Endocrine System: Osteoporosis

Clinical features of osteoporosis

• Low bone mass and structural deterioration of bone

• Asymptomatic, often undiagnosed until a fragility fracture occurs

  • Fractures occur in the wrist, spine, and hip

How is osteoporosis diagnosed?

• Calculate fragility fracture risk with QFracture or FRAX

• Confirm in high-risk patients with dual-energy X-ray absorptiometry (DEXA scan)

Osteoporosis risk factors

• Female sex

• Increasing age (over 50)

• Menopause

• Taking oral glucocorticoid treatment (3+ months)

• Smoking and drinking

• History of fractures

• Low BMI

• Calcium and vitamin D deficiency

• Physical inactivity

Lifestyle changes for osteoporosis

• Balanced diet

• Increased vit D and calcium intake (supplements if needed)

• Increase exercise

• Smoking cessation

• Reduce alcohol intake

When to review osteoporosis treatment

Review need for medication after 5 years (3 years for zoledronic acid)

First line OP treatment

Oral bisphosphonates (alendronic, ibandronic, zoledronic acid / risedronate sodium)

Postmenopausal OP therapies

• Strontium

• Densumab

• Teriparatide

• HRT

• Tibolone

• Raloxifene

When are strontium and teriparatide used?

Severe postmenopausal osteoporosis

When are HRT and tibolone used?

Osteoporosis in younger postmenopausal women

When is raloxifene used?

When other OP treatments are contraindicated or unsuitable

OP treatments in men

• Strontium

• Denosumab

• Teriparatide

Treatment for glucocorticoid-induced osteoporosis

• Teriparatide

• Denosumab

Who should osteoporosis prophylaxis at onset of glucocorticoid treatment be started in?

• Women >= 70 years

• Women with prior fragility fracture

• Women taking large doses of glucocorticoids

• Men >= 70 with:

  • High dose glucocorticoids (>= 7.5 mg/day of prednisolone or equivalent over 3 months)

  • FRAX probability of major/hip fracture exceeding the intervention threshold

What side effects of bisphosphonates should be reported, and the medication stopped?

• Oesophagitis

• Oesophageal ulcers

• Oesophageal erosions

How to take bisphosphonates

With a full glass of water while standing and remain upright for 30 mins after

How to take alendronic acid

30 mins before breakfast/other oral meds

How to take risedronate sodium

30 mins before breakfast or leave 2 hours before and after food/drink if at a different time in the day

How to avoid decreased absorption of bisphosphonate

• Leave 30 mins between bisphosphonate and calcium supplements or antacids

• Leave 30 mins between bisphosphonate and food and drinks (other than plain water)

Medication to avoid with bisphosphonates

NSAIDs - increased risk of GI irritation

What to do if missed dose of once weekly bisphosphonate

• Take missed tablet on the day it is remembered

• Continue taking one tablet once a week on the day the tablet is normally taken

• Two tablets should not be taken on the same day

MHRA warnings for bisphosphonates

• Atypical femoral fractures

  • Report any thigh, hip, or groin pain

• Osteonecrosis of the jaw

  • Report any dental pain, swelling, non-healing sores or discharge

• Osteonecrosis of the external auditory canal

  • Report ear pain, discharge, or ear infection