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Tackling osteoporosis is everybody's job

Alison Graham
MB BS MRCGP DOccMed
GP Principal
Yaxley Group Practice
Peterborough, and
Medical Advisor to Scancare Services

Osteoporosis statistics make grim reading. With a cost of £1,700m per year to the NHS,(1) and more deaths than cancer of the ovary, cervix and uterus combined, it is a costly disease. The tragic fact is that much of it is preventable and effective treatments are available. Most cases are simple to manage in general practice. The key is to use a case-finding approach looking for people at high risk, rather than population screening. Certain clinical presentations should act as red flags.
Height loss, especially with kyphosis: These patients require a thoracic spine X-ray to confirm the presence of any vertebral collapse (make it clear that this is the purpose of the examination). If vertebral fracture is seen, patients should be investigated to exclude secondary deposits and myeloma. They then require a bisphosphonate, hormone replacement therapy (HRT) or a SERM (selective estrogen receptor modulator).
Previous fragility fracture: If there is a clear history of a fracture that seems unexpected given the degree of trauma, osteoporosis should be suspected. These patients require aggressive treatment. It is a controversial issue as to whether they require bone densitometry or not. The FIT study suggested that, of those who had fractured, only those with low bone density responded well to bisphosphonates.(2) HRT or a SERM may be more cost-effective. However, more data are required and I personally reserve DXA (dual X-ray absorptio­metry) for situations where the history is unclear.
Oral steroid therapy: Steroids are bad for bones. Patients over 65 years need bone protection and there is no need to investigate further. Evidence points to using bisphosphonates in these high-risk patients. Even very low doses (5-7.5mg daily) can have deleterious effects in susceptible patients. In the under-65s, bone densitometry should be used to guide the therapy.(3)
Premature menopause: These women should be educated about the protective benefits of HRT. Measurement of follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels every 2-3 years in women after hysterectomy with preservation of ovaries is recommended by some to detect the development of an occult menopause.
Frail elderly: There is now compelling evidence to give calcium and vitamin D supplements to all frail, house-bound and institutionalised elderly, as significant fracture prevention is achieved as early as 18 months.(4)
Osteoporosis is a very active area for research and new products are on the horizon. The key developments are with bisphosphonates and SERMs.
There are three bisphosphonates available. Fosamax (Merck Sharpe Dohme) and Actonel (Procter and Gamble), both of which have powerful data for fracture prevention, will largely supersede Didronel PMO (Procter and Gamble). They are, however, difficult drugs to take correctly, and the complex dosing regimens significantly intrude into patients' daily lives. Fosamax has recently become available as a once-weekly preparation, and postmarketing surveillance will be required to demonstrate whether this leads to a better side-effect profile. Actonel seems to be better tolerated than daily Fosamax and the dosage regimen is slightly more flexible, but it is not licensed for men.
In the field of HRT there is an increasing choice of preparations, vital to allow therapy to be tailored to the patient. It is especially good to see flexible doses for continuous combined HRT with the arrival of Indivina (Orion Pharma). Recent research suggests that lower doses of estrogen are enough in older women for bone protection. There is currently only one SERM available (Evista; Lilly), but others are in development.
Calcium and vitamin D supplements at pharmacological doses are usually coprescribed with bisphosphonates and should be considered for all frail elderly, especially if they have already fractured. In my experience, side-effects are minimal but compliance with chewy tablets is not good, and soluble preparations such as Cacit D3 (Procter and Gamble) are taken more willingly.
The diagnosis of osteoporosis has traditionally been made using DXA. It is now suggested that the T-scores obtained should be reserved for DXA at the hip.(5) Many believe that risk assessment may be clinically more useful than diagnosis. QUS (quantitative heel ultrasound) has been shown to predict fractures as well as DXA in the elderly(6) and in postmenopausal women. However, it can easily be misunderstood as providing a diagnosis; in fact it assesses risk. It must be subject to quality control, and operator training is vital. Results should be considered along with other risk factors.
The management of osteoporosis is relatively straightforward for most patients. The RCP has produced a simple algorithm.(7) First, exclude secondary causes by checking basic blood parameters. X-ray the spine if vertebral fractures are suspected because of pain, height loss or deformity, and refer for DXA if it will change your management. Second, start bone protection. HRT remains the treatment of choice in most women. I favour a bisphosphonate if there is a clear history of fragility fracture or use of steroids. A SERM is useful if other therapies are not tolerated.
Monitoring responses to therapy is controversial, but the consensus is that QUS is not accurate enough, and although DXA is, repeated measurements probably do not change management.
Men, premenopausal women and children should all be managed in specialist centres because of the lack of treatments licensed for them. Indications for DXA referral should be covered by local protocols.
Not all interventions are expensive. Simple responses to common clinical triggers and a sense of collective responsibility can help prevent many osteoporotic fractures. If you have diagnosed the first fracture, why not prevent the second?

Five-year ­forecast

  • A move away from simply diagnosing ­osteoporosis with DXA alone, towards a five-year hip ­fracture risk ­calculation
  • Increasing use of other methods of assessing bone quality such as QUS (quantitative heel ­ultrasound), which will make testing more ­accessible to those at risk
  • A greater choice of therapies, ­especially ­bisphosphonates and SERMs, with better ­­side-effect profiles
  • The clinical use of urine bone markers will become ­established, with point-of-care tests to provide a dynamic view of the rate of bone loss

References

  1. Torgerson DJ, Iglesias CP, Reid DM. The ­economics of fracture prevention. Key advances in the effective management of osteoporosis. London: Aesculapius Medical Press; 2001.
  2. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of ­alendronate on risk of fracture in women with existing vertebral ­fractures. Lancet 1996;348:1535-41.
  3. National Osteoporosis Society. Guidance on the prevention and ­management of corticosteroid-induced osteoporosis. Bath: NOS; 2000.
  4. Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992; 327:1637-42.
  5. Kanis JA, Gluer CC. An update on the diagnosis and assessment of osteoporosis with densitometry. Osteoporosis Int 2000;11:192-202.
  6. Bauer DC, Gluer CC, Cauley JA, et al. Broad-band ­ultrasound attenuation predicts ­fractures strongly and independently of densitometry in older women: a prospective study. Arch Intern Med 1997;157:629-34.
  7. Royal College of Physicians and the Bone and Tooth Society. Osteoporosis: clinical guidelines for the prevention and treatment. London: RCP; 2000.

Resources
National Osteoporosis Society
T:01761 471771
W:www.nos.org.uk

Osteoporosis Dorset
T:01202 443064
W:ds.dial.pipex.oxm/osteo.dorset

Department of Health
(RCP ­guidelines)
W:www.open.gov.uk/doh/osteop.htm

Scancare Services
T:01476 514682
E:scancare@compuserve.com
W:www.scancare.co.uk

Palliative Nursing Group
c/o RCN
T:0845 7726100
W:www.rcn.org.uk