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Clinical guidelines

Guidelines for preventive activities in general practice 8th 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

Review of fracture risk factors for women aged over 45 years and men aged over 50 years is recommended (C). Those with increased risk should have bone density assessed (A).

Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and increased fracture risk.620 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 BMD as a T-score of ≤–2.5. However, age, lifestyle factors, family history and some medications and diseases all contribute to bone loss and increased risk of fragility fractures. Thus, the goal of prevention and treatment is to reduce a person’s overall fracture risk (not just bone density maintenance).

Methods to estimate absolute fracture risk for osteoporotic fractures are available at:

As bone densitometry is part of these estimates, BMD should be considered as part of the overall fracture risk assessment (D). Risk estimation is imperfect, but the calculator’s predictive performance is similar to absolute cardiovascular risk calculators.621 Risk factors (e.g. falls, glucocorticoid use, etc.) not included in one or other risk algorithm require clinical judgement to modify the risk estimate.

To date, there are no RCTs directly evaluating screening effectiveness, harms and intervals, whether screening is performed by bone density screening by dual-energy X-ray absorptiometry (DXA) or by estimating absolute fracture risk. 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 risk
  • Postmenopausal women (aged 45 years or older)
  • Men aged 50 years or older
Assessment for risk factors (II,C)
Preventive advice (II,C)
Every 12 months (Practice Point)620,621
Increased risk
  • Age >60 years for men and >50 years for women plus any of:
  • family history of fragility fracture
    • smoking
    • high alcohol intake (>2–4 standard drinks per day for men, less for women)
    • vitamin D deficiency <60 nmol (screening for vitamin D not indicated just for risk assessment)
    • low body weight (BMI <20)
    • 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:
    • endocrine (e.g. hypogonadism, Cushing syndrome, hyperparathyroidism, hyperthyroidism)
    • inflammatory conditions (e.g. rheumatoid arthritis)
    • malabsorption (e.g. coeliac)
    • CKD, chronic liver disease
    • drugs, especially corticosteroids (e.g. 7.5 mg x
      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 (also known as SSRIs)
Bone mineral densitometry and management of risk factors (II,A)
Investigate for causes of secondary osteoporosis if indicated by history, examination findings or BMD result (Practice Point)
At presentation and no more than every 2 years. Repeat when it is likely to change management (II,C)622,623
Where there is a specific bone mineral wasting condition or medication, consider more frequent repeat of DXA if likely to change treatment (Practice Point)
High risk of further fracture
  • Patients aged over 45 years who sustain a low trauma fracture
  • Postmenopausal women, and men with a suspected vertebral fracture (loss of height >3 cm, kyphosis, back pain)
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 2 years (II,B)620
Repeat only when it is likely to change management (Practice Point)
Where there is a specific bone mineral wasting condition or medication, consider more frequent repeat of DXA (Practice Point)
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 within 5–10 years, this is equivalent risk as any other fragility fracture)
  • loss of height (>3 cm) and/or thoracic kyphosis (consider lateral spine X-ray for vertebral deformity)
  • premature menopause
  • anorexia nervosa or amenorrhea for greater than 12 months before age 45 years
Preventive actions
  • Ensure adequate daily calcium intake: dietary calcium ((A) for prevention of bone loss, (C) for fracture) 1200 mg/day. Exercise caution with supplements.*
  • Encourage healthy lifestyle (e.g. smoking cessation and limiting alcohol and caffeine intake) (D).
  • Education and psychosocial support for risk factor modification (Practice Point)
  • Falls reduction strategies: for fracture risk reduction (Practice Point)
  • Encourage exercise: for prevention of bone loss (A) and fracture risk reduction (Practice Point).
  • Advise on safe sun exposure levels as a source of vitamin D (II,C).†
  • Discuss absolute risk of fracture (Practice Point)
Bone mineral densitometry (BMD) BMD should be measured by DXA scanning performed on two sites, preferably antero-posterior spine and hip. Without bone-losing medical conditions (e.g. steroid use), it is unlikely to change significantly in less than 2 years (II,B) and DXA should generally be repeated only when patient is at risk of reaching treatment thresholds (average decrease in T-score is usually approx 0.1/year if no specific bone-losing medical conditions) (Practice Point). Rate of bone loss tends to be slower in early older age (60+) than in later old age (80+), and slower in men than women.624

* Controversial level II evidence of increased risk of cardiovascular events with calcium supplements in postmenopausal women, not seen in dietary studies.625-627
† Population screening for vitamin D deficiency is not recommended, but targeted testing of people who are at risk of osteoporosis and 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 (i.e. <25 nmol/L) and so is less likely to be corrected by safe sun exposure628 (Practice Point).

Other tests for bone density

A number of other X-ray and ultrasound tests have been shown to predict fractures, although not as well as DXA. Moreover, intervention trials have been based on cases identified through DXA assessment, so their results cannot readily be applied to individuals identified by other means.620,621

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.629,630 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. Optimal treatment includes ensuring adequate calcium intake and correcting vitamin D deficiency.

There are inequities in the use of BMD measurement with relative underutilisation in people from rural and remote locations and men.631

References

  1. National Health and Medical Research Council. Clinical practice guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. Melbourne: RACGP, 2010
  2. 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. Evidence syntheses no. 77. Rockville, MD: Agency for Healthcare Research and Quality, 2010
  3. US Preventive Services Task Force. Screening for osteoporosis: clinical summary of US Preventive Services Task Force Recommendation. Rockville, MD: Agency for Healthcare Research and Quality, 2011
  4. Nakamura T, Tsujimoto M, Hamaya E, Sowa H, Chen P. Consistency of fracture risk reduction in Japanese and Caucasian osteoporosis patients treated with teriparatide: a meta-analysis. J Bone Miner Metab 2012;30(3):321–5
  5. 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):1800–7
  6. Bolland MJ, Barber PA, Doughty RN, Mason B, Horne A, Ames R, et al. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ 2008;336(7638):262–6
  7. Bolland MJ. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta analysis. BMJ 2010;341:3691
  8. Lewis JR, Calver J, Zhu K, Flicker L, Prince RL. Response to ‘calcium supplements and cardiovascular risk’. J Bone Miner Res 2011;26(4):900–1
  9. 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):92–9
  10. National Institute of Clinical Studies. Evidence – practice gaps report. Melbourne: NICS, 2005
  11. 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):310–5
  12. Ewald DP, Eisman JA, Ewald BD, Winzenberg TM, Seibel MJ, Ebeling PR, 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):126–8
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