The information provided was valid at the time of the publication of this CPD article.
Osteoporosis is defined as a systemic skeletal disease characterised by low bone mass, micro architectural deterioration of bone tissue and compromised bone strength, with a consequent increase in bone fragility and susceptibility to fracture, particularly of the wrist, hip and spine. It is a silent painless disease and often goes undetected until a fracture occurs.
In Ireland, approximately 300,000 of the population aged 50 years and over may have osteoporosis. It is a major public health hazard, with a high morbidity, mortality and socio-economic costs. The number of osteoporosis sufferers is increasing at an alarming rate. This is mainly due to people living longer, exercising less and poor nutrition. The number of people suffering with osteoporosis is set to double in the next 20 years. The risk of developing osteoporosis can be greatly reduced by taking the appropriate preventative measures along with early diagnosis and treatment.
| Non-modifiable | Modifiable |
| Advanced age | Poor nutrition (low calcium and vitamin D intake) |
| Female gender | Sedentary lifestyle |
| White/Asian Race | Smoking |
| Family history of osteoporosis and hip fracture | Stress/depression |
| Metabolic bone diseases | Long-term glucocorticoid therapy |
| Certain malignancies (myeloma, lymphoma) | Surgical or drug-induced hypogonadism |
| Hormonal factors (premature menopause before 45 years of age) | Weight loss or low BMI (less than 19kg/m²) |
Table 1. Risk factors for osteoporosis
Figure 1. Bone density decreases in older population.
The gold standard and most widely used method for assessing bone mineral density (BMD) is the Dual Energy X-ray Absorptiometry (DEXA) scan. In general, the spine is the first region to lose a significant amount of bone mineral density. However, in some women, the first significant loss is in the hip region, and it is important that both hips are scanned in these circumstances as fractures of the hip have the highest morbidity and mortality rates. Osteoporosis is defined by a T-score value of the hips and lumbar spine from DEXA scanning (Table 2). It is important to note that the presence of a low trauma fracture constitutes a clinical diagnosis of osteoporosis regardless of a patient’s T-score.
| Normal | T-score = | 0 to -1.0 |
| Mild Osteopenia | T-score = | -1.0 to -1.49 |
| Moderate Osteopenia | T-score = | -1.5 to -1.9 |
| Marked Osteopenia | T-score = | -2.0 to -2.49 |
| Osteoporosis | T-score = | -2.5 and lower |
Table 2: T-score range used in diagnosing osteoporosis.
As per NICE guidelines, there are several scenarios in which a fracture risk assessment (FRAX) is recommended. These are as follows:
All treatments are aimed at preventing further bone loss, increasing bone formation, preventing further fractures and increasing a person’s quality of life. Calcium and vitamin D should be recommended along with osteoporosis medication and appropriate weight bearing exercise.
Bisphosphonates have an inhibitory effect on osteoclasts. They decrease bone resorption and decrease risk of fractures in both the spine and hips. They should be taken first thing in the morning, half an hour before food, with plenty of water and the patient must avoid lying down and remain upright for half an hour after taking these medicines to minimise the risk of gastrointestinal side-effects and oesophageal reactions. The most common side-effect with bisphosphonates is stomach upset. Bisphosphonates are contraindicated in patients with oesophageal abnormalities, gastritis, hiatus hernia and gastric or duodenum ulcers. Another known side-effect associated with bisphosphonates is osteonecrosis of the jaw. The HPRA states that a dental examination with appropriate preventive dentistry should be considered prior to treatment with bisphosphonates in patients with concomitant risk factors (e.g. cancer, chemotherapy, radiotherapy, corticosteroids, poor oral hygiene). While on treatment, patients should avoid invasive dental procedures if possible. Atypical femoral fractures have been reported rarely with bisphosphonate therapy, primarily in patients receiving long-term treatment for osteoporosis. During bisphosphonate treatment, patients should be advised to report any thigh, hip or groin pain.
NICE guidelines recommends that the clinician discuss with their patients stopping bisphosphonates after three years as there is no consistent evidence of further benefit from continuing bisphosphonate for another three years. It is recommended before stopping treatment that risk/benefits of bisphosphonate therapy, fracture risk, patient choice and life expectancy be considered.
Raloxifene is an oestrogen receptor agonist. It helps to maintain bone density and reduce fracture rates, specifically at the spine in postmenopausal women. The most common side-effects with raloxifene (seen in more than 1 patient in 10) are vasodilation (hot flushes) and flu-like symptoms. Raloxifene has been associated with increased risk of venous thrombosis similar to that for HRT. The EMA recommends it should not be used in women who have or had a history of DVT or pulmonary embolism.
This recombinant human parathyroid hormone 1-34 is a bone forming agent that stimulates the formation of new bone. Forsteo® is used in the treatment of osteoporosis in postmenopausal women and in men at increased risk of fracture and in the treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in women and men at risk for fractures. This high-tech medicine is given as a 20mcg once daily subcutaneous injection in either the thigh or abdomen for 24 months. The patient should then have a repeat DEXA scan, and a new treatment plan should be implemented at the end of the course of treatment. Following cessation of Forsteo therapy, patients may be continued on other osteoporosis therapies.
The most common cause of osteoporosis in women is oestrogen loss. Loss of oestrogen can result in significant and accelerated bone loss, particularly in the first 5 to 10 years following menopause. Pharmacological therapy is required to inhibit further bone loss in postmenopausal women.
Oestrogen slows bone resorption by blocking cytokine signalling to the osteoclasts and increases bone mineral density. HRT prevents the relatively rapid bone loss in the first three to five years following menopause. In general, the use of HRT for osteoporosis prevention is restricted to short-term use for younger post-menopausal women with menopausal symptoms with a high risk of fracture. It is not recommended as a first-line therapy for the prevention or treatment of osteoporosis in older post-menopausal women. However, it may be considered in an older population if other therapies are contraindicated or not tolerated. The risk and benefits must be explained to the patient. While on HRT, breast examination should be carried out every 12 months and a mammogram every 2 to 3 years. If the patient still has a uterus, they should have a pelvic examination and a cervical smear every 3 to 5 years.
Denosumab is a relatively new monoclonal antibody which binds to RANK Ligand, inhibiting the maturation of osteoclasts, thus protecting the bone from degradation, preventing bone loss and osteoporosis. It is given as a subcutaneous injection once every six months. It is used in the treatment of osteoporosis in post-menopausal women at increased risk of fractures and in the treatment of bone loss associated with hormone ablation therapy in men with prostate cancer at increased risk of fractures.
Lifestyle changes in all age groups can significantly improve the modifiable risk factors of osteoporosis.
Some examples that can help decrease chances of falling:
The Irish Osteoporosis Society provides advice and information for patients living with osteoporosis (www.irishosteoporosis.ie).
References available upon request.
Grainne Doyle
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