Osteoporosis is a systemic skeletal disease characterised by low bone mass, micro architectural deterioration of bone tissue and compromised bone strength, with a consequent increase in bone fragility and susceptibility to fracture, particularly of the wrist, hip and spine. Osteoporosis is preventable and treatable in the majority of people, however the diagnosis rate is only 15 per cent (20,000), leaving 280,000 undiagnosed.
If a person does not have a condition or they are not on a medication that causes bone loss, they have the opportunity to reverse their bone density back to normal. For this to happen, all causes of bone loss must be found and addressed.
One in two women over the age of 50 will develop a fracture due to osteoporosis. As women age, their risk increases, this is why, in an ideal, women would be scanned when they first go into the menopause, earlier if they have risk factors for bone loss. More women die from complications of osteoporotic fractures, than from a combination of all cancers of the ovary, uterus and cervix. Lung cancer is the only cancer that supersedes Osteoporosis in death. The majority of people who fracture have moderate to marked osteopenia. The risk of a subsequent fracture is much higher in postmenopausal women who already have had a fracture. It is the result of the negative balance between bone formation and bone resorption, i.e. more bone is lost than formed. Bones require normal levels of sex hormones, adequate caloric intake, particularly protein, calcium and vitamin D and regular (30 minutes) appropriate, daily weight bearing exercise.
Referring patients at risk will not only help to reduce the significant amount of those losing their independence but also to reduce the millions spent treating multiple, preventable fractures. Osteoporosis is a complication of many medical and surgical specialties, either the disease itself, or medications used to treat these conditions. There are approximately 200 risk factors and the most common cause in females is oestrogen deficiency. Some women lose up to 30 per cent of their overall bone in their body, whilst going through the menopause.
Additional causes include endocrine disorders, gastrointestinal disorders, neurological and drug induced osteoporosis (Warfarin, Heparin, Corticosteroids, Losec, Lithium, Depo Provera, Arimidex, Aromatase inhibitors). Age, family history of osteoporosis (especially hip fracture), early menopause before 45, inactivity or excessive exercise, excessive physiological or psychological stress, Asian or Caucasian, low body weight, high fibre, high caffeine, excessive alcohol intake and smoking.
Psychological or physiological stress results in high levels of Cortisol, which increases RANK Ligand and the formation of Osteoclasts, which remove bone. The majority of fractures occur in the wrist, hip and vertebrae, but any bone can be affected. Patients who need chemotherapy, radiation or Aromatase inhibitors, should have a DXA prior to treatment and be put on medication to prevent bone loss. If a patients DXA scan is negative, they need to monitored closely. Significant bone loss with Corticosteroids occurs in the first six months of treatment.
A previous fracture is the greatest risk factor for having subsequent fractures in an osteoporotic patient. If a person has one vertebral fracture and they are not treated, they are guaranteed to have a second fracture within six months to one year. All low trauma fractures should be considered osteoporotic, unless proven otherwise. Patients should have a DXA and be assessed for the degree of osteoporosis or osteopenia in the lumbar spine, both hips and if they have lost height, back pain, postural changes, Dowagers hump or scoliosis, they should have a DXA with a Lateral Vertebral Assessment (LVA). This is to determine if they have vertebral fractures, degenerative disc disease and/or osteoarthritis.
Causes of bone loss
It is essential to determine the cause/s of bone loss and treat the cause, otherwise they may initially improve but will then begin to decline. Patients need to fill in an extensive questionnaire and one is available from the Irish Osteoporosis Society (IOS). Essential blood Investigations: Vitamin D, PTH, Cortisol, FBC, ESR, Ferritin, Renal, Liver and Thyroid Function. There is a world epidemic of low levels of Vitamin D and Low levels are more likely to occur during the winter e.g.30nmol/L, which will result in secondary Hyperparathyroidism. It is essential that patients understand why they have developed osteoporosis or osteopenia and the consequences of not taking the appropriate treatment. Calcium and Vitamin D on their own are not sufficient and intake through food sources should be encouraged.
Choosing the most suitable medication
A patient with GI problems e.g. Coeliac, Crohn’s disease, poor absorption or reflux, will usually not tolerate medication by mouth and many continue to fill the prescription, but do not take the treatment. If a patient requires to be prescribed either Prolia or Forsteo, Ideally, they should have a vitamin D level of 70-80nmol/L and their PTH should be below 60ng/L or 6pmol/L. They also require normal Calcium levels and renal function.
The DXA results should be explained to the patient. Explanation on IOS website. They should be given lifestyle advice and put on treatment, to prevent further fractures. Appropriate weight bearing exercise is an essential part of the treatment, especially if they have osteopenia or osteoporosis in their neck of femur or total hips.
Tip: Up and down a flight of stairs once is equivalent to one minute of weight bearing