Osteoporosis
Overview
Low bone density, decreased bone strength, increased bone fragility and fracture risk
Any osteoporotic fracture = double risk of further fractures + dramatically increases morbidity and death
Under-diagnosed
History
Previous fractures
Risk factors
Age > 70
Age > 60 (men) and age > 50 (women) plus any of -
Prior fracture < 45 years
Parental history hip fracture
Low body weight
Smoking
High alcohol > 2 to 4 drinks per drink
Recurrent falls
Low calcium diet
Low vitamin D
Early menopause < 45 years
Chronic conditions
Endocrine
Diabetes
Thyroid disease
Parathyroid disease
Other
Inflammation e.g IBD
Malabsorption e.g. Coeliac
CKD, CLD
Medications
Steroids > 3 months
Anticonvulsants
Chemotherapy
Antiandrogens
Acute self-limiting episodes of back pain
Acute regional MSK pain
Minimal trauma fracture
Exam
Height accurately
Posture
Muscle wasting
BMI
Falls risk
Stand from seated position without hands
Stand on one leg
XRAY if
Height loss > 3cm
Kyphosis
Unexplained back pain
BMD
Minimal trauma fracture (MTF)
If >50 years with MTF, BMD is not essential, but should have presumptive diagonsis of osteoporosis
Screening as per algorithms
Pathology
Baseline
EUC
FBC
LFT
ESR, CRP
Calcium, phosphate
Vitamin D
TSH
Parathyroid hormone (PTH)
Testosterone (males only)
Addition if indicated
Coeliac screen
Estrogen, LH, and FSH in women if premature menopause is suspected
24-hour urine calcium and creatinine excretion
Tools
Management
Treat if
MTF irespective
BMD T score < -2.5
Long-term steroids + BMD T score < -1.5
Consider self funded treatment if
> 70 years and no MTF
High 10 year fracture risk of hip > 3% or any > 20%
Dental review before treatment
Risk MRONJ = 1 in 10k
Prolia lower risk
Osteopenia
Adequate calcium, Vit D, exercise
No smoke, low alcohol
Caklcium + Vit D if indiciated
Medication
Bisphosphonates
Stop bone reabsorption
CI - Dysphagia, Achalasia, eGFR < 35
SE - GIT Sx, MRONJ