Osteoporotic Fractures are a major health problem in older people, affecting one in two women and one in five men over 50. These fractures are associated with significant morbidity and increased mortality, and cost the health service an estimated 1.8 billion pound per year.
Diagnosis for Osteoporotic Fracture
The diagnosis of osteoporosis has traditionally been based on the measurement of bone mineral density (BMD) by dual-energy X-Ray absorption (DXA) at the lumber vertebrae and proximal femur. A T-score (The number of SDs below normal peak bone mass) of <=2.5 indicates osteoporosis. DXA measurement can also be performed at the wrist. A low T-score can be regarded as a risk factor but should not be used to diagnose osteoporosis. The risk of fracture increases progressively with decreasing BMD. However, the issue of BMD alone to predict future risk has a high specificity but low sensitivity, and the majority of fractures occur inpatients with a BMD T-score higher than -2.5. Recently, it has been shown the prediction of fracture risk can be improved by the use of clinical risk factors independent of BMD. The such clinical factors are:
Diagnosis for Osteoporotic Fracture
The diagnosis of osteoporosis has traditionally been based on the measurement of bone mineral density (BMD) by dual-energy X-Ray absorption (DXA) at the lumber vertebrae and proximal femur. A T-score (The number of SDs below normal peak bone mass) of <=2.5 indicates osteoporosis. DXA measurement can also be performed at the wrist. A low T-score can be regarded as a risk factor but should not be used to diagnose osteoporosis. The risk of fracture increases progressively with decreasing BMD. However, the issue of BMD alone to predict future risk has a high specificity but low sensitivity, and the majority of fractures occur inpatients with a BMD T-score higher than -2.5. Recently, it has been shown the prediction of fracture risk can be improved by the use of clinical risk factors independent of BMD. The such clinical factors are:
- Falls (not recommended in the FRAX algorithm at present)
- Age.
- Sex.
- Low body mass index (<=19 kg/square meter).
- Previous fragility feature, particularly of the hip, wrist or spine including morphometric vertebral fracture.
- Parental history of hip fracture.
- Current glucocorticoid treatment (any dose, by mouth for three months or more).
- Current smoking.
- Alcohol intake three or more units daily.
- Secondary causes of osteoporosis including
- Rheumatoid arthritis.
- Untreated hypogonadism.
- Prolonged immobility.
- Organ transplantation.
- Type 1 diabetes.
- Hyperthyroidism.
- Gastrointestinal disease.
- Chronic liver disease.
- COPD.
Treatment of Osteoporotic Fracture
A number of drug treatment have been approved for the prevention of fracture in postmenopausal women. All have been advised to reduce vertebral fracture risk when given with calcium and vitamin D supplements, and some have been shown to reduce non-vertebral fracture.
Alendroin acid, risedronate and teriparatide are also approved for men at high risk of fracture. If the patient is unable to take or tolerate alendronic acid, other bisphosphonates, strontium ranelate or raloxifene can be used.
FALL: Important to Manage Osteoporosis
FALLs risk assessment and prevention is an important aspect of the management of osteoporosis. Other measures include maintenance of mobility, advice about smoking cessation and alcohol intake, and correction of vitamin D deficiency.
Nutrition advice is also important and adequate calcium and protein intake should be ensured. Calcium and vitamin D supplements should be prescribed unless their is clear evidence of a normal vitamin D level and adequate dietary calcium intake. The recommended daily doses of calcium and vitamin D are 1-1.2 mg and 800IU respectively.
The optimum duration of bone protective treatment is unknown.
NICE Guidance: For Prevent Osteoporosis Fracture
NICE has recently produced new guidance on the primary and secondary prevention of osteoporotic fracture. This guidance is restricted to post menopausal women with osteoporosis and excludes men, patients taking oral glucocorticoids, and dose not include newer interventions such as ibandronic acid and zoledronic acid.
FRAX is not incorporated in this guideline and intervention threshold are based on age, T-scores and the presence of a fracture.
A number of drug treatment have been approved for the prevention of fracture in postmenopausal women. All have been advised to reduce vertebral fracture risk when given with calcium and vitamin D supplements, and some have been shown to reduce non-vertebral fracture.
Alendroin acid, risedronate and teriparatide are also approved for men at high risk of fracture. If the patient is unable to take or tolerate alendronic acid, other bisphosphonates, strontium ranelate or raloxifene can be used.
FALL: Important to Manage Osteoporosis
FALLs risk assessment and prevention is an important aspect of the management of osteoporosis. Other measures include maintenance of mobility, advice about smoking cessation and alcohol intake, and correction of vitamin D deficiency.
Nutrition advice is also important and adequate calcium and protein intake should be ensured. Calcium and vitamin D supplements should be prescribed unless their is clear evidence of a normal vitamin D level and adequate dietary calcium intake. The recommended daily doses of calcium and vitamin D are 1-1.2 mg and 800IU respectively.
The optimum duration of bone protective treatment is unknown.
NICE Guidance: For Prevent Osteoporosis Fracture
NICE has recently produced new guidance on the primary and secondary prevention of osteoporotic fracture. This guidance is restricted to post menopausal women with osteoporosis and excludes men, patients taking oral glucocorticoids, and dose not include newer interventions such as ibandronic acid and zoledronic acid.
FRAX is not incorporated in this guideline and intervention threshold are based on age, T-scores and the presence of a fracture.
