Osteoporosis

History

  • Previous fractures

  • Minimal trauma fractures

  • Acute self-limiting episodes of back pain due to vertebral fractures

  • Acute regional musculoskeletal pain such as stress fractures

Risk Factors

Age > 70

Age > 60 in men and >50 in women plus

  • Prior fracture if > 45 years

  • Parental history of hip fracture

  • Low body weight

  • Smoking

  • High alcohol intake

  • Recurrent falls

  • Diet lacking calcium

  • Vitamin D Deficiency

  • Premature menopause <45 years

Any adult with these chronic conditions

  • Endocrine

    • Hypogonadism

    • Cushing’s Syndrome

    • Hyperparathyroidism

    • Hyperthyroidism

    • Diabetes

Systemic illness

  • Inflammatory such as CT disorders

  • Malabsorption e.g. Coeliac

  • Chronic organ failure

Medications

  • Glucocorticoids for >3 months

  • Anticonulvsants

  • Anti-androgen, anti-oestrogen

  • Chemotherapy

Exam

  • Height - check for loss of >3cm

  • Posture - Kyphosis

  • Muscle wasting - Risk of falling and sarcopenia

  • BMI

  • Sit-to-stand ability

  • Stand-on-one-leg ability

Imaging

Tests

  • EUC

  • FBC

  • LFT

  • ESR, CRP

  • Calcium, phosphate

  • Vitamin D

  • TSH

  • Parathyroid hormone (PTH)

  • Testosterone (males only)

  • If relevant

    • Coeliac screen

    • Estrogen, LH, and FSH in women if premature menopause is suspected

    • Hypercortisolism screen

      • 24‑hour urine collection for cortisol and creatinine, or

      • 1 mg overnight dexamethasone suppression test (DST):

    • 24-hour urine calcium and creatinine excretion

Secondary causes

  • Bone marrow transplants

  • CKD, CLD

  • Depression

  • Diabetes

  • HIV

  • PTH, TSH

  • Myeloma, MGUS

  • Vitamin D Deficiency

  • RA

  • Menopause

  • Depo contraception

Tools

Consider assessing absolute fracture risk, using either the Garvan Fracture Risk Calculator or the Fracture Risk Assessment Tool, to guide the need for treatment in individuals who do not clearly fit established criteria.

Diagnosis

World Health Organization (WHO) criteria:

  • Normal: T-score −1 or higher

  • Osteopenia: T-score between −1 and −2.5

  • Osteoporosis: T-score −2.5 or lower

Management

Treatment recommended if

  • minimal trauma fracture (MTF), regardless of age and BMD.

  • patient aged ≥ 70 years with T-score ≤ −2.5.

  • patient on prolonged corticosteroid treatment (i.e. > 3 months, ≥ 7.5 mg/day of prednisolone or equivalent) with T-score ≤ −1.5.

Consider self-funded treatment for patients who have a T‑score > −2.5 but:

Dental assessment before starting treatment

Osteopenia

(T‑score between −1.0 and −2.5) without history of MTF

Osteopenia education

  • Educate the patient about the need for adequate calcium, vitamin D, and exercise.

  • Advise the patient to get calcium through dietary means where possible.

  • Recommend oral calcium supplements when daily dietary intake is low.

  • Encourage healthy lifestyle choices to optimise bone health e.g., smoking cessation, alcohol minimisation.

  • Educate the patient about features suggestive of a vertebral fracture e.g., height loss, new episodes of back pain.

  • See osteopenia consumer fact sheet.

Regularly reassess

Consider bisphophonate treatment for primary prevention

Exercise

Exercise can delay the onset of osteoporosis.

  • Recommend resistance exercise – this should be regular (2 to 3 days per week), moderate to vigorous, progressive, and varied to influence BMD and reduce fall and fracture risk.

  • Advise older patients to participate in high-intensity progressive resistance training and balance training to prevent further bone loss and/or improve BMD, improve function, treat sarcopenia, and decrease fall and fracture risk.

  • Tailor exercise advice to the individual. Avoid:

    • high-impact activities in patients at high risk of fracture.

    • forward flexion and twisting in vertebral osteoporosis.

  • Consider referral to a specialised exercise program or exercise physiologist.

  • See Healthy Bones Australia – Exercise and Bone Density.

Review

Review all patients 3 to 6 months after starting specific osteoporosis pharmacotherapy to check medication adherence, side-effects, and patient understanding of management plan:

  • At this review do not:

    • test BMD, or

    • use biochemical markers of bone turnover – currently confined to specialist practice.

  • Review annually thereafter.

Medications

  • Bisphosphonates – Includes alendronate (e.g., Fosamax™), risedronate (e.g., Actonel™), and zoledronic acid.

    • Inhibits osteoclasts

    • Contraindications

      • Upper GIT disorders

      • Dysphagia

      • Achalasia

      • eGFR < 35

    • SE - upper GIT adverse effects

    • Take first thing in morning, on empty stomach, with glass of water, remain upright 30 minutes after

  • Denosumab (e.g. Prolia™)

    • Monoclonal antibody against RANK-ligand

    • Reversibly inhibits bone resorption by effects on osteoclasts

    • 60mg S/C every 6 months

    • SE - Generally well tolerated

      • MSK pain

      • Increased risk cellulitis

      • Hypocalcaemia

  • Hormone therapy – Hormone therapy can be useful in some women with osteoporosis. Consider oestrogen and tibolone in post-menopausal women younger than 60 years, particularly those who have another indication for hormone therapy (e.g., menopausal symptoms).

  • Raloxifene (e.g. Evista™) – Consider raloxifene in young post-menopausal women with spinal osteoporosis, particularly if they have risk factors for breast cancer.

  • Anabolic therapy – Includes teriparatide (e.g. Forteo™) and romosozumab (e.g. Evenity™). Use of these drugs is limited by strict Pharmaceutical Benefits Scheme (PBS) funding criteria. They are usually reserved as a second-line treatment for patients who experience a fracture while on anti-resorptive therapy. It requires specialist prescription.

  • Calcium supplementation

  • Vitamin D supplementation

References: