Osteoporosis is characterised by low bone mineral density (BMD) and deterioration of bone structure, resulting in an increased susceptibility to fractures of the hip, spine, and wrist.¹

• Based on measures of BMD in Caucasians, osteoporosis is present in 15% of those 50-59 years of age, but these figures increase quickly to 70% of those over 80 years of age.
• The most costly result of osteoporosis is the hip fracture, which nearly always requires hospitalisation, is fatal 20% of the time and permanently disables a further 50%; only 30% fully recover.
• 1.7 million hip fractures occurred worldwide in 1990; this figure is expected to rise to 6 million by 2050.¹

Primary Care is ideally situated to try to identify patients at increased risk before symptoms develop, whilst both orthopaedic surgeons and Primary Care should be vigilant to assess all patients with suspected fragility fractures. There are several risk factors which often coexist to increase risk substantially:

Risk factors²

As far as 'case finding' is concerned - consider doing full assessments and/or BMD dual-energy X-ray absorptiometry (DEXA) scans on patients with one or more risk factors:³

• Known low BMD (DEXA at spine or hip).
• Prior vertebral fracture or fragility fracture.
• Long-term glucocorticoid treatment.
• Rheumatoid arthritis.
• Other secondary case of osteoporosis: type 1 diabetes, osteogenesis imperfecta in adults, anorexia nervosa, hyperparathyroidism, untreated long-standing hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition or malabsorption (e.g. coeliac disease, inflammatory bowel disease) and chronic liver disease
• Family history of osteoporosis (maternal, paternal and sisters - including history of fragility fractures in those aged >50).⁴
• Low BMI (particularly in postmenopausal women).
• Alcohol intake >3 units per day.³
• Cigarette smoker.
• Long-term anticonvulsant therapy (phenytoin, phenobarbital and carbamazepine).⁵

Suggested implementation procedures

See separate article Osteoporosis Case Finding in Primary Care.

• Primary Care surgeries might identify all reported cases of fractures (hip, pelvic, vertebral, humeral or wrist) from discharge summaries and perform a risk assessment on these patients.
  Applying the NICE osteoporosis guideline to these patients,.⁶ those <75 years of age may be referred for a DEXA scan, whereas those over this age with definite fragility fracture can be assumed to have osteoporosis and be treated anyway. An absolute 10 year risk of fracture may be obtained via FRAX® risk assessments³ and the QFracture® calculator (an alternative based on the UK population).^7,8
• Search practice database to identify all patients on long-term glucocorticoids, those with chronic liver disease, and those with type 1 diabetes and assess osteoporosis risk on these patients as well.³
• Consider osteoporosis risk during the annual reviews of other chronic diseases (e.g. CHD, hypertension, etc.).

Patients found to be at increased risk of fracture should be offered a bone-preserving agent, depending on the agreed threshold. The National Osteoporosis Guideline Group (NOGG) suggests interventions according to the patient's risk⁹ - click on the NOGG button available after using the FRAX® calculator. See our separate Osteoporosis article for discussion on treatments.

Primary prevention

Diet and exercise have a considerable influence on whether patients go on to develop osteoporosis:^10,11

• The patient should be encouraged to take adequate calcium throughout life. Where intake may be suboptimal, provide supplementation with calcium and vitamin D3 (particularly for patients with low BMI and patients in residential and nursing homes).
  Calcium-rich foods include milk and dairy products (can be reduced fat) and vegetables such as broccoli and cabbage.
  The healthy eating diet, with '5 a day' of fruit and vegetables (vitamin C), fish meals at least weekly (vitamins D and K¹²), is a good start. Encourage a reduced salt and phosphate intake, the moderation of alcohol intake and give anti-smoking advice as appropriate.
• Encourage exercise, both traditional weight-bearing exercise, and exercise that involves pulling forces acting on entheses (tendon insertions) of long bones.

Primary prevention of fragility fractures in established osteoporosis is covered in the Osteoporosis article.

Document references

1. Chronic Rheumatic Conditions, World Health Organization
2. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level, World Health Organization (2004)
3. WHO Fracture Risk Assessment Tool (FRAX®), World Health Organization Collaborating Centre for Metabolic Bone Diseases
4. Management of osteoporosis, Scottish Intercollegiate Guidelines Network (SIGN), 2004
5. Sheth RD; Metabolic concerns associated with antiepileptic medications. Neurology. 2004 Nov 23;63(10 Suppl 4):S24-9. [abstract]
6. Osteoporosis - secondary prevention including strontium ranelate, NICE Technology Appraisal Guideline (January 2011); Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
7. QFracture® - risk calculator for hip fracture or osteoporotic fracture (hip, vertebral, or distal radius fracture) over the next 10 years
8. Hippisley-Cox J, Coupland C; Predicting risk of osteoporotic fracture in men and women in England and Wales: BMJ. 2009 Nov 19;339:b4229. doi: 10.1136/bmj.b4229. [abstract]
9. Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, National Osteoporosis Guideline Group (October 2008, Updated July 2010)
10. Clinician's Guide to Prevention and Treatment of Osteoporosis, National Osteoporosis Foundation (2010)
11. Stransky M, Rysava L; Nutrition as prevention and treatment of osteoporosis. Physiol Res. 2009;58 Suppl 1:S7-S11. [abstract]
12. Stevenson M, Lloyd-Jones M, Papaioannou D; Vitamin K to prevent fractures in older women: systematic review and economic Health Technol Assess. 2009 Sep;13(45):iii-xi, 1-134. [abstract]

Internet and further reading

• WHO Fracture Risk Assessment Tool (FRAX®), World Health Organization Collaborating Centre for Metabolic Bone Diseases
• Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK, National Osteoporosis Guideline Group (October 2008, Updated July 2010)
• Osteoporosis - primary prevention, NICE Technology Appraisal Guideline (January 2011); Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women
• Osteoporosis - secondary prevention including strontium ranelate, NICE Technology Appraisal Guideline (January 2011); Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

Acknowledgements