Introduction
Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis leads to nearly 9 million fractures annually worldwide (Johnell and Kanis, 2006), and over 300,000 patients present with fragility fractures to hospitals in the UK each year.
The conceptual definition of osteoporosis was made by the World Health Organization (WHO) in 1994 as a “progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture”. Since microarchitectural deterioration could not be measured clinically, the operational description was based on a bone mineral density (BMD) T-Score of ≤-2.5.
The clinical significance of osteoporosis lies in the fractures that arise. In adults, approximately one in two women and one in five men will sustain one or more fragility fractures (a low trauma fracture sustained from a fall from standing height or less) in their lifetime. In the UK, the prevalence of femoral neck BMD T-Score ≤-2.5, in those aged 50 years and older, is 6.8% in men and 21.8% in women.
Common sites of fragility fracture include the vertebral bodies, hip, distal radius, proximal humerus and pelvis. Hip fracture is the most common reason for emergency anaesthesia and surgery in older people. It is also the most common cause of death following a fall. Such fractures cause severe pain, disability, and reduction in quality of life.
Assessment of Fracture Risk in Postmenopausal Women and Men Age ≥50
- Conduct a FRAX assessment in people with a clinical risk factor for fragility fracture. Clinical risk factors included in FRAX assessment:
- Age
- Sex
- Body mass index (calculated from weight and height in kg/m²)
- Previous fragility fracture, including morphometric vertebral fracture
- Parental history of hip fracture
- Current glucocorticoid treatment (any dose, ≥3 months, by mouth)
- Current smoking
- Alcohol intake ≥3 units daily
- Rheumatoid arthritis
- Secondary causes of osteoporosis:
- Type 1 diabetes
- Long-standing untreated hyperthyroidism
- Untreated hypogonadism/premature menopause
- Chronic malnutrition/malabsorption
- Chronic liver disease
- Non-dialysis chronic renal failure (CKD 3a–5)
- Femoral neck BMD
- Measure BMD in people with intermediate fracture risk by FRAX to refine the estimate of 10-year risk.
- Measure BMD in people with high and very high fracture risk by FRAX to guide drug choice and provide a baseline for BMD monitoring.
- Consider imaging for vertebral fracture in people with acute back pain who have risk factors, and/or those with history of ≥4 cm height loss, kyphosis, long-term glucocorticoid therapy, or BMD T-score ≤-2.5.
- Assess falls risk in patients with osteoporosis and/or fragility fractures, offering those at risk an exercise programme to improve balance and muscle strength.
Additional independent risk factors:
- Low BMI
- History of prior fracture
- Parental history of hip fracture
- Smoking
- Oral glucocorticoid therapy
- Alcohol intake
- Secondary causes of osteoporosis (e.g., endocrine disorders, inflammatory bowel disease)
- Rheumatoid arthritis
- Diabetes mellitus (both type 1 and 2)
Investigation of Osteoporosis and Fragility Fractures
Routine investigations:
- Clinical history
- Physical examination including height and thoracic kyphosis assessment
- Full blood count
- ESR or CRP
- Renal function
- Serum calcium, albumin, creatinine, phosphate, alkaline phosphatase, liver transaminases
- Serum 25-hydroxyvitamin D
- Thyroid function tests
Other investigations, if indicated:
- Serum electrophoresis, immunoglobulins, free light chain assay
- Plasma parathyroid hormone (PTH)
- Serum testosterone, SHBG, FSH, LH
- 24-hour urinary free cortisol / overnight dexamethasone suppression test
- Serum prolactin
- Serum magnesium if hypocalcaemic
- Coeliac disease screen (tissue transglutaminase ± endomysial antibodies)
- Urinary calcium excretion
- Markers of bone turnover (CTX, P1NP)
- Lateral radiographs of lumbar/thoracic spine or DXA lateral vertebral imaging
- Bone densitometry (DXA) if indicated by FRAX
- Isotope bone scan
Non-Pharmacological Management of Osteoporosis
Postmenopausal women, and men age ≥50 years, with osteoporosis or at risk of fragility fracture should:
- Maintain a healthy, nutrient-rich balanced diet
- Consume adequate calcium (≥700 mg daily) via diet or supplements
- Take vitamin D (≥800 IU/day) if insufficient or at risk; housebound or care home residents may require supplementation
- Engage in regular weight-bearing and muscle-strengthening exercise
- Avoid smoking
- Limit alcohol intake to ≤2 units/day
Pharmacological Treatment Options
Recommendations
Fracture risk assessment, patient suitability and preference should inform the choice of drug treatment. Anti-resorptive therapy is the first-line option for most at-risk individuals.
Antiresorptive Drug Treatment
- Oral bisphosphonates (alendronate, risedronate) or IV zoledronate
- Denosumab, ibandronate, HRT, raloxifene, strontium ranelate (alternatives)
- IV zoledronate first-line after hip fracture
- HRT for younger postmenopausal women (≤60 years) with high fracture risk and low baseline risk of malignancy/thromboembolism
Anabolic Drug Treatment
- Teriparatide, abaloparatide, romosozumab for postmenopausal women at very high fracture risk, especially with vertebral fractures
- Second-line: teriparatide for postmenopausal women and men ≥50, abaloparatide or romosozumab in postmenopausal women intolerant to bisphosphonates
- Raloxifene as follow-on therapy after anabolic treatment
Other Treatments
- Strontium ranelate if other treatments contraindicated or not tolerated (specialist initiation advised)
- Calcium and/or vitamin D supplementation if dietary intake low or insufficiency risk present
- Treat vitamin D deficiency prior to initiation of parenteral therapy and alongside oral therapy
References
- Compston J, Cooper A, Cooper C, et al. Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 2009; 62(2): 105-8.
- Compston J, Bowring C, Cooper A, et al. Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013. Maturitas 2013; 75(4): 392-6.
- Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017; 12(1): 43.
- NICE guidelines on Osteoporosis: assessing the risk of fragility fracture. Clinical guideline CG146, Published: 08 August 2012
Compiled By:
Dr. Md. Sajid Bin Ashraf Sami
Contributors
- Prof Dr Fawzia Hossain
- Dr Tasnuva Akhter
- Dr Nurun Nahar
- Dr Lutfa Akhter
- Dr Farjana Akhter
- Dr Walida Afrin
- Dr Taslima Akhter
- Dr Jinat Fatema
- Dr Sumaiya Binte Asif
- Dr Shanjida Kabir
- Dr Georgia Hoque