Osteoporosis

Question 1

Osteoporosis:

Risk factors to consider and what is covered bny MBS to qualify for a BMD?

Answer 1

MBS approved BMD based on risk factors:
≥70yo
Hypogonadism
Premature menopause
Rheumatoid arthritis
Hyperthyroidism
Chronic kidney disease
Chronic liver disease
Coeliac disease or malabsorption
Prolonged corticosteroids (≥3/12 or ≥7.5mg per day)
Antiandrogen therapy (All men prior to androgen deprivation therapy should be screened for OP)

Non Approved MBS BMD based on risk factors:
frequent falls
FHx of hip fracture/OP
height loss ≥3cm
back pain suggestive of fracture
women
anorexia
sedentary or prolonged immobility
poor balance
smoking
high alcohol intake ≥2 Standard drinks per day
undernutrition
vitamin D insufficiency

Question 2

Osteoporosis:

Diagnosis definitions and treatment indications?

Answer 2

T score ≤ -2.5

> 50yo AND minimal trauma fracture (fall from standing height) = OP

spinal compression fracture without trauma and/or the patient is deemed to be at high risk of osteoporotic fracture = presumptive OP

10 year risk of Hip fracture >3% OR Any fracture risk >20% using Fracture Risk Assessment Tool (www.shef.ac.uk/FRAX) = presumed OP so start medication (NOT PBS)

Prolonged corticosteroids (≥3/12 or ≥7.5mg per day) AND T score ≤ -1.5 = Start medication to prevent OP (ON PBS for bisphosphonates)

10 years post menopause AND osteopenic (T score ≤ -1.5) = Bisphosphonate therapy as primary prevention of vertebral fractures

Question 3

Osteoporosis:

Management?

Answer 3

Non pharmacological:

Lifestyle advice for the >50yo or post menopausal patients:

• Adequate calcium (≥1000 mg per day for adults, rising to 1300 mg per day for women ≥50yo and men ≥70yo)
• Adequate protein intake
• Adequate but safe exposure to sunlight as a source of vitamin D
• Maintenance of a healthy weight and body mass index
• Cessation of smoking
• Avoidance of excessive alcohol consumption
• Resistance exercise 2–3 days per week, moderate–vigorous for older adults with osteoporosis to prevent further bone loss and/or improve BMD, improve function, treat sarcopenia, and decrease fall and fracture risk.
• hip protectors indicated if concern in RACFs
• > 75yo should engage with falls risk assessments, exercise programs and home safety interventions
• Exercise that progresses in intensity as capacity improves is recommended (3 times a week – impact aerobics, tennis, dance, skipping, stair climbing, hill walking, resistance training, jogging)
• *Calcium and vitamin D supplements should not be used routinely as the absolute benefit of calcium and vitamin D supplements in terms of fracture reduction is low.
• *There is evidence of significant benefit in people at risk of deficiency, particularly institutionalised individuals.**

Pharmacological:
Management algorithm in WOMEN with osteoporosis
1) oestrogen replacement therapy OR Bisphosphonate
2) Denosumab if post menopausal
3) SERM’s in postmenopausal women with OP where vertebral fractures are the main concern (from BMD), even more so if there is a FHx of breast cancer

• Cease bisphosphonate therapy IF treated for 5–10 years in postmenopausal women and men >50years AND good response (T-score ≥–2.5 and no recent fractures)*
• Restart treatment after cessation if there is evidence of bone loss or further minimal trauma fracture*

IF
10 years post menopause AND osteopenic (T score ≥-1.5) = Bisphosphonate therapy as primary prevention (of vertebral fractures)

IF
on antiresorptive therapy and sustained another fragility fracture
1) Teriparatide
2) Strontium (Not if clinically active CVD, uncontrolled HTN)

Review 3 – 6 months post starting antiresorptive therapy and then annually
Bone markers not routinely advised in GP (specialist only)

Repeat BMD scans ≥2years

If BMD is stable and/or individual is at low risk of fracture (normal or mild osteopenia; T-score >–1.5), less-frequent monitoring, up to an interval of 5–15 years, can be considered.

Duration of therapy
If T-score remains below –2.5, and/or there are incident vertebral fractures, continue treatment.

There is insufficient evidence to interrupt therapy for minor oral surgery, or to measure bone turnover markers to predict onset of ONJ.

Question 4

Osteoporosis:

Special groups to sonsider?

Answer 4

Aromataze inhibitors:

• Women about to start Aromataze inhibitors should be screened for OP
• If >70yo OR >50yo with a fragility fracture/high 10 year risk score = antiresorptive therapy
• Fracture risk should determine duration of antiresorptive treatment while on an AI

All men prior to androgen deprivation therapy should be screened for OP

Question 5

Osteoporosis:

Pharmacological therapy key points/

Answer 5

Bisphosphonates

• inhibit osteoclasts
• Renally cleared (Caution in GFR<30)
• daily or weekly.

Intravenous bisphosphonates (once yearly 5 mg zoledronic acid) can be used as a first-line osteoporosis therapy but are often used in patients intolerant to oral preparations or likely to be non-adherent to oral medications.

Contraindicated oral therapy if active upper gastrointestinal (GIT) disorders

Potential Side effects: 
ONJ
stomach discomfort
diarrhoea
giddiness
atypical femoral fractures

Inititation:

1) Optimise oral hygiene and treat dental disease prior to therapy (risk of ONJ 1-10 cases per 10,000 patients)
2) Get Vit D above 50 *(levels below this risk hypocalcaemia)

• No antacids, calcium, iron or mineral supplements within 2 hours of bisphosphonate as they may interfere with its absorption.
• Swallow whole; do not chew or suck on the tablet
• Full glass of plain water at least 30 minutes before food or drink and remain upright during this time and until after you eat.

Denosumab

• monoclonal antibody that prevents RANKL binding to its receptor (RANK) on the osteoclast surface which disrupts osteoclast formation and survival.
• 60mg subcutaneous injection every 6 months.

Potential Side effects:

• hypocalcaemia
• cellulitis
• RCTs to date show no significant increased risk of ONJ or atypical femoral fractures with denosumab over placebo

Starting denosumab therapy

1) Optimise calcium & vitamin D levels prior
* Effects of denosumab on bone resorption do not persist after treatment has stopped - Discontinuation results in BMD loss and risk of fractures

Hormone therapy
Oestrogen is available on the PBS for the prevention and treatment of osteoporosis in postmenopausal women.

Tibolonehas similar efficacy to traditional MHT in reducing fracture risk

Raloxifene is a selective oestrogen receptor modulator (SERM) and is available on the PBS for treatment of postmenopausal osteoporosis in patients with minimal trauma fracture. It is effective for reduction in vertebral fractures and has evidence of breast cancer prevention.

Teriparatide
It is parathyroid hormone that when used intermittently predominantly on osteoblasts to increase new bone formation

recommended to reduce fracture risk in postmenopausal women and men over the age of 50 with osteoporosis who have sustained a subsequent fracture while on anti-resorptive therapy, or in whom anti-resorptive therapy is contraindicated.

Teriparatide is a costly medication with a recommended 18-month course duration.

Daily subcut injection

PBS treatment must be commenced by a specialist

Strontium
an effective second-line option for reducing the risk of further osteoporotic fractures in postmenopausal women with prevalent fractures.

Dont use IF:

• previous or clinically active cardiovascular disease
• uncontrolled hypertension
• only be used when other medications for the treatment of osteoporosis are unsuitable.

no evidence available for the effect of strontium ranelate in reducing fracture risk in men and early postmenopausal women.