Although effective treatments have been available for more than a decade, studies show many persons who fracture, or are at risk of fracture, are never evaluated or treated for their underlying osteoporosis, who subsequently go on to have additional fractures and the associated morbidity. As many as 280,000 people are undiagnosed and prevention should start in utero.
- Why prevention or treatment of osteoporosis is essential:
- 90 per cent of hip fractures are due to osteoporosis.
- From age 75+ a person is 25 times more at risk of fracturing a hip.
- One fractured hip in total costs €55,000,
- Currently €500+ million is being spent treating fractures
GPs can make a significant impact on screening patients who are high risk for bone loss. Long-term this will save billions of euro (estimated cost to treat fractures by 2025 is one billion) in the health care budget. It will help to reduce the amount of senior citizens losing their independence, reduce the amount of people on hospital trolleys, reduce GP visits from secondary complications from untreated Osteoporosis, and significantly improve the quality of life of senior citizens.
Tip: Morphine will not eliminate the pain from Osteoporotic vertebral fractures, however Forsteo can in the majority of cases.
Osteoporosis is connected to so many specialities that a risk factor questionnaire is necessary to capture these patients. This is why the IOS (Irish Osteoporosis Society) does not recommend FRAX, as it only lists 14 risk factors, when there are approximately 200 causes of bone loss. An extensive questionnaire can be requested from the IOS for your clinic: Email: firstname.lastname@example.org
There are approximately 200 causes as to why a person can develop osteoporosis, not just the menopause.
- Which of your patients are at risk of developing Osteoporosis?
- Family History of a hip fracture is the strongest risk factor
- Specific to Males: Hypogonadism in males and low levels of testosterone,
- Specific to females: Late menarche > 15, prolonged amenorrhea or history of irregular menstruation, frequent loss of periods for more than 3 months (not due to pregnancy). All forms of Turner’s syndrome in females. Endometriosis,
- Premature menopause (before 45 years) either natural, surgical or radiation.
- Depo-Provera contraceptive proven to cause bone loss, particularly high risk during adolescence.
Tip: Senior citizens are highest risk group as they are more likely to have low oestrogen and testosterone levels, low vitamin D levels, poor nutrition, take less exercise, have other medical conditions or be on a medication that causes bone loss.
Hyperadrenocorticism: endogenous or exogenous, e.g. Cushing’s Syndrome. Hyperthyroidism. Hyperparathyroidism (Primary or secondary due to low vitamin D or poor renal function). Acromegaly. Hypopituitarism. Hyperprolactinaemia. Insulin dependent Diabetes. Haemochromatosis. Hypophosphataemia. Hypercalcuria
Renal Osteodystrophy, Chronic renal insufficiency, Renal tubular acidosis
Inactivity, or prolonged immobility for more than six weeks or long term
Asian and Caucasians are more at risk, however ALL races can develop osteoporosis.
TIP: Dark skinned people tend to have denser bones, however they have decreased ability to absorb vitamin D from the sun.
Vitamin D Deficiency
Vitamin D resistant rickets, Low Vitamin D, Osteomalacia
Nutritional and Lifestyle
Excessive protein increases calcium loss. Excessive caffeine and alcohol, smoking, excessive exercise, particularly with inadequate caloric intake, Athletic Triad (Amenorrhea, Eating Disorder and Osteoporosis or osteopenia), excessive psychological and physiological stress as well as eating disorders (Anorexia Nervosa and/or Bulimia – past or present)
Malabsorption problems; Coeliac or Gluten and wheat sensitivity, lactose intolerance or Cystic Fibrosis, Inflammatory Bowel Disease; Chron’s Disease, Irritable Bowel, Ulcerative Colitis. Gastrectomy or small bowel resection. Severe liver disease. Chronic obstructive jaundice. Primary Biliary cirrhosis. Amyloidosis. Gaucher’s disease.
- Bone Marrow Disorders
- Multiple Myeloma
- Systemic Mastocytosis
- Disseminated Carcinomatosis
Collagen Disorders and other medical conditions
- Ehlers-Danlos Syndrome. Marfan’s Syndrome. Homocystinuria. Rheumatoid Arthritis. Polymyalgia. Sarcoidosis. Psoriatic arthritis.
- Ankylosing Spondylitis
Stroke. Dementia. Multiple Sclerosis. Spinal cord lesions. Muscular Dystrophy. Idiopathic Scoliosis
Psychotic patients. Down syndrome. Pernicious Anaemia. Thalassemia. Haemophilia. Congenital Porphyria. Cancer; Leukaemia, Lymphoma. Severe eczema. COPD. AIDS/ HIV
Long-term use of Corticosteroids are the most common cause of secondary osteoporosis. Main bone loss occurs in the first six months.
Corticosteroids 7.5 mg a day for > 3 months in a year.
Chemotherapy. Radiation. Thyroxine, if serum levels are high. Post organ transplant. Anticonvulsant therapy, Anti-epileptic medications, can interfere with calcium absorption and the production of vitamin D. Chronic heparin or Warfarin therapy. Long-term lithium therapy. GnRh analogues. LHRH analogues; testosterone suppression; leuprorelin. Prolactin raising drugs, Antipsychotic medication, e.g. some SSRI. Aromatase inhibitors for the treatment of Prostatic and. Breast Cancers. Diuretics. Proton Pump Inhibitors, Tranquillizers and sedatives may increase the risk of a fall
So what can you do?
In an ideal world, all your patients should be screened but unless you have a way of quadrupling your staff, that do not require a pay cheque, this is not feasible. Therefore, starting to screen those at high risk is essential. Request the risk factor questionnaire from the IOS – it is free!
Initiate the screening process on those over 65 first
Have all patients on medications or conditions that cause bone loss fill it out. This can be done when patients come in for a GP visit
Initiate screening all women going through the menopause
All patients asked to fill out the questionnaire when they are in your waiting room. Have your medical students collate the information for research.
All patients should be told that they need to take the daily amounts of calcium and vitamin D throughout life, preferably through food. Those contemplating pregnancy, already pregnant and those who are breast-feeding must be told the importance of taking them, as more cases are occurring of vertebral fractures mid and post pregnancy.
NOTE: Calcium alone is not enough to treat bone loss and is not a substitute for drug therapies that treat bone loss.
Those at risk
Those with one or more risk factors should be referred for a DXA scan of their spine and hips, NOT an ultrasound of their Tibia or heel. If access to DXA scanning is an issue, patients need to be informed that private clinics offer this service. They could ask their children for help, they did raise them. A DXA scan instead of a Birthday or Christmas gift, is a worthwhile gift. This helps to prevent their future inheritance paying for a nursing home!