Key learning points:
– Every postmenopausal woman with risk factors for fracture should be offered a bone health assessment
– A reduction in height of more than 4cm suggests at least one vertebral fracture
– Osteoporosis can be diagnosed, prevented and treated in primary care
Osteoporosis is a silent disease where bones become fragile due to loss of tissue. It leads to low-trauma or fragility fractures that can cause pain, disability and premature death. Some 50% of women over the age of 50 experience a fracture mainly as a result of osteoporosis.1
Osteoporosis is seen more frequently in women because the rapid decrease in oestrogen production after the menopause accelerates bone loss. Women tend to have smaller bones and live longer than men. The longer lifespan makes it more likely to reach the low level of bone density at which bones break. Some conditions have an adverse effect on bone density and accelerate this normal loss. These include the use of oral steroids, alcohol abuse, rheumatoid arthritis, type 1 diabetes, hyperthyroidism and a family history of osteoporosis.
Osteoporosis is diagnosed with a dual energy X-ray absorptiometry (DXA) scan. This involves lying on a couch, fully clothed, for about 15 minutes while the scanner X-rays the hips and spine. DXA results are usually reported as a ‘T’ score:
– T-score above -1 is normal.
– T-score between -1 and -2.5 SD is defined as osteopenia. This is bone mineral density (BMD) that is reduced by -1 to -2.5 SD compared to peak bone mass.
– T-score at or below -2.5 SD is defined as osteoporosis. A BMD that is 2.5 standard deviations or more below the young adult mean.
Osteoporosis is measured by bone density levels with the object of preventing fractures. An analogy would be hypertension diagnosed by measuring blood pressure with the object of preventing stroke. Just as hypertension is not the only risk factor for a stroke, low BMD is not the only risk factor for future fracture. Fracture risk assessment tools (FRAX2 and QFracture3), developed over the past few years, help us to incorporate these other risk factors, providing a more comprehensive assessment of total fracture risk.
The National Institute for Health and Care Excellence (NICE)4, advised in 2012 an assessment of fracture risk (FRAX or Q fracture) for all female patients 50-65 years following a fragility fracture. The Scottish Intercollegiate Guidelines Network (SIGN)5 advice and some local guidelines recommend referring patients for a DXA scan as a first-line option. The National Osteoporosis Guidelines Group (NOGG)6 also provides guidance. There are some discrepancies between guidance. Both NICE and NOGG include recommendations to consider treating elderly postmenopausal women with a fragility fracture, without need for a DXA result and that bone mineral density measurements may be useful in younger postmenopausal women with a fragility fracture. Whereas NICE requires a T-score ≤-2.5 in most women for prevention treatments, NOGG incorporates independent clinical risk factors to fracture prediction and recommends the use of the fracture risk algorithm FRAX to ascertain treatment levels.
Additional clinical risk factors that provide information on fracture risk independently of BMD include a history of a prior fragility fracture, a parental history of hip fracture, a low body mass index (BMI), use of oral steroid medications, a high alcohol intake and rheumatoid arthritis.
FRAX and NOGG will recommend whether a person needs:
– Reassurance, along with advice about diet and exercise.
– Further assessment, such as a DXA scan if results are not included already.
– Drug therapy.
Following the diagnosis, investigations should be considered to rule out disease that can cause or mimic osteoporosis.
What can primary care nurses do?
Primary care nurses are well placed to identify high-risk patients, provide support with management and refer patients appropriately (eg, when first-line treatments are not suitable). Some drug regimens for osteoporosis are complex. Persistence with therapy and adherence to dose frequency are poor. This is recognised as a roadblock to achieving better outcomes for patients. Clear, relevant information and interaction between patients and healthcare professionals is likely to be beneficial. Information relayed to fracture patients while in hospital needs to be reinforced so that long-term adherence is achieved.
In some parts of the country, fracture liaison services provide case-finding and intervention for patients following a fragility fracture. Practice nurses are ideally placed to recognise gaps in care and signpost patients who would benefit from referral to these or other services – eg, to exercise sessions, smoking cessation groups, bone health specialists and falls intervention teams as appropriate.
The National Osteoporosis Society (NOS) helpline offers information and support to patients and practitioners by telephone, email or letter. It also produces information leaflets and an online elearning programme for allied health practitioners and a general practice information resource.7
Read coding fragility fractures will facilitate the osteoporosis quality and outcomes framework8 (QOF). The QOF assesses the number of >50-year-olds within the practice that have had a fragility fracture and whether they are being treated with an appropriate bone-sparing agent.
A combination of weight-bearing exercise, a well-balanced diet (including protein and dairy), optimum levels of calcium and vitamin D, moderating alcohol intake and not smoking are all considered good lifestyle measures for patients on bone-sparing medications and at a high fracture risk. Fragility fractures often result from a fall; interventions to reduce falls are considered essential as part of a comprehensive fracture reduction strategy.9
Calcium and vitamin D
Guidelines advise that when practitioners prescribe bone-sparing medications, they also prescribe calcium and vitamin D supplements unless they are confident that the patient’s intake is sufficient. The elderly absorb dietary calcium less well and patients over 75 years, especially those with small appetites who spend little time outdoors, will need supplementation. Other patients should have their dietary calcium intake measured. Vitamin D on its own can be prescribed if calcium is not necessary and the patient spends little time outdoors. Dairy products and oily fish that are eaten with the bones, such as sardines, and vegetables (such as broccoli and cabbage) contain reasonable amounts of calcium. A calcium calculator is available on the NOS website.10
Patients with osteoporosis are recommended to ingest more than 800mg of calcium and at least 400IU of vitamin D a day.
The range of calcium and vitamin D preparations available include effervescent, dissolvable and caplets. Patients often tire of one preparation and should be offered another. While it is advised to take calcium supplements after meals, vitamin D is fat soluble and best absorbed if taken with food.
Exercise and osteoporosis
Bone-strengthening exercises are those that are weight bearing (eg, walking and tennis). Exercise that involves pulling forces on the tendon insertions of long bones also improves bone density.7 Patients with established osteoporosis need to avoid activities where the spine is twisted or curled (eg, some poses in yoga). High-impact exercises are not advised. Patients should make their exercise instructor aware of their condition. Specific information on exercises for osteoporotic patients is available from the NOS website.1
Vertebral fractures, often referred to as ‘crush’ or ‘wedge’ fractures, are the commonest fragility fracture and often go undiagnosed. Their presence constitutes a significant risk for new fractures independent of bone mineral density. Patients who lose 4cm or more in height are likely to have such a fracture; all need treatment. Healed spinal fractures do not return to their original shape and can cause an outward curve of the back. Sometimes these changes can result in a lack of space for the internal organs so other problems such as breathlessness, a protruding abdomen, indigestion or stress incontinence can occur.
Medications for osteoporosis
Guidelines advocate alendronic acid or risedronate as a first-line therapy.4,6 Patients will be advised to stop treatment if they develop worsening of gastrointestinal (GI) symptoms; oesophageal irritation is a side-effect. Patients may have contraindications, intolerance or be unable to comply with the dosing instructions. Alternative medications, such as ibandronate or raloxifene, may be used in certain instances. Six-monthly subcutaneous denosumab, annual zolendronic acid or three-monthly intravenous ibandronate acid will be considered if oral therapies are not tolerated. Teriparatide may be prescribed by bone health specialists for specific high-risk patients. HRT, including tibolone, is effective in the prevention of bone loss in postmenopausal women; however, it is no longer recommended solely for this purpose. Denosumab11 was previously reserved for initiation by secondary care and is now being initiated in general practice.
A 66-year-old female, newly diagnosed with osteoporosis, has a T-score of -2.7. She wishes to know how long she will need to take bone medications. She suffered a fragility fracture six months previously. Relevant medical history is of a hysterectomy at 40 years. She is a non-smoker and drinks only on social occasions. She is active, has a normal body mass index (BMI), and there is no family history of osteoporosis.
The current expert opinion would suggest that oral bisphosphonates be recommended for five years of treatment followed by a re-evaluation. At this stage, some people remain at high risk of fracture and require continued treatment (eg, those who have re-fractured on treatment, or who have a history of vertebral or hip fractures, or are currently on prednisolone >5mg per day or those who remain osteoporotic). Others may benefit from a drug holiday for two or more years. During this time, it is advised to ensure patients remain vitamin D and calcium replete.
A 65-year-old female patient attends for her medicines review.
You note that she fractured her forearm when she tripped five months ago.
1.Read code as ‘fragility fracture’ if this is not already done.
2.Inform patient that a low-trauma fracture could be an indication of osteoporosis. Advise her to make an appointment for a fracture risk assessment or DXA scan.
General measures for high-risk patients
– Recommend a balanced and nutritious diet to maintain calcium levels and an adequate BMI.
– Refer for falls risk assessment if appropriate.
– Recommend regular weight-bearing exercise.
– Advise them to stop smoking and avoid excessive alcohol.
Recent developments, such as the FRAX2 and QFracture3 assessment tools, and the ability to initiate some injectable bone medications in GP surgeries means that many more patients with osteoporosis can now be identified, treated and managed in primary care alone.
There are 3 million UK residents with osteoporosis and probably many more who are undiagnosed and have a high risk of fracture. A recognised gap in care exists in that many patients are not diagnosed and others who lack support to adhere to treatment regimens. Practice nurses will meet many of these often elderly patients in the course of their work and can provide valuable intervention and signposting for preventive care.
1. National Osteoporosis Society. UK Facts and Figures. nos.org.uk/about-us/media-centre/facts-and-figures (acessed 11 July 2016).
2. FRAX Tool. shef.ac.uk/FRAX (accessed 11 July 2016).
3. QFracture Tool-2013 risk calculator. qfracture.org (accessed 11 July 2016).
4. NICE. Secondary Prevention of Fractures: TA 161, 2010. nice.org.uk/guidance/ta161/ (accessed 11 July 2016).
5. Scottish Intercollegiate Guidelines Network. Management of Osteoporosis, SIGN Short clinical guideline, 2015. sign.ac.uk/pdf/QRG142.pdf. (accessed 11 July 2016).
6. National Osteoporosis Guidelines Group. Osteoporosis – Clinical Guideline for Prevention and Treatment, 2014. shef.ac.uk/NOGG/NOGG_Executive_Summary.pdf (accessed 11 July 2016).
7. NOS. Osteoporosis Resources for Primary Care. nos.org.uk/health-professionals/osteoporosis-resources-for-primary-care (accessed 11 July 2016).
8. The Keep it Simple Guide to QOF 2015/2016. nbmedical.com/pdf/Keep%20it20Simple%20QOF%202015.pdf (accessed 11 July 2016).
9. NICE. Falls in Older People, 2015. nice.org.uk/guidance/qs86 (accessed 11 July 2016).
10. NOS. Healthy Eating for Strong Bones, 2014. nos.org.uk/healthy-bones-and-risks/healthy-bones? (accessed 11 July 2016).
11. NICE. Denosumab for the Prevention of Osteoporotic Fractures in Postmenopausal Women. nice.org.uk/guidance/ta204. (accessed 11 July 2016).