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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Osteoporosis

Author Dr Emma Fitzsimons 
Expert reviewer Dr Dina LoGiudice

Background

Osteoporosis is defined as a condition in which there is low bone mass and deterioration of the microarchitecture of the bones, causing bone fragility and an increased risk of fracture. It is usually diagnosed by a bone mineral density (BMD) test, dual energy X-ray absorptiometry (DXA), which measures BMD at the hip and spine. BMD is expressed as a T-score, defined by the World Health Organization (WHO) as a measure of standard deviation from the reference values of bone density for a person aged 30 years of the same sex.3 A T-score of –2.5 or lower is diagnostic of osteoporosis, and a T-score between –1.0 and –2.5 is diagnostic of osteopaenia.

Osteoporosis is common in the general population, with 27% of women and 11% of men over 60 years of age meeting the WHO criteria for osteoporosis.4 The lifetime risk of a minimal trauma fracture is approximately 56% for women aged over 60 years and 29% for men aged over 60 years.5 These fractures can occur at sites other that the classic osteoporotic sites of wrist, hip and vertebra.

Little is known, however, about the prevalence of osteoporosis in Aboriginal and Torres Strait Islander people. One study from Cairns found that the age standardised rate of hip fracture among Aboriginal and Torres Strait Islander people was similar to non-Indigenous people, though in that study the fractures in Aboriginal and Torres Strait Islander women tended to occur at a somewhat older age.6 

A number of factors increase the risk of osteoporotic fractures. Women have approximately double the lifetime risk of men. Fracture incidence increases exponentially with age in both men and women, approximately doubling with each decade.7,8 A previous fracture doubles the risk of subsequent fracture, and a previous vertebral fracture increases the risk of a further vertebral fracture 4–5 times.9,10 Low bone density as measured by DXA approximately doubles the fracture risk for each unit of standard deviation from the mean (each –1.0 of T-score).11 A history of falls at least doubles the risk of an osteoporotic fracture compared to non-fallers.12

A family history of fragility fractures after age 50 years, kyphosis or diagnosed osteoporosis in a father, mother and sister increase the risk of osteoporotic fractures.13 A meta-analysis found smoking increases the risk of osteoporosis after the menopause with an average of 2% greater bone density loss per decade for smokers compared with non-smokers.14 Smokers had a 17% increased risk of hip fracture at age 60 and a 108% increased risk at age 90 compared with non-smokers after adjusting for other risk factors.14 There was also a dose-response relationship between the number of cigarettes smoked per day and the risk of hip fracture.14 Low body mass index has also been shown to be associated with lower bone density after menopause, and more rapid bone loss than in heavier women.15 Other risk factors include immobility, vitamin D deficiency and certain medications, especially corticosteroids, excessive thyroxine, anti-androgen and anti-oestrogen treatments, selective serotonin re-uptake inhibitors, thiazolidenediones and certain anti-epileptic drugs.5 

A fracture risk calculator has been developed based on data from the Dubbo Osteoporosis Epidemiology Study (see Resources). An individual’s age, gender, fracture and fall history and BMD are used to calculate an estimated 5 and 10 year absolute fracture risk for both hip fracture and any fragility fracture.

Interventions

Calcium intake

The recommended daily intake of calcium varies according to age. The best dietary sources of calcium are milk, hard cheeses and yoghurt. Other sources with moderate calcium content include white bread, sardines and calcium enriched soy milk. Adequate dietary intake has been shown to be as effective as supplements. For people unable to achieve adequate intake through diet alone, supplementation is necessary.5 Dietary intake should especially be assessed in people who are commencing specific anti-osteoporosis therapies.

Vitamin D

Vitamin D is primarily formed in the skin from sunlight exposure although small amounts are found in the diet. It has been estimated that fair-skinned people in Australia can produce adequate vitamin D with sun exposure to their face, arms and hands for a few minutes either before 10 am or after 3 pm on most days of the week.16 In winter in southern parts of Australia this exposure may need to be longer. People with darker skin require more sun exposure. The evidence for the use of vitamin D supplementation in preventing bone loss and osteoporotic fractures is mixed. A benefit has been shown for treating those at high risk of vitamin D deficiency (residents of aged care facilities and housebound people) and for these groups, vitamin D supplementation is considered standard care.5 For those in the community, the results are less clear and supplementation should be reserved for those at high risk. In addition, the benefits of specific anti-osteoporotic therapies have been demonstrated in the context of adequate vitamin D levels. Patients who are to be commenced on specific anti-osteoporotic medication should have their vitamin D levels checked and should commence supplementation if their level is less than 60 nmol/L.5

Exercise

Regular, high intensity weightbearing exercise has been shown to slow bone density loss in postmenopausal women and older men.5 For bone health, short, intense exercise sessions are better than prolonged, less intense exercise. People without osteoporosis should be encouraged to exercise at least three times weekly for 1 year to improve BMD, and ideally they should participate in 30–40 minute sessions 4–6 times per week.5 Walking, jogging, dancing, tennis and strength and resistance training are recommended.17 There is some evidence that regular exercise throughout the lifespan increases bone density. Children and adolescents who are more active achieve higher bone density, and this is maintained into middle age.17 

People diagnosed with osteoporosis need to have these recommendations modified because of their increased risk of fracture. They should undergo high intensity strength training and low impact weightbearing exercise.13 High intensity strength training is the use of moderate to high overload resistance to increase muscle strength and BMD. Low impact weightbearing exercise is defined as exercise performed while standing but with one foot always on the floor. High impact activities such as jumping are not appropriate for people with established osteoporosis. In addition, people with osteoporosis may benefit from flexibility and balance training to reduce the risk of falls.5 A physiotherapist, exercise physiologist or other appropriately trained professional should supervise the introduction of an exercise program for people with osteoporosis.

Smoking cessation

The increased risk of fracture significantly declines from around 10 years after giving up smoking.18

Pharmacological treatment

Bisphosphonates may be used in both primary prevention and after osteoporosis is established. Note that they have been shown to be effective in primary prevention (in postmenopausal women at risk of osteoporosis) but are not listed on the Pharmaceutical Benefits Scheme (PBS) for this indication.

Hormone replacement therapy

Oestrogen +/– progestogens are effective in improving BMD and reducing the risk of fractures in postmenopausal women. They have been shown to be effective in primary prevention and in treating established osteoporosis. However there are a number of adverse effects including an increased risk of invasive breast cancer, stroke and thromboembolic events. The potential benefits and harms must be carefully considered. Long term use is not recommended by existing guidelines.5 

Strontium

Strontium ranelate has been shown to decrease BMD loss in early postmenopausal women. It is not approved on the PBS for primary prevention but is approved for the treatment of established osteoporosis.

Table 16.1. Risk levels for osteoporosis
Average riskModerate riskHigh risk
All postmenopausal women and men over 50 years of age Age 60–70 years and any of the following:
  • family history of osteoporotic fractures
  • hypogonadism
  • prolonged glucocorticoid use (>3 months)
  • inflammatory conditions
  • malabsorption, eg. coeliac disease
  • hyperparathyroidism
  • hyperthyroidism
  • smoking
  • history of a fall
  • age over 70 years
  • Previous fracture due to minimal trauma
  • Vertebral fractures

 

Recommendations: Osteoporosis
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All postmenopausal women and men over 50 years of age Assess risk factors for osteoporosis (see Table 16.1) As part of an annual health assessment IIB5
People at moderate and high risk (see Table 16.1) Recommend dual energy X-ray absorptiometry (DXA) to determine bone mineral density (BMD) If DXA confirms osteoporosis then manage as high risk At baseline, then 2 yearly if needed IA5
Behavioural All postmenopausal women and men over 50 at all levels of risk Advise adequate dietary calcium intake: 1300 mg/day for women over 50 and men over 70; 1000 mg/day for men 50–70 years Opportunistic and as part of an annual health assessment IA5
Recommend smoking cessation (see Chapter 1: Lifestyle, section on smoking) Recommend maintenance of a healthy weight and body mass index (see Chapter 1: Lifestyle, section on overweight/obesity) IA
Advise adequate but safe sunlight exposure as a source of vitamin D* GPP
People at average and moderate risk (see Table 16.1) Advise regular high intensity weightbearing exercise for postmenopausal women and older men aiming to achieve a target of 30 minutes/day on most days of the week (see Chapter 1: Lifestyle, section on physical activity) Opportunistic and as part of an annual health assessment 1A5
People at high risk (see Table 16.1) Advise regular low impact weightbearing exercise as part of a tailored program emphasising improved balance and flexibility Opportunistic and as part of an annual health assessment GPP5
Chemoprophylaxis   All postmenopausal women and men over 50 at all levels of risk Consider calcium supplementation for those with inadequate dietary intake Also consider vitamin D supplementation for those with inadequate sunlight exposure, particularly those in residential care Opportunistic and as part of an annual health assessment ID5
People at moderate and high risk (see Table 16.1)     Consider bisphosphonates† in conjunction with calcium and vitamin D supplementation At diagnosis     IA5
Consider hormone replacement therapy to increase BMD and reduce fracture risk. Long term use is not recommended due to increased potential for harm, particularly increased breast cancer and cardiovascular disease risk IA
Consider strontium ranelate‡ See management guidelines for further information§ IIC
People at high risk (see Table 16.1) If the above medications are ineffective or contraindicated consider selective oestrogen receptor modulators (raloxifene) or parathyroid hormone (teriparatide) || See management guidelines for further information§ At diagnosis IIC5
Environmental People at moderate and high risk Consider a multifactorial falls reduction program (see Falls recommendations below) At diagnosis ID5
* Fair-skinned people in Australia can produce adequate vitamin D with sun exposure to their face, arms and hands for a few minutes either before 10 am or after 3 pm on most days of the week. In winter in southern parts of Australia this exposure may need to be longer. People with darker skin generally require more sun exposure16
† Bisphosphonates are subsidised under the PBS for the following conditions: concurrent use of oral corticosteroids (>7.5 mg/day) for 3 months or more and a BMD T-score of –1.5 or less, women aged ≥70 years with a BMD T-score of –2.5 or less, any person with a radiologically confirmed fracture due to minimal trauma
‡ Strontium is subsidised under the PBS for the following conditions: women aged >70 years with a BMD T-score of –3.0 or less, all people with a radiologically confirmed fracture due to minimal trauma
§ Refer to clinical practice guidelines for specific treatment recommendations19
|| Selective oestrogen receptor modulators and teriparatide are not subsidised under the PBS in the absence of a fracture due to minimal trauma. Recommend review the PBS for specific criteria

Resources

Fracture risk calculator
www.fractureriskcalculator.com

RACGP Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men
RACGP algorithm for the detection, prevention and treatment of osteoporosis
www.racgp.org.au/ your-practice/guidelines/ musculoskeletal/osteoporosis/

Guidelines for exercise in preventing and treating osteoporosis
www.osteoporosis.org.au/ health-professionals/ research-position-papers/#makebreak

Risks and benefits of sun exposure
www.osteoporosis.org.au/ images/stories/ documents/research/Sunexposure_OA_2007.pdf.

References

  1. WHO Scientific Group on the Prevention and Management of Osteoporosis. Prevention and management of osteoporosis: report of a WHO scientific group. WHO Technical Report Series 921 (serial on the internet), 2000. Cited January 2012. Available at http://whqlibdoc.who.int/trs/who_trs_921.pdf.
  2. Nguyen TV, Center JR, Eisman JA. Osteoporosis: underrated, underdiagnosed and undertreated. Med J Aust 2004;180(Suppl 5):S18–S22.
  3. The Royal Australian College of General Practitioners. Clinical guidelines for the prevention and treatment of osteoporosis in postemenopausal women and older men. Melbourne: RACGP, 2010. Cited October 2011. Available at www.racgp.org.au/ your-practice/guidelines/ musculoskeletal/osteoporosis/.
  4. Macintosh D, Pearson B. Fractures of the femoral neck in Australian Aboriginals and Torres Strait Islanders. Aust J Rural Health 2001;9(3):127–33.
  5. Jones G, Nguyen T, Sambrook P, Kelly P, Gilbert C, Eisman J. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994;4(5):277–82.
  6. Cooley H, Jones G. A population-based study of fracture incidence in southern Tasmania: lifetime fracture risk and evidence for geographic variations within the same country. Osteoporos Int 2001;12(2):124–30.
  7. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000;15(4):721–39.
  8. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict fracture incidence in women. Ann Intern Med 1991;114(11):919–23.
  9. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996;312(7041):1254–8.
  10. Nguyen TV, Center JR, Sambrook PN, Eisman JA. Risk factors for proximal humerus, forearm, and wrist fractures in elderly men and women: the Dubbo Osteoporosis Study. Am J Epidemiol 2001;153(6):587–95.
  11. Scottish Intercollegiate Guidelines Network. Management of osteoporosis: a national clinical guideline. Guideline no. 71. Edinburgh: SIGN, 2003. Cited October 2011. Available at www.sign.ac.uk/pdf/sign71.pdf.
  12. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997;315:841–6.
  13. Ravn P, Cizza G, Bjarnason N, et al. Low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. Early Postmenopausal Intervention Cohort (EPIC) study group. J Bone Miner Res 1999;14(9):1622–7.
  14. Cancer Council Australia. Risks and benefits of sun exposure position statement. Sydney: Cancer Council Australia, 2007. Cited October 2011. Available at www.cancer.org.au/File/ PolicyPublications/PSRisksBenefitsSunExposure 03May07.pdf.
  15. Minne HW. Make it or break it: how exercise helps to build and maintain strong bones, prevent falls and fractures, and speed rehabilitation. Nyon, Switzerland: International Osteoporosis Foundation, 2006. Cited October 2011. Available at www.osteoporosis.org.au/ images/stories/documents/research/ Invest_IOF_2006.pdf.
  16. Cornuz J, Feskanich D, Willett WC, Colditz GA. Smoking, smoking cessation, and risk of hip fracture in women. Am J Med 1999;106(3):311–4.
  17. Endocrinology Expert Group. Therapeutic guidelines: endocrinology. Version 4. Melbourne: Therapeutic Guidelines Limited, 2009.
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