Osteoporosis

Low bone mass and microarchitectural deterioration leading to increased fracture risk. The diagnosis may be made clinically, or on bone densitometry scanning.

Secondary endocrine causes suspected or identified

Arrange further investigation and treatment as appropriate for possible thyrotoxicosis, hyperparathyroidism, Cushing's syndrome or hypopituitarism. Premature ovarian failure and other forms of hypogonadism also require specific treatments, with testosterone continued life long in many patients, and estrogen replacement therapy continued to age 50 in most cases.

Other secondary causes identified

Anorexia and eating disorders will need long term specialist input, though treatment for osteoporosis should be discussed. Ideally, estrogen and vitamin D replacement should be considered in these patients.

Where osteoporosis is iatrogenic, review medication and steroid use if possible.

Lifestyle measures

Recommend a dietary calcium intake of 1000mg a day in all patients (except those with hyperparathyroidism in whom a normal diet should be followed).

Recommend low impact weight bearing and high intensity strength training as both have been shown to maintain bone density. Falls prevention programmes may also be suitable for some patients to reduce fracture risk.

Osteoporosis confirmed either on clinical or bone densitometry grounds

Patients with a low impact fracture, or loss of height, carry a clinical diagnosis of osteoporosis and do not require bone mineral density scanning.

A bone mineral density T score of -2.5 or below also indicates osteoporosis.

Assess individualised fracture risk and potential benefit of treatment

The decision to treat or not may be difficult and needs to be discussed with patients. A recognised tool - for example FRAX - can aid this decision.

The side effect profiles, duration and aims of treatment, and the lack of expected effects on existing symptoms, such as back pain, should also be discussed.

Start treatment

NICE recommends treatment according to a standardised diagnostic criteria and aims for maximal cost effectiveness.

SIGN also offers detailed management guidance.

Calcium and vitamin D

Start Calcium and vitamin D supplementation in all patients over 65 years.

Pharmacological strength ergocalciferol replacement should be prescribed if serum vitamin D is low (<25nmol/l) in all patients.

Serum vitamin D levels should be tested, with thyroid function and 9am testosterone at diagnosis in all patients.

First line bisphosphonates

Weekly oral generic alendronate 70mg is the usual first line treatment for post menopausal women with osteoporosis.

Patients must be given clear instructions on how best to take bisphosphonates to aid absorption and prevent oesophageal irritation: after an overnight fast, with a large glass of water, and staying upright for at least 30 minutes after taking.

Patients can usually be discharged at this stage, with a recommendation of treatment duration. It is no longer considered worthwhile to routinely repeat bone densitometry scanning after two years treatment.

Second line bisphosphonates

Switch to an alternative bisphosphonate if the patient cannot tolerate weekly oral treatment, or has a deterioration in their condition - they sustain a further fracture, or have a documented fall in bone mineral density - during treatment.

Monthly oral ibandronate, three monthly intravenous ibandronate, or annual intravenous zolendronic acid are usually well tolerated.

Consider alternative treatments

If the patient cannot tolerate any bisphosphonate, or clinically deteriorates despite these treatments, second line medications may be considered.

Selected estrogen receptor modulator: raloxifene

This is suitable for post menopausal women, to reduce vertebral fracture risk, though should be avoided in those with liver disease, or an elevated risk or previous history of thromboembolic disease.

Calcitonin

Intranasal calcitonin has also been shown to reduce vertebral fracture risk, though is not widely used.

Strontium ranelate

This is also suitable for post menopausal women or for men, though it is sometimes poorly tolerated causing diarrhoea and nausea in some patients.

Synthetic parathyroid hormone analogue teriparatide

This may be considered in severe and non responding cases, though is expensive and requires subcutaneous administration.

Follow up

Patients with osteoporosis can usually be managed long term by their general practitioner.

Optimal treatment duration remains unclear, though is generally assumed to be long term.

It is no longer considered necessary to repeat bone densitometry studies routinely.

Further treatment changes will be necessary if the patient’s clinical condition changes, in which case re-referral and/or repeat imaging may be considered, or the treatment may be changed on purely clinical grounds.