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Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of the bone tissue , leading to enhanced bone fragility and a consequent increased fracture risk ( WHO 1994 ) 

According to WHO criteria OP is defined as a BMD that lies 2.5 standard deviations or more below the average value for young healthy women ( a T score of < 2.5 )
How common
Osteoporosis is a global health problem and the its incidence and importance is increasing with an ageing population worldwide A review of OP related fractures in 27 European countries in 2010 showed that
- 2/3rd of all incident occurred in women
- fracture incidence increased with age
- majority of hip fractures reported in patients >= 80 yrs
- Most common fractures were hip 18 % , forearm 16 % , vertebral 15 % and others 51 % It is estimated that 1 in2 women and 1 in 5 men over 50 will experience a fragility fracture in their lifetime ( European data ) Osteoporosis affects 21 % of women and 6 % of men aged 50-84 in the EU It is estimated that approximately 0.3 million hip fractures per annum in the US and 1.7 million hip fractures in Europe and virtually all of these events can be attributed to osteoporosis 3 million people in the UK have OP resulting in more than 500,000 sustaining a fragility fracture each year ( NOP 2015 ) The estimated cost of treatment is 
- 4.3 billion pounds / year in the UK ( RCP )
- on average fragility fractures account for 3 % of European countries healthcare spending -estimated 37.4 billion Euros in 2010 , rising to 98 billion Euros when taking into account the impact on health related QoL Rates of hip fracture varies markedly between populations – they are more common in Scandinavian and N American regions than those in S Europe , Asian and L American countries
Primary –Juvenile Post-menopausal ( most common ) Male and senile osteoporosis
Secondary- The following conditions are associated with increased
 risk of secondary osteoporosis ( OP ) low body weight ( from any cause ) chronic inflammatory diseases as inflammatory bowel disease , rheumatoid arthritis , COPD , coeliac disease , inflammatory CTD iatrogenic glucocorticoid excess or Cushing’s disease Hypogonadism or premature menopause Excess alcohol use and smoking Some other conditions associated with low BMD include type 1 DM ,untreated long standing hyperthyroidism , hyperparathyroidism , chronic malnutrition or malabsorption , bariatric surgery , chronic liver disease , MGUS , myeloma Medication related – aromatase inhibitors , androgen deprivation therapy in men with Ca Prostate , chronic PPI use
Risk factors – Age > 65 yrs for women 
and > 75 yrs in men BMI < 18 and 22 for PM women Family h/o osteoporosis Smoking ( current ) Glucocorticoid use ( current ) Early menopause > 2 alcoholic drinks daily Rheumatoid arthritis H/O eating disorders ,Previous fragility fracture Height loss > 2 cm within 3 yrs Low calcium intake Inadequate sun exposure Long term immobilisation H/O falls H/O eating disorders Inactive lifestyle
Assessment –Enquire why has the patient raised the topic Check awareness Assess for risk factors ( see box risk factors ) Falls history Full medication history Physical examination should include BMI , checking for kyphosis and deformities and looking for features of secondary osteporosis
disease burden –Risk of loosing independence , reduction in QoL Friends / relative turn to carers National programmes often difficult to access or insufficient Increased risk of institutionalization OP fractures of hip and spine increases the relative risk of mortality
Bone mineral density –The most widely validated test for measuring bone mineral density ( BMD ) is dual energy X-Ray absoptiometry ( DXA ) DXA may not be widely available and is expensive BMD reduction is a significant risk factor for fractures BMD measurement tests have high sensitivity but low specificity ie risk of fracture is high when OP is present but it is not negligible when BMD is normal Risk factors along with BMD enhance the information provided by BMD alone
 ( risk factors can be partially or wholly independent of BMD ) Normal BMD is a T score between 2.5 and – 1
- osteopenia is BMD between -1.0 and -2.5 As most critically relevant OP fractures occur at vertebral and femoral levels , the most frequently measures sites are L spine and proximal femur
Tests for secondary osteoporosis –Diagnosis is made following

- presence of a fragility fracture
- or a hip and or spine DXA BMD T score of – 2.5 or lower

The following tests can be done to assess the risk factors for secondary osteoporosis in primary care
 Us and Es FBC Bone profile and Vitamin D , PTH ( 1 hyperparathyroidism ) TSH , LFTs ESR , CRP ( inflammatory disorders ) Fasting Bl glucose , Hba1c Testosterone ( hypogonadism ) Serum protein electrophoresis ( for MGUS , Myeloma ) Anti-TTG antibodies ( celiac disease ) Anti-HIV antibodies ( HIV , AIDS ) Serum bone specific or total AP activity ( Paget’s dis ; osteomalacia ) Lateral X ray of Thoracic and Lumbar spine for vertebral fractures
Treatment gap –Reports mention that most patients are being failed by healthcare systems Even after fracture 60-85 % of women in the EU do not receive treatment Most people who are at increased risk do not get treated AND treatment uptake has been decreasing over time Treatment rates have declined in recent years despite a projected increase in prevalence This ‘ Treatment gap ‘ which is increasing indicates a need for
- better evaluation of patients
- consensus in recognition and treatment of high risk patients Public awareness of the condition is poor with only 25 % of adults familiar with the term ( NOS 2014 ) The disease remains silent until a fracture happens GPs tend to underestimate the importance and consider OP far less important than other chronic disease Difficulty with result interpretation and to know when to prescribe treatment , concerns about safety and efficacy of treatment Despite the very high economic burden there is currently minimal investment in pharmacological prevention ( in Europe 2010 ) which accounts for 5 % of the overall management cost , compared with cost of treating incident fracture ( 66 % ) and long -term fracture care ( 29 % ) Patient do not notice an immediate change in their condition , some may not understand the significance of prevention
Early detection-OP is a silent disease with no warning signs prior to the appearance of fracture – but it is identifiable and treatable at risk is the key to prevention A careful assessment of risk profile is an essential step in identifying those who need a BMD measurement Currently there is no universally accepted policy for population screening in the UK to identify individuals with OP or those at high risk of fracture
Risk calculators –NICE recommends estimating fracture risk 
( for e.g the predicted risk of major OP or hip fracture over 10 yrs ) expressed as percentage ).Tools as FRAX and Q Fracture are recommended by NICE
 FRAX tool computes the 10-year probability of hip or a major osteoporotic fracture ( clinical spine , hip , forearm or humerus ) using risk factors alone or the combination of clinical risk factors + BMD
The FRAX tool has been independently validated as the most accurate tool to measure fracture risk 
 Q Fracture – often integrated into the EMIS computer system. This was designed for primary care based on the UK population
 Others -several other tools are available as
-Simple Calculated OP Risk Estimation ( SCORE )
- OP Risk Assessment Instrument ( ORAI )
- OP Self Assessment Tool ( OST )

Fracture Liaison Service- Cost-effective , clinically proven way to identify , asses and treat- usually secondary care based service . Studies have shown that liasion nurses in primary care may be better placed than those in hospital to ensure the implementation of best practice
Lifestyle advice-Address modifiable lifestyle factors like
- alcohol
- smoking
- weight
- regular exercises- weight bearing physical activity Dietary modifications
Pharmacological management –Vitamin D supplementation is widely given as deficiency is common and may contribute to low bone mass and falls
 If the calcium intake is inadequate prescribe preparations containing 1000 mg of Ca daily
Inhibitors of bone resorption by osteoclasts-These include
 Bisphosphonates Selective oestrogen receptor modulators Monoclonal antibodies to the receptor activator of nuclear factor kappa-B ligand.
Bisphosphonates – Aaendronate and risedronate have been shown to reduce the risk of hip , vertebral and non-vertebral fractures ( first line treatment ) Gastrointestinal irritation is the most common SE affecting up to 20-30 % of users ( main reason of poor adherence )
Other rare SEs of bisphosphonate therapy include atypical femoral fractures and osteonecrosis of the jaw Zoledronate is an IV bisphosphonate which can be given once yearly Denosumab is a human monoclonal antibody that inhibits osteoclast formation Seek advice or used reduced dose in renal insufficiency ( bisphosphonates ) NICE in its guidance Bisphosphnates for OP comments that the duration of treatment in clinical practice is uncertain and based on persons risk treatment for up to 60 months ( 5 yrs ) may be recommended.
Anabolic agents that stimulate bone formation as terparatide
 ( parathyroid hormone PTH ) Strontium ranelate- unclear mechanism but possibly works by changes in bone quality and a weak effect on bone turnover.
Referral-GFR < 30 with OP Confirmed complex secondary causes Multiple fragility fractures and very low BMD Patients who sustain fragility fracture despite adherence to treatment some local protocols recommend referring male patients with OP to secondary care Pre-menopausal women with OP Oral bisphosphonates are not tolerated or contraindicated


Royal Osteoporosis Society – a valuable patient information resource on all aspects of OP
National OP foundation
Oxford University Hospital PIL on alendronic acid
Medicine compendium on alendronic acid
Women’s Health Gov on OP
Q Fracture
American Bone Health
International Society of Bone Densitometry


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