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Osteoporosis
Last updated 4th March 2024
Contacts and Referrals
- Sister Katrina Martin, Osteoporosis/Menopause Specialist Nurse on 32182, sci gateway referral/advice (Fracture Liaison Service), [email protected]
- Dr Anne Drever, Osteoporosis Clinical Lead on 33023 or [email protected] or sci-gateway referral/advice (Osteoporosis Clinic) [email protected]
- All low trauma hip fracture or other low trauma fracture patients on orthopaedic wards triaged by ward nursing team to assessment by orthogeriatric or fracture liaison team
- Patients aged 50 years or above with low trauma fractures assessed via virtual fracture clinic in D&G receive fracture risk assessment by questionnaire and triage to fracture liaison service if required
Fracture Risk Assessment
- Management has shifted from diagnosing osteoporosis by bone density definition (lumbar spine or hip bone density 2.5 standard deviations or more below the young adult mean value for women, reported as T score < -2.5, by DEXA Scan) to assessing and reducing fracture risk
- A DEXA scan is recommended as part of the fracture risk assessment if already identified as “increased risk” – see Referral Criteria for DEXA, table below and link to Qfracture risk assessment calculator
- If multiple vertebral collapse (2 or more) exclude myeloma or metastatic disease and commence treatment to reduce fracture risk regardless of bone density (DEXA not required however can be useful as baseline for younger, less frail patients)
Referral Criteria for DEXA
Fracture Low trauma in past 5 years | DEXA |
Steroids Current corticosteroid therapy equivalent to prednisolone 5mg or above for past 3 months | DEXA if age <65 and no low trauma fractures |
If 65 or above, or prior low trauma fracture, treat for duration of steroid therapy without need for DEXA | |
Other Risk Factors Risk factor other than low trauma fracture or steroid use | Qfracture 10% or > = DEXA |
Qfracture <10% = No DEXA |
Vertebral Fracture Assessment (VFA) / Morphometry during DEXA
- Prevalent vertebral fractures are a strong risk factor for fracture and may be clinically “silent”
- If no spinal imaging in year prior to DEXA recommend request Morphometry preformed at time of DEXA
Contraindications for DEXA
- Age <21 years, weight >205kg or severe, excessive abdominal girth
- Unable to lie on DEXA couch (for acute fracture patients delay DEXA until out of plaster)
- Result unlikely to alter current or future management
Additional Bone Health Screening Investigations
- Check FBC, ESR, U&E, Calcium, LFT, TFT, 25 Hydroxyvitamin D (if no record in past year and not required if low trauma hip fracture as all treated at DGRI routinely receive loading dose course vitamin D pre-discharge, unless contraindication)
- Myeloma screen by serum electrophoresis & Urine Bence-Jones protein if multiple vertebral collapse
- Serum testosterone in men aged <65
The Treatment Pyramid
Calcium and Vitamin D in Addition to Above
Calcium & Vitamin D | Vitamin D Deficiency (<25 mmol/L) |
---|---|
Aim for dietary sources if possible, supplements if required if: - Biochemical insufficiency - Dietary deficiency unable to be improved - High dose steroid - Frailty with likely reduced absorption | Loading dose (see guideline on Beacon) Sterexol D3 x 25,000 unites per week OR Invita D3 50,000 unit drops (2 x 25,000 unit vials) per week for 6 weeks |
adcal D3 2 capsules or 1 tablet twice a day theiCal D3 1 tablet per day | Maintenance after loading for deficiency or without loading for insufficiency Cholecalciferol D3 1,000 - 2,000 units per day (otc) Sterol D3 1,000 units per day or 25,000 units per month Invita D3 25,000 unit drops (1 vial) per month |
Acute Atraumatic Vertebral Fractures & Incidental Finding of Vertebral Fractures in Acute Setting
- Pain control as per analgesic ladder, assistance from pain team if required
- Check bone biochemistry, exclude myeloma or metastasis (particularly if known primary)
- Correct vitamin D deficiency (link below)
- If persistent severe, unremitting pain in spite of acute pain management, consider MRI to exclude fracture instability or other pathology; urgent MRI if “red flags”
- Provide plan for secondary fracture prevention as per algorithm (link below)
- Consider giving IV bisphosphonate if would struggle with oral bisphosphonate (link below)
- If multiple vertebral fractures and no contraindication to bone building treatment (no renal impairment, malignancy, frailty) refer to osteoporosis clinic.
- Encourage early mobilisation and exercise, refer PT if mobility impaired or falls risk
- Consider referral to Fracture Liaison Service for follow up (see contacts above) and DEXA as baseline (DEXA not required prior to treatment or if would not alter future management)
- Provide patient info leaflet and signpost to ROS website (links below)
Inpatient IV Zoledronate (Zol) Prescribing
- For those with incident low trauma hip fracture, vertebral fracture, requiring prolonged high dose steroid (eg GCA) or cognitive impairment (where oral bisphosphonate impractical) on the ward consider giving IV Zol 5mg during admission.
- Check U & E, calcium and vitamin D.
- See checklist for IV Zol (link below)
- If checklist criteria met, record verbal consent, prescribe Zoledronic Acid 5mg in 100mls over 30mins, send checklist plus copy discharge to Dr Anne Drever, sci-gateway for follow up.
Steroid Induced Osteoporosis
- At risk if exposed to oral steroid for >3 months
- If ≥65 years or previous fragility fracture treat prophylactically with bisphosphonate for duration of steroid
- If <65 years and no fragility fracture, refer for DEXA scan (including morphometry) & treat if T-score < -1.5
- If prolonged high dose steroid consider IV Zol as per checklist (link below)
Refer to Osteoporosis Clinic if:
- Established osteoporosis and unable to take oral preparations
- Multiple fragility fractures and T score < -3.5
- Further fracture despite appropriate treatment and compliance
Links
- QFracture – 10 year fracture risk assessment tool
- FRAX – fracture risk assessment tool (University of Sheffield)
- New Fracture Despite Treatment in D&G Questionnaire
- NHSD&G Vitamin D Policy 2023
- Miniguide to DEXA referral and fracture risk reduction
- Initial management of patients at increased risk of fracture – Primary prevention
- Initial management of patients at increased risk of fracture – Secondary prevention
- Bisphosphonate Long-Term Use in D&G Algorithm
- Bisphosphonate Review in D&G 5 & 10 Year Questionnaires 2023
- Clinician dental advice when prescribing bisphosphonate
- Patient dental information leaflet when prescribed bisphosphonate
- IV Zol inpatient prescribing check list
- IV Zol patient information leaflet
- Denosumab shared care protocol
- Denosumab patient information leaflet
- Royal Osteoporosis Society Website
- Vertebral Fracture – A Guide to Diagnosis for Healthcare Professionals in Primary Care (University of Bristol and NIHR)
- Spinal Fracture: Breaks in the bones in your spine: A guide to diagnosis for patients and carers
- Guide to Management of Atraumatic Vertebral Fracture in D&G
Content updated by Dr Anne Drever