This guide aims to support clinicians on osteoporosis and fragility fracture investigation and management of patients at risk in primary care. It is also available as a two-page visual summary.
Primary prevention
For patients with no fragility fracture, consider fracture risk assessment in postmenopausal women, or men 50 years or over with risk factors. Clinical risk factors:
Included in Fracture Risk Assessment Tool (FRAX®):
- Low body mass index,
- Hip fracture in parent,
- Current or previous glucocorticoid use (over 5mg prednisolone for duration of more than 3 months),
- Current smoking,
- Alcohol intake of 3 or more units daily,
- Rheumatoid arthritis
Secondary causes of osteoporosis including:
- Type I diabetes,
- Long-standing untreated hyperthyroidism,
- Untreated hypogonadism or premature menopause under 45 years),
- Chronic malnutrition or malabsorption,
- Chronic liver disease,
- Non-dialysis chronic renal failure (i.e., Chronic Kidney Disease 3a to 5)
Not included in FRAX® but should trigger Fracture risk assessment:
- Thoracic kyphosis,
- Height loss (over 4cm),
- Falls and Frailty,
- Inflammatory disease: for example, ankylosing spondylitis, other inflammatory arthritides, connective tissue diseases, systemic lupus erythematosus,
- Endocrine disease: for example, Type I and II diabetes mellitus, hyperparathyroidism, hyperthyroidism, hypogonadism, Cushing’s disease or syndrome,
- Haematological disorders or malignancy: for example, multiple myeloma, thalassaemia
- Muscle disease: for example, myositis, myopathies and dystrophies, sarcopenia
- Lung disease: for example, asthma, cystic fibrosis, chronic obstructive pulmonary disease
- Human Immunodeficiency Virus
- Neurological or psychiatric disease: for example, Parkinson’s disease and associated syndromes, multiple sclerosis, epilepsy, stroke, depression, dementia
- Nutritional deficiencies: for example, calcium, vitamin D [note that vitamin D deficiency may contribute to fracture risk through undermineralisation of bone (osteomalacia) rather than osteoporosis]
- Bariatric surgery and other conditions associated with intestinal malabsorption
- Medications for example,:
- Excess thyroid hormone treatment (levothyroxine and or liothyronine), patients with thyroid cancer with suppressed Thyroid Stimulating Hormone are at particular risk
- Drugs affecting gonadal hormone production – aromatase inhibitors (i.e letrazole or anastrazole), androgen deprivation therapy (i.e Zoladex®) medroxyprogesterone acetate (i.e depo-provera® starting under 20 years or used after 35 years), gonadotrophin hormone releasing agonists, gonadotrophin hormone receptor antagonists
- Some diabetes drugs (e.g., thiazolidinediones)
- Some antiepileptics (e.g., phenytoin and carbamazepine)
- Some immunosuppressants (tacrolimus or ciclosporin)
- See National Osteoporosis Guideline Group (NOGG) guidelines table 4 for full list.
For patients at risk, pre-DEXA scan
Calculate pre-DEXA fracture risk using FRAX® tool and consult pre-DEXA NOGG Graph. Following this, the patient may be classified to be at low, intermediate, high or very high risk.
Low risk (green)
Reassure and give lifestyle advice. Some patients will require ongoing monitoring, where risk is borderline and ongoing clinical risk factors of concern.
Intermediate risk (amber), high or very high risk (red)
Patients should undergo a DEXA scan to measure Bone Mineral Density (BMD) and then facture risk should be recalculated using the FRAX® tool incorporating BMD. If patient is unable to attend or comply with DEXA scan, then treat as per FRAX® intervention threshold recommendation as per the NOGG graph.
Post DEXA scan
Following recalculation of the fracture risk with BMD, manage patients as determined by the updated risk classification:
Low risk (green)
Reassure and give lifestyle advice. Some patients will require ongoing monitoring, where risk is borderline and ongoing clinical risk factors of concern.
High risk (red)
Baseline Investigations and treat osteoporosis in primary care with oral bisphosphonates.
Very High risk (maroon)
Consider undertaking baseline investigations listed below, start treatment and refer to secondary care for first-line anabolic agents using the SWL referral form.
Baseline investigations:
- Clinical history
- Physical examination including measurement of height and assessment of thoracic kyphosis
- Consider x-ray of thoracic-lumbar spine if loss of height is more than 4cm from baseline or clinical kyphosis
- Full blood cell count
- Erythrocyte sedimentation rate or C-reactive protein
- Serum calcium, albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases – persistent low phosphate or alkaline phosphatase should not be overlooked as this can indicate underlying metabolic bone disease.
- Serum 25-hydroxyvitamin D
- Thyroid function tests
- Myeloma screen – serum electrophoresis, serum immunoglobulins and urine Bence Jones protein
- Consider checking plasma parathyroid hormone (PTH) if raised serum calcium more than 2.6 mmol per litre on 2 occasions
- Consider coeliac screen if suspicious of malabsorption
- For referral for very high-risk patients – QRISK
Review
It is good practice to consider reviewing and checking tolerance and compliance after starting oral bisphosphonate at 12 to 16 weeks, at 1 year and at 5 years.
Tolerant of oral bisphosphonate:
- Patients at lower fracture risk: treat for 5 years in the first instance with a plan to re-assess. If a patient experiences a fracture during treatment, review choice of medication; seek specialist input via advice and refer.
- Patients at higher fracture risk such as patient over 70 years, had previous fractured hip or vertebra, on oral glucocorticoids treatment for over 3 months should be continued on bisphosphonate for at least 10 years.
Intolerant to oral alendronate due to upper GI symptom:
Consider risedronate 35mg tablets (2nd line) and effervescent alendronate 70mg tablets (3rd line).
Referral
Consider referral using SWL referral form on DXS/Ardens® via GP clinical system if intolerant to oral alendronate due to upper GI symptom and 2nd line and or 3rd line options have been tried or are not appropriate, moderate or severe cognitive problem, contraindication or estimated glomerular filtration rate is below 35ml per minute.
Secondary prevention
Patients with any fracture of wrist, vertebra, hip or humerus following fall from own height or less should undergo a DEXA scan to measure BMD and then facture risk should be calculated using the FRAX® tool incorporating BMD. If the patient is unable to attend or comply with DEXA scan, then treat as per FRAX® intervention threshold recommendation as per the NOGG graph.
Post DEXA scan
Following the calculation of the fracture risk with BMD, manage patients as determined by the risk classification:
Low risk (green)
Reassure and give lifestyle advice. Some patients will require ongoing monitoring, where risk is borderline and ongoing clinical risk factors of concern.
High risk (red)
Baseline investigations and treat osteoporosis in primary care with oral bisphosphonates.
Very High risk (maroon)
Consider undertaking baseline investigations listed below, start treatment and refer to secondary care for first-line anabolic agents using the SWL referral form.
Baseline investigations:
- Clinical history
- Physical examination including measurement of height and assessment of thoracic kyphosis
- Consider x-ray of thoracic-lumbar spine if loss of height is more than 4cm from baseline or clinical kyphosis
- Full blood cell count
- Erythrocyte sedimentation rate or C-reactive protein
- Serum calcium, albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases – persistent low phosphate or alkaline phosphatase should not be overlooked as this can indicate underlying metabolic bone disease.
- Serum 25-hydroxyvitamin D
- Thyroid function tests
- Myeloma screen – serum electrophoresis, serum immunoglobulins and urine Bence Jones protein
- Consider checking plasma parathyroid hormone (PTH) if raised serum calcium more than 2.6 mmol per litre on 2 occasions
- Consider coeliac screen if suspicious of malabsorption
- For referral for very high-risk patients – QRISK
Review
It is good practice to consider reviewing and checking tolerance & compliance after starting oral bisphosphonate at 12 to 16 weeks, at 1 year, and at 5 years.
Tolerant of oral bisphosphonate:
- Patients at lower fracture risk: treat for 5 years in the first instance with a plan to re-assess. If a patient experiences a fracture during treatment, review choice of medication; seek specialist input via advice and refer.
- Patients at higher fracture risk such as patient over 70 years, had previous fractured hip or vertebra, on oral glucocorticoids treatment for over 3 months should be continued on bisphosphonate for at least 10 years.
Intolerant to oral Alendronate due to upper GI symptom
Consider risedronate 35mg tablets (2nd line) and effervescent alendronate 70mg tablets (3rd line).
Referral
Consider referral using SWL referral form on DXS/Ardens® via GP clinical system if intolerant to oral alendronate due to upper GI symptom and 2nd line and or 3rd line options have been tried or are not appropriate, moderate or severe cognitive problem, contraindication or estimated glomerular filtration rate is below 35ml per minute.
Approved by: Integrated medicines optimisation committee (IMOC) July 24