Osteoporosis

1. Assess osteoporosis risk of all adult patients as part of their periodic health examination.

2. Use bone mineral density testing judiciously (e.g., don’t test everybody, follow a guideline).

3. Counsel all patients about primary prevention of osteoporosis (i.e., dietary calcium, physical activity, smoking cessation), especially those at higher risk (e.g., young female athletes, patients with eating disorders).

4. In menopausal or peri-menopausal women, provide advice about fracture prevention that includes improving their physical fitness, reducing alcohol, smoking cessation, risks of physical abuse, and environmental factors that may contribute to falls (e.g., don’t stop at suggesting calcium and vitamin D).

5. In patients with osteoporosis, avoid prescribing medications that may increase the risk of falls.

6. Provide advice and counseling about fracture prevention to older men, as they too are at risk for osteoporosis.

7. Treat patients with established osteoporosis regardless of their gender (e.g., use bisphosphonates in men).

Investigation

• Screen with FRAX +/- BMD T-score to determine 10-year risk of fracture 

  • All men and women ≥ 65yo

    • Consider simplified Osteoporosis Self-Assessment Tool (OST) = Weight (kg) - Age (years) 

      • >10, reassess OST in 5y

      • <10, do  FRAX

    • Note: USPSTF 2018 only recommends screening women

  • ≥ 50yo if risk factor:

    • Fragility fracture after age 40 (low trauma fractures) and risk of future fractures

    • Vertebral compression fracture or osteopenia on X-ray

    • Parental hip fracture

    • Prolonged use of glucocorticoids (3mo of >7.5 mg prednisone daily in past year)

    • Rheumatoid arthritis, malabsorption syndrome

    • Current smoker

    • High alcohol intake (>3 units/day)

    • Major weight loss (10% below body weight at age 25)

  • <50 yo if disorder associated with rapid bone loss

    • Fragility fractures

    • High-risk medications

    • Malabsorption

    • Inflammatory

    • Primary hyperparathyroidism

• Consider lateral T4-L4 spine X-ray if vertebral fracture suspected (historical height loss >5cm or measured height loss >2cm)

• Consider labs for secondary causes of osteoporosis

  • Calcium, Albumin

  • CBC

  • Creatinine

  • Alk phos

  • TSH

  • SPEP (if vertebral fractures on X-ray)

  • 25-OH Vitamin D checked once after 3 month of supplementation in impaired instesinal absorption, or osteoporosis requiring pharmacotherapy

Prevention

• Smoking cessation, alcohol reduction <3 drinks/day

• Vitamin D 1000-2000 IU PO daily

  • Consider 10,000 IU PO weekly or 50,000 IU monthly

• Calcium intake 1200mg/day from diet (three servings of low fat milk products)

  • Can consider Calcium supplement ≤500mg PO daily in those who cannot meet recommended dietary allowance at high risk of fractures

• Sufficient protein intake (1g/kg/day)

• Exercise Multicomponent program includes

  • Resistance training ≥ twice weekly, including exercises targeting abdominal and back extensor muscles.

    • Back extensor muscles daily

  • Balance and functional training ≥ twice weekly to reduce the risk of falls.

    • Shifting body weight to the limits of stability

    • Reacting to things that upset one’s balance (e.g., catching and throwing a ball)

    • Maintaining balance while moving (e.g., Tai chi, heel raises, agility training)

    • Reducing base of support (e.g., standing on one foot)

  • Aerobic physical activity 150 mins/week of moderate intensity 

• Fall awareness and prevention

  • Assistive devices

  • Medication review (fall risk)

  • Environmental hazards

  • Hip protectors

  • Urinary incontinence

Treatment

• Offer medication if high risk (>20% 10-year fracture risk) or moderate but high risk features

• Oral bisphosphonate: Alendronate 70mg PO weekly or Risedronate 35mg PO weekly or 150mg PO monthly

  • Take 1 hour before breakfast with 250mL water, upright 30 mins, avoid any calcium for 2-3h

  • Adverse: Osteonecrosis of the jaw, atypical femur fractures, esophagitis, esophageal ulcers

  • Duration of therapy: 3-6 years

    • 6 years of therapy is appropriate for individuals with a history of hip, vertebral or multiple nonvertebral fractures, or new or ongoing risk factor(s) for accelerated bone loss or fracture

      • If inadequate response (> 1 fracture or substantial bone density decline (e.g., ≥ 5%) occurs despite adherence to an adequate course of treatment (typically > 1 yr)) or ongoing concern for fracture after 3-6 years, consider:

        • Extending or switching therapy

        • Reassessing for secondary causes 

        • Consult endocrinology

• IV bisphosphonate: Zoledronic acid 5mg IV once yearly if GI/esophageal disorders, or inability to tolerate (eg. sit upright for 30-60 mins)

  • Consider Drug Holiday after 3y (6y in high risk)

• Monoclonal Ab (RANKL inhibitor): Denosumab (Prolia) 60mg sc twice yearly if impaired renal function

  • No drug holiday on Denosumab

  • Adverse: Joint/muscle pain, osteonecrosis of jaw, contraindicated in pregnancy

• PTH Analog: Teriparatide (Forteo) 20mcg sc daily in severe osteoporosis who cannot tolerate bisphosphonate

  • Adverse: Hypercalciuria/emia, angioedema

• SERM: Raloxifene

  • Risk of thromboembolism

• Other: Calcitonin intranasal, Hormone therapy (in menopausal symptoms)

Referral to specialist

• Multiple fractures despite adherence to therapy

• Secondary causes of osteoporosis/metabolic bone disease outside expertise

• Extremely low BMD not explained by risk factors

• CKD (eGFR<30mL/min)