A complex topic- Osteoporosis. This review of this condition on A4Medicine presents the GP with a practical easy to use visual on Osteoporosis. Based mainly on the National Osteoporosis Guideline Group ( NOGG ) 2017 this presents a summary of main recommendations. This appears more straightforward compared to other guidelines currently available. The most favourable anti-resorptive drugs are bisphosphonates. Management outlines have been shown to help the clinician make a decision. Alendronic acid is the usual first line bisphosphonate. Patients who cannot tolerate alendronic acid are offered risedronate as an alternative. Despite the attempt to simplify the issue, this remains a complex topic and the GP may consider seeking further advice as and when needed from their local specialists – for eg rheumatologists, endocrinologists, geriatricians or general medicine consultants.
Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue , with a consequent increase in bone fragility and susceptibility to fracture ( Kanis et al 1994 )
A fragility fracture – fracture following a fall from standing height or less , although vertebral fractures may occur spontaneously , or as a result of routine activities as bending and lifting.Osteoporosis can be prevented , diagnosed and treated before fractures occur , even after the first fracture has occurred , there are effective treatments to decrease risk of further fractures.Known as ” silent disease ” –> deterioration of skeletal tissue proceeds with no outward symptoms OP itself is asymptomatic – often remains undiagnosed until a fragility fracture occurs
Risk factors –previous fragility fracture current use or frequent recent use of oral systemic glucocorticoids history of falls family h/o hip fracture low body mass index ( BMI < 18.5 ) smoking alcohol intake of > 14 units/ week for women and 21 units for men other secondary causes of osteoporosis
Aetiology- endocrine-Hypogonadism including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy Hyperthyroidism Hyperparathyroidism Hyperprolactinaemia Cushing’s disease Diabetes GI-Coeliac disease Inflammatory bowel disease Chronic liver disease Chronic pancreatitis Other causes of malabsorption Others -Rheumatological- eg RhArthritis , other inflammatory polyarthropathies Haematological ( multiple myeloma , haemoglobinopathies ) Respiratory- cystic fibrosis , COPD Metabolic – homocystinuria CKD Immobility
History- History and physical examination Blood cell count ESR or CRP Serum calcium Albumin Creatinine phosphatase and Liver transaminases Thyroid function tests Bone densitometry ( DXA ) Testing to consider -Lateral radiographs of lumbar and thoracic spine or DXA based lateral vertebral imaging Serum protein immunoelectrophoresis and urinary BJP Serum 25-hydroxyvitamin D Plasma parathyroid hormone Serum testosterone SHBG FSH LH Serum prolactin 24 hr urinary free cortisol / overnight dexamethasone suppression test Endomysial and / or TTG antibodies Isotope bone scan Markers of bone turnover Urinary calcium excretion
Alendronate or Residronate first line in majority.
Complications of therapy-Osteonecrosis of jaw- rare , risk factors are poor oral hygiene , dental disease , dental interventions , cancer, chemotherapy or glucocorticoid Rx Atypical femoral fracture- risk is low and associated with prolonged use of BP. Fractures often b/l associated with prodromal pain and tend to heal poorly
Consider referral-Multiple fractures despite good compliance Secondary causes-outside your expertise Extremely low BMD not explained by patients known risk factors CKD –> GFR < 30