:

A. FRAX outcome without a BMD result will suggest one of three outcomes:

• Low risk – reassure
• Intermediate risk – offer DEXA scan and recalculate the risk with the results
• High risk – offer treatment ASAP

FRAX outcome with a BMD result will suggest one of two outcomes:

• Treat
• Lifestyle advice and reassure

Question 4

FRAX tool

Answer 4

estimates the 10-year risk of fragility fracture

valid for patients aged 40-90 years

Question 5

Management

Medical Management

Answer 5

NICE recommend calcium supplementation with vitamin D in patients at risk of fragility fractures with an inadequate intake of calcium. An example of this would be Calcichew-D3

T-score (compares bone density to young people) less than - 2.5 SD warrants management
Z-score: adjusted to size and age

Bisphosphonates are the first line treatment (once a week). Side effects:

• Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
• Atypical fractures (e.g. atypical femoral fractures)
• Osteonecrosis of the jaw
• Osteonecrosis of the external auditory canal

Second line: Denoxumab is a monoclonal antibody that works by blocking the activity of osteoclasts.

Question 6

Conservative management

Answer 6

Activity and exercise
Maintain a health weight
Adequate calcium intake
Adequate vitamin D
Avoiding falls
Stop smoking
Reduce alcohol consumption

Question 7

Follow up

Answer 7

Low risk patients not being put on treatment should be given lifestyle advice and followed up within 5 years for a repeat assessment.

Patients on bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years and a treatment holiday should be considered if their BMD has improved and they have not suffered any fragility fractures.

Treatment holiday involves a break from treatment of 18 months to 3 years before repeating the assessment.