Osteoporosis

24/06/2013 by admin | Rheumatology
  1. Lifetime risk of OP fracture =40% in women, 13% in men.
  2. Highest morbidity linked to hip fracture in >70yo.
  3. OP is a bone mineral density (BMD) >2.5 SD below the young adult mean (T = – 2.5), tested by DEXA (dual energy x-ray absorptionometry) scan.
  4. Complete DEXA scan if: <75yo and previous fragility fracture, on long term steroids <65yo, suggested osteopenia (precursor state to OP) on xray.
  5. RFs: Increasing age, glucocorticoid use (should be on calcium/vit D supplements/bisphosphonates), previous fragility fracture (falling from standing height or less), low BMI (<19), FH of premature maternal hip fracture, untreated premature menopause/prolonged amenorrhoea/hypogonadism, prolonged immobility and lack of weight bearing, medical conditions linked to bone loss = IBD, coeliac, chronic liver disease, hyperthyroid, ank spon, chronic renal failure, RA, DM.
  6. Ix: DEXA if <75yo, exclude other causes of pathological fracture = malignancy, osteomalacia, hyperparathyroidism. Check – FBC, ESR, TSH, LFTs. Consider checking serum paraproteins/urine Bence Jones proteins for MM.
  7. Mx: if >75, tx without DEXA, if 64-75 tx if DEXA is T= <-2.5.
    1. o Lifestyle advice: adequate nutrition (sardines, yogurt, milk, cheese…), sufficient calcium and vit D, maintain BMI>19, give Ca2 and vit D to postmenopausal women, or if on longterm steroids, or if housebound/institionalised. Advise regular exercise (>30mins/d), smoking cessation, reduced alcohol consumption.
  8. Medicines:
    1. o Bisphosphonates: alendronate 10mg OD or 70mg weekly – mainstay of tx, reduces fracture risk.
    2. o Strontium ranelate: 2g OD in water – increases formation and reduces resorption on bone. Use for postmenopausal women, or when bisphosphonates are not tolerated.
    3.  
    1. o Selective oestrogen receptor modulators (SERMs): raloxifene 60mg OD – again if bisphos are not tolerated. Expensive.
    2. o HRT: postpones menopausal bone loss. Optimum duration of use uncertain (5~7 years) – benefits disappear in 5 years and inc risk of CVD and breast cancer.
  1. Referral: to endocrinology or menopause clinic if premature <40yo, OP in man, 
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