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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

14. Osteoporosis

Women

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Men

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

The goal of the prevention and treatment of osteoporosis is to reduce a person’s overall fracture risk, not just to maintain bone density.

Review of fracture risk factors for postmenopausal women aged >45 years and men aged >50 years is recommended (Practice Point). Those with increased risk should have bone density assessed (Practice Point).

Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and increased fracture risk.1 It is diagnosed on the presence of a fragility fracture (fracture from the equivalent of a fall from standing height or less, or a fracture that under normal circumstances would not be expected in a healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is defined by bone mineral density (BMD) as a T-score of ≤–2.5. However, age, lifestyle factors, family history, and some medications and diseases contribute to bone loss and increased risk of fragility fractures. Furthermore, it is important to note that in an individual who has sustained a fragility fracture, a T-score of ≤–2.5 is not also required to make the diagnosis of osteoporosis, the presence of a fragile fracture is sufficient. Thus, the goal of prevention and treatment is to reduce a person’s overall fracture risk (not just maintain bone density).

Two of the most widely validated methods to estimate absolute fracture risk for osteoporotic fractures relevant to the Australian population are available at:

These calculators can be used with and without measuring BMD, though the Garvan fracture risk calculator has not been validated in an external cohort when BMD has not been used in the calculator.2 Risk estimation is imperfect, with the tools being modest predictors of fracture risk.3,4 Risk factors (eg falls, glucocorticoid use) not included in one or the other risk algorithm require clinical judgement to modify the risk estimate.

To date, there are no randomised controlled trials (RCTs) directly evaluating screening effectiveness, harms and intervals, and whether screening is performed by bone density screening by dual-energy X-ray absorptiometry (DXA) or by estimating absolute fracture risk.4 The place of absolute fracture risk assessment in the prevention and management of osteoporosis requires further clarification as its effectiveness is yet to be tested.

Table 14.1. Osteoporosis: Identifying risk
Who is at risk?What should be done?How often
Average risk1, 3, 5
  • Postmenopausal women (aged ≥45 years)
  • Men aged ≥50 years
Clinical assessment for risk factors (Practice Point)

Preventive advice (II, C)
Every 12 months (Practice Point)
Increased risk3, 5–8
  • Aged >60 years for men and >50 years for women plus any of:
    • family history of fragility fracture
    • smoking
    • high alcohol intake (>4 standard drinks per day for men and >2 for women)
    • vitamin D deficiency <50 nmol (screening for vitamin D not indicated just for risk assessment)*
    • low body weight (body mass index [BMI] <20kg/m2)
    • recurrent falls
    • low levels of physical activity†
    • immobility (to the extent that person cannot leave their home or cannot do any housework)
  • Medical conditions and medications that may cause secondary osteoporosis including:
    • endocrine disorders (eg hypogonadism, Cushing syndrome, hyperparathyroidism, hyperthyroidism)
    • premature menopause
    • anorexia nervosa or amenorrhea for >12 months (unrelated to pregnancy) before 45 years of age
    • inflammatory conditions (eg rheumatoid arthritis)
    • malabsorption (eg coeliac disease)
    • chronic kidney or liver disease
    • multiple myeloma and monoclonal gammopathies
    • human immunodeficiency virus (HIV) and its treatment
    • Type 1 and type 2 diabetes mellitus
    • drugs, especially corticosteroids (eg 7.5 mg for >3 months) used for immunosuppression including as part of chronic anti-rejection therapy in organ or bone marrow transplant, anti-epileptic, aromatase inhibitors, anti-androgen, excessive thyroxine, possibly selective serotonin reuptake inhibitors (SSRIs)
Dual X-ray absorptiometry (DXA) to measure bone mineral density (BMD) and management of risk factors (II, A to III, D depending on risk factor)

Investigate for causes of secondary osteoporosis if indicated by history, examination findings or BMD result (Practice Point)
The optimal timing of repeated DXA for screening is unknown but is likely to vary depending on baseline BMD

Women with baseline T-score >–1.0 may take longer than 15 years to transition to osteoporosis

Repeat only when it is likely to change management (II, C)

Where there is a specific condition or medication present likely to lead to accelerated bone loss (eg corticosteroid use [refer to causes of secondary osteoporosis]), consider more frequent repeat of DXA (Practice Point)
High risk of further fracture1
  • Patients aged >45 years who have sustained a low-trauma fracture
  • Postmenopausal women, and older men with a vertebral fracture. Such fractures should be ruled out if clinically suspected (eg from loss of height >3 cm, kyphosis, back pain)
DXA to measure BMD and management of risk factors (II, A)

Investigate for causes of secondary osteoporosis if indicated by history, examination findings or BMD result (Practice Point)

Recommend that such individuals are initiated on effective anti-osteoporosis therapy unless there are specific contraindications
DXA at presentation and no more than every two years (II, B).

It is appropriate to recommend a repeat BMD by DXA after two years for patients at risk of developing osteoporosis, to assist in re-evaluation of fracture risk

In patients with confirmed osteoporosis, repeat BMD is generally not required; however, it may be conducted before initiating a change in, or cessation of, anti-osteoporotic therapy (Practice Point)

Where there is a specific condition or medication present likely to lead to accelerated bone loss (eg corticosteroid use [refer to causes of secondary osteoporosis]), consider more frequent repeat of DXA (Practice Point)
* Assessment of the potential clinical importance of a given serum vitamin D level should take into consideration the season in which the test was done, as levels in an individual will be higher from late spring to autumn than in winter to early spring6,9 (Practice Point)

† There is no accepted cut-off or standard definition for defining low levels of physical activity as a risk factor for osteoporosis. Those at risk would include people with higher levels of sedentary behaviour, (eg those who participate in no recreational exercise,10 or who are sitting and lying for more than 20 hours per day).11 It also includes those who perform relatively low levels of weight bearing physical activity (eg people who walk less than 60 minutes per day,11 less than 12 km per week,12 or do not walk for exercise)10

BMD, bone mineral density; BMI, body mass index; DXA, dual X-ray absorptiometry; HIV, human immunodeficiency virus; SSRI, selective serotonin reuptake inhibitor
Table 14.2. Osteoporosis: Preventive interventions
InterventionTechnique
Assessment of risk factors Take a thorough history, paying particular attention to the risk factors above plus:
  • vertebral deformity (if has occurred within 5–10 years, this creates an equivalent risk to any other fragility fracture)
  • loss of height (>3 cm) and/or thoracic kyphosis (consider lateral spine X-ray for vertebral deformity)
Preventive actions13–19 Encourage a daily dietary calcium intake that meets the age-appropriate Australian recommended daily intake (1000 mg for adult men until 70 years of age and women until 50 years of age, 1300 mg after this age; prevention of bone loss [I, A] but not for fracture prevention [III-2, D])

Encourage healthy lifestyle (eg smoking cessation and limiting alcohol intake) (D)

Education and psychosocial support for risk factor modification (Practice Point)

Falls reduction strategies: Falls (I, A), and fracture risk reduction (Practice Point)

Encourage regular weight-bearing and resistance exercise for the prevention of falls (I, A), bone loss (I, A) and fracture risk reduction (I, C)

Advise on appropriate sun exposure levels (which minimise the risk of skin cancer) as a source of vitamin D (II, C)*

Discuss absolute risk of fracture (Practice Point)
Bone mineral densitometry (BMD)8, 20 BMD should be measured by dual X-ray absorptiometry (DXA) scanning performed on two sites, preferably antero-posterior spine and hip. Without bone-losing medical conditions (eg hypogonadism, anti-gonadal therapy or corticosteroid use), BMD is unlikely to change significantly in <2 years (II, B)

DXA should generally be repeated only when patient is at risk of reaching treatment thresholds (average decrease in T-score is usually approximately 0.1/year if no specific bone-losing medical conditions; Practice Point)
* Population screening for vitamin D deficiency is not recommended, but targeted testing of people who are at risk of osteoporosis and/or who are at high risk of vitamin D deficiency should be considered. Vitamin D supplements could be considered in deficient individuals if increasing sun exposure is contraindicated or not feasible or if deficiency is more than mild (ie <30 nmol/L) and so is less likely to be corrected by low-risk levels of sun exposure21 (Practice Point)

BMD, bone mineral density; DXA, dual X-ray absorptiometry

Quantitative ultrasound

An alternative imaging technique for assessing fracture risk is quantitative ultrasound, which measures parameters such as speed of sound (SOS) and broadband ultrasound attenuation (BUA), with these values being combined into composite parameters such as stiffness index. These parameters predict fracture to a similar degree as DXA measures of BMD. However, there is no agreed definition of osteoporosis using quantitative ultrasound, and it cannot be used to assess the response to osteoporosis treatment.22 Moreover, intervention trials have predominantly been based on cases identified through DXA assessment, so their results cannot readily be applied to individuals identified by other means.1,3 For this reason, DXA remains the recommended method of assessment.

Implementation

Several Australian studies have shown an evidence–practice gap, where the majority of people with a fragility fracture tend to have their fracture treated, but not the underlying osteoporosis.23,24 Those with a previous fragility fracture have a very high risk of further fracture, and have greatest benefit from specific anti-osteoporosis treatment. Fracture risk reductions with optimal therapy are substantial and treatment according to current guidelines is recommended unless absolutely contraindicated. This is unlikely given the range of treatments now available. Optimal treatment necessitates the use of a specific anti-osteoporosis treatment such as a bisphosphonate, but also includes ensuring adequate calcium intake and correcting vitamin D deficiency.

There are inequities in the use of BMD measurement with relative underuse in men and people from rural and remote locations.25

There is insufficient evidence to support population screening of younger women by DXA. However, if a DXA is performed for a clinical indication, the results could be used opportunistically to improve bone health via feedback of relative fracture risk. In women aged 25–45 years, written feedback of being at high risk compared to not at high risk of fracture in later life (based on mean DXA hip and lumbar spine T-score being less than or greater than or equal or zero) resulted in improved osteoporosis preventive behaviours and femoral neck BMD at two26 and 12 years.27

References

  1. The Royal Australian College of General Practitioners. Clinical practice guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. South Melbourne, Vic: RACGP, 2010.
  2. Marques A, Ferreira RJ, Santos E, Loza E, Carmona L, da Silva JA. The accuracy of osteoporotic fracture risk prediction tools: A systematic review and meta-analysis. Ann Rheum Dis 2015;74(11):1958–67.
  3. Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C. Screening for osteoporosis: Systematic review to update the 2002 US Preventive Services Task Force Recommendation. Rockville, MD: USPSTF, 2010.
  4. Rubin KH, Friis-Holmberg T, Hermann AP, Abrahamsen B, Brixen K. Risk assessment tools to identify women with increased risk of osteoporotic fracture: Complexity or simplicity? A systematic review. J Bone Miner Res 2013;28(8):1701–17.
  5. US Preventive Services Task Force. Screening for osteoporosis: Clinical summary of US Preventive Services Task Force Recommendation: Rockville, MD: USPSTF, 2011.
  6. Nowson CA, McGrath JJ, Ebeling PR, et al. Vitamin D and health in adults in Australia and New Zealand: A position statement. Med J Aust 2012;196(11):686–87.
  7. Maurel DB, Boisseau N, Benhamou CL, Jaffre C. Alcohol and bone: Review of dose effects and mechanisms. Osteoporos Int 2012;23(1):1–16.
  8. Gourlay ML, Fine JP, Preisser JS, et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med 2012;366(3):225–33.
  9. Bolland MJ, Grey AB, Ames RW, et al. The effects of seasonal variation of 25-hydroxyvitamin D and fat mass on a diagnosis of vitamin D sufficiency. Am J Clin Nutr 2007;86(4):959–64.
  10. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995;332(12):767–73.
  11. Coupland C, Wood D, Cooper C. Physical inactivity is an independent risk factor for hip fracture in the elderly. J Epidemiol Community Health 1993;47(6):441–43.
  12. Krall EA, Dawson-Hughes B. Walking is related to bone density and rates of bone loss. Am J Med 1994;96(1):20–26.
  13. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation, 2014.
  14. Ebeling PR, Daly RM, Kerr DA, Kimlin MG. Building healthy bones throughout life: An evidence-informed strategy to prevent osteoporosis in Australia. Med J Aust 2013;199(7 Suppl):S1.
  15. Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: Systematic review. BMJ 2015;351:h4580.
  16. Tai V, Leung W, Grey A, Reid IR, Bolland MJ. Calcium intake and bone mineral density: Systematic review and meta-analysis. BMJ 2015;351:h4183.
  17. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.
  18. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev 2011;7:CD000333.
  19. Kemmler W, Haberle L, von Stengel S. Effects of exercise on fracture reduction in older adults: A systematic review and meta-analysis. Osteoporos Int 2013;24(7):1937–50.
  20. Frost SA, Nguyen ND, Center JR, Eisman JA, Nguyen TV. Timing of repeat BMD measurements: Development of an absolute risk-based prognostic model. J Bone Miner Res 2009;24(11):1800–07.
  21. Winzenberg T, van der Mei I, Mason RS, Nowson C, Jones G. Vitamin D and the musculoskeletal health of older adults. Aust Fam Physician 2012;41(3):92–99.
  22. Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive summary of the 2013 International Society for Clinical Densitometry Position Development Conference on bone densitometry. J Clin Densitom 2013;16(4):455–66.
  23. Barrack CM, McGirr EE, Fuller JD, Foster NM, Ewald DP. Secondary prevention of osteoporosis post minimal trauma fracture in an Australian regional and rural population. Aust J Rural Health 2009;17(6):310–15.
  24. National Institute of Clinical Studies. Evidence – Practice gaps report. Melbourne: NICS, 2005.
  25. Ewald DP, Eisman JA, Ewald BD, et al. Population rates of bone densitometry use in Australia, 2001-2005, by sex and rural versus urban location. Med J Aust 2009;190(3):126–28.
  26. Winzenberg T, Oldenburg B, Frendin S, De Wit L, Riley M, Jones G. The effect on behavior and bone mineral density of individualized bone mineral density feedback and educational interventions in premenopausal women: A randomized controlled trial [NCT00273260]. BMC Public Health 2006;6:12.
  27. Wu F, Laslett L, Wills K, Oldenburg B, Jones G, Winzenberg T. Effects of individualised bone density feedback and educational interventions on osteoporosis knowledge and self-efficacy in young women: A 12-yr prospective study. Plenary poster P11, ANZBMS 23rd Annual Scientific Meeting; Hilton on the Park, Melbourne, 2013.
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