Osteoporosis

Last updated 03.11.12

 

Definition

-  Systemic deterioration of skeletal bones associated with low bone mass and deterioration of bone microarchitecture causing fragility and increased risk of fracture

 

Features

-  Uncoupled bone formation & resorption

-  Multifactorial aetiology

-  Women > Men

-  27% women & 11% men >60yrs old

 

Associated S/S

-  Loss of height, thoracic kyphosis/scoliosis, Dowagers hump

-  Pathological Fracture

-  Vertebral compression fracture

- Previous fracture doubles risk of subsequent fracture

- Previous Vertebral compression fracture increases risk of another by 4-5 times

- Each unit of SD away from mean doubles fracture risk

   

Risk Factors

- Previous fracture: NOF or vertebral

-  Age related, Menopause

-  Smoking : dose response

-  Caffeine: >3 coffees per day

-  EtOH: >2 standard per day

-  Vitamin D deficieny

-  Hypocalcaemia

- Malabsorption: Coeliac disease

-  Hyperparathyroidism

-  Hyperthyroidsm

-  Immobility

-  Cushings Syndrome/Disease

-  Pagets Disease of Bone

-  Renal Osteodystrophy : CRF

- Medications

-  PPI

- Corticosteroids

- Excessive Thyroxine

- SSRIs

- Anti-epileptics

- Anti-oestrogens, anti-androgens

 

Ix

-  BMD indicated if

- Every 1-2yrs after commencing pharmacotherapy

-  >70yrs old

-  >60yrs old for men or >50yrs for women if any of

-  Family Hx of minimal trauma fractures

-  Smoking

-  High EtOH intake

-  Lack of dietary calcium

-  Low BMI

-  Recurrent falls

-  Sedentary lifestyle for many years

-  Endocrine disease: Hypogonadism, Cushings, Hyperaparathyroidism, Hyperthyroidism

-  RA

-  Malabsorption

-  Organ or bone marraw transplant

-  Drugs: anti-epileptics, anti-oestrogens, anti-androgens, corticosteroids, thyroxine, SSRIs

-  Multiple myeloma

-  CMP: Hypocalcaemia

-  Vitamin D

-  PTH

-  Fracture Risk Assessment

-  Garvan Risk Calculator

-  WHO

-  X-rays

-  Osteopaenia

-  Pathological Fracture

-  Codfish vertebrae: exaggerated concavities of upper & lower endplates of vertebrae

-  Vertebral wedge deformities:Vertebral compression fracture

 

Mx

-  Pharmacotherapy

- Bisphosphanates

- Reconsider use after 5-10yrs

-  Alendronate (Fosamax) 70mg PO Weekly +/- Calcium +/- Vitamin D

-  Risedronate (Actonel)

- 5mg PO Daily

- OR 35mg Weekly +/- Calcium +/- Vitamin D

- OR 150mg Monthly

- Zoledronic acid (Aclasta) 5mg IV Yearly

- Etidronate + Calcium (Didrocal)

- Strontium (Protos) 2g sachet Nocte

- Take at least 2hrs after food

- For PBS coverage need a proven fracture

- Denosumab (Prolia)

- Monoclonal antibody to RANKL

- S/C every 6months

- Only for postmenopausal women

- Raloxifene (Evista) 60mg PO Daily

- SERM

- Contraindicated if VTE (DVT, PE)

- May cause hot flushes

- Only for postmenopausal women

- Teriparatide (Forteo) 20mcg S/C Daily

- Synthetic human parathyroid hormone

- Must be prescribed by a specialist

- Restricted to 18months lifetime exposure

- HRT

-  Calcium

-  1500mg/day

- Dietary intake can be as effective as supplement: milk, hard cheese, yoghurt

- Ostelin drops is a cheap alternative

-  Vitamin D if <60nmol/L

-  Exercise

- Weight bearing: walking, jogging, tennis, Taichi

- Short, intense exercise better for bone health

- At least 3x per week for 30-40minutes a time

-  Smoking cessation : risk reduces signifcantly after 10yrs

- Falls reduction

 

 

 

References

 

RACGP Clinical Guideline

RACGP Treatment Algorithm

AFP: Osteoporosis March 2012

Osteoporosis Australia