Author: Paul Hayes
Newly updated guidelines offer GPs the most up-to-date information and recommendations for patients who present with osteoporosis.
As the age of Australia’s population continues to increase, so too does the likelihood and prevalence of certain illnesses.
Osteoporosis, a condition characterised by low bone mineral density and deterioration of bone tissue which leads to decreased bone strength and increased fracture risk,1 is common among people over the age of 50. As many as 1.2 million people in Australia are believed to currently be living with the condition, while a further 6.3 million have low bone density (osteopenia).2 In addition, it is estimated that 6.2 million Australians over the age of 50 will have osteoporosis or osteopenia by 2022.3
The common nature of the condition means GPs are at the frontline for diagnosis and providing patients with treatment and ongoing management.
‘The GP’s role in managing osteoporosis is hugely important because it’s really only through primary care that we are going to have contact with the population that we need to focus on,’ Dr Dan Ewald, a GP with an interest in osteoporosis, told Good Practice.
‘Managing osteoporosis is a high-volume condition, it’s a common condition and a long-term condition … so it’s ideally suited to the general models of chronic disease management that modern-day general practice should be geared towards.
‘Osteoporosis is bread-and-butter work for general practice, like managing diabetes or hypertension.’
Prof Peter Ebeling, endocrinologist, head of the Monash University Department of Medicine and medical director of Osteoporosis Australia, agrees that the common nature of the condition in Australia amplifies GPs’ role.
‘The GP has a critical role. The most important thing for a GP is to be aware of bone health and also to assess patients sitting in front of them regarding their risk of osteoporosis,’ he told Good Practice.
While the idea that 1.2 million Australians are living with osteoporosis is alarming, the fact fewer than 20% of patients who present to healthcare services with minimal-trauma fractures are investigated or treated for osteoporosis may be even more surprising.4,5
Minimal-trauma fractures, or fragility fractures, occur following little or no trauma and are the best indicator of a possible osteoporosis diagnosis in people over the age of 50.
‘If a patient has an altercation that presents with a minimal-trauma fracture, that really means that patient has osteoporosis,’ Prof Ebeling said. ‘So they really … need to go on treatment.
‘[But] GPs are sometimes so busy that osteoporosis and bone health can slip off the radar of problems that might face their older patients.’
The increasing number of people with the condition and the small number who are receiving appropriate treatment, combined with new evidence and available medications, helped spur the RACGP and Osteoporosis Australia to produce an updated second edition of Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age (the Guidelines).
‘The new Guidelines provide GPs with timely and much needed expert guidance to better detect, diagnose, and manage patients with osteoporosis. They will take away the ambiguity that has previously been associated with osteoporosis management,’ RACGP President Dr Bastian Seidel said.
‘GPs are often the first port of call for patients with osteoporosis and therefore must have the most up-to-date information and expert guidance on how to treat osteoporosis. The new Guidelines provide just that.’
According to Prof Ebeling, Chair of the Guidelines working group, the updated second edition was necessary in light of newly developed evidence.
‘We have got new medications available, and some of the older medications aren’t used as much now,’ he said. ‘We have modified the Guidelines to reflect the changes in practice that have occurred over the last several years.
‘It is also timely given the increasing prevalence of osteoporosis and the ageing of the Australian population.
‘GPs play a frontline role in osteoporosis management and these new Guidelines create a real opportunity for improving detection rates in general practice and reducing the burden of fractures.’
The updated edition of the Guidelines features a total of 42 new recommendations in the areas of risk factor assessment, diagnosis and referral; general bone health maintenance and fracture prevention; pharmacologic approaches to prevention and treatment; ongoing monitoring; and special issues.
‘The new Guidelines make it clear which interventions, pharmacological and non-pharmacological, are well evidence-based,’ Dr Ewald, a member of the Guidelines’ working group, said. ‘They also look at different models and their strengths and hospital-based re-fracture preventions programs, and clarify the evidence around calcium and vitamin D as a treatment for osteoporosis versus the regular medicines of bisphosphonates and denosumab.’
Once the appropriate tests have been completed and a diagnosis of osteoporosis has been established, Prof Ebeling recommends discussing treatment options, including risks and benefits, with the patient.
‘We have got a number of treatment options – largely the oral or intravenous bisphosphonates or subcutaneous denosumab – and the patient’s acceptance of these will depend on their appreciation of the benefits and risks of these individual treatments,’ he said.
According to Prof Ebeling, while orally administered medications can potentially cause indigestion or other minor stomach upsets, and an initial intravenous injection can cause minor flu-like symptoms in up to one-third of people, the benefits of these treatments are clear.
‘They are mostly very effective in reducing spinal fractures,’ he said. ‘Those reductions in spinal fractures range from about 40–70%. They also reduce hip fractures by about 50% and other fractures by about 20%.
‘So they are effective at reducing fractures.’
One of the key features of the updated Guidelines is the introduction of single-page osteoporosis risk assessment, diagnosis and management flowchart which summarises key practice tips and new treatment recommendations.
The chart offers GPs tips and information, including diagnosis and treatment options, for patients who present with minimal trauma hip or vertebral fracture, minimal-trauma fracture at any other site, and no history of minimal-trauma fracture.
‘The flowchart is a decision-making tree that will give GPs all the advice they need about managing patients with osteoporosis in just one page,’ Prof Ebeling said. ‘We have tried to make it very easy.’
The use of osteoporosis risk-assessment tools, such as the Garvan Fracture Risk Calculator or the Fracture Risk Assessment Tool (FRAX), is an important addition in that they provide other means to help patients better understand their own susceptibility to osteoporosis.
‘The absolute risk assessment tools give you a risk in five years or 10 years of having any fragility fracture,’ Dr Ewald said. ‘That not only helps the patient understand the level of risk, it also helps them understand the amount that risk could reduce if they went on treatment.
‘If the absolute risk is high and they can reduce that by 40%, that is obviously quite a useful reduction.’
The availability of new evidence also led to the inclusion of new information and recommendations for patients with breast cancer and prostate cancer.
‘We have added those sections because we think it’s really important that those two groups are recognised. At the moment they are probably not recognised as much as they should be,’ Prof Ebeling said.
‘Men who go onto treatment for prostate cancer have treatments that reduce their testosterone to very low levels and that can result in bone loss.
‘The same is true for women going on a treatment for breast cancer called aromatase inhibitor therapy. That reduces their oestrogen levels to about zero and they can get fractures very commonly after starting those types of drugs.
‘So those patients really need to be assessed for their bone health.’
Prof Ebeling and Dr Ewald both agree the most important factor in GPs providing the best treatment to people with osteoporosis, particularly in light of the fact so many people are not receiving treatment, is being aware of the condition and maintaining awareness when working with patients over the age of 50.
‘Managing osteoporosis is actually quite easy to do and it’s just a matter of it being in people’s minds,’ Dr Ewald said. ‘The people who I am most concerned about and who continue to be missed are people who have already had a fragility fracture, meaning they are at very high risk for subsequent fracture.
‘Any time someone over 50 has a fracture, assume it was a fragility fracture until you have worked out that it wasn’t.’
- The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd edn. East Melbourne, Vic: RACGP, 2017.
- Osteoporosis Australia. About osteoporosis. Glebe, NSW: Osteoporosis Australia. Available at www.osteoporosis.org.au/about-osteoporosis [Accessed 28 March 2017].
- Watts JJ, Abimanyi-Ochom J, Sanders K. Osteoporosis costing all Australians: A new burden of disease analysis – 2012 to 2022. Glebe, NSW: Osteoporosis Australia, 2013.
- Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: A systematic review. Osteoporos Int 2004;15:767–78.
- Eisman J, Clapman S, Kehow L. Osteoporosis prevalence and levels of treatment in primary care: The Australian BoneCare Study. J Bone Miner Res 2004;19(12):1969–75.