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• To increase your knowledge of osteoporosis, its causes and consequences
• To recognise approaches to the identification of osteoporosis and fracture risk reduction strategies
• To enhance your understanding of the pharmacological treatment of osteoporosis
Osteoporosis is a common musculoskeletal condition characterised by diminished bone density and structural deterioration and is a significant global health concern. The condition predisposes individuals to an increased risk of sustaining fragility fractures, which are associated with substantial morbidity and mortality and present a significant healthcare burden. Osteoporosis is often asymptomatic until fractures occur, therefore preventive measures and early intervention are crucial to mitigate its debilitating consequences. This article describes fragility fractures and some of the causes of osteoporosis and details approaches to the identification and management of the condition, including lifestyle modifications, calcium and vitamin D supplementation and pharmacological therapies.
Primary Health Care. doi: 10.7748/phc.2024.e1843
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Walker J (2024) Identification, assessment and management of osteoporosis in primary care. Primary Health Care. doi: 10.7748/phc.2024.e1843
Published online: 21 August 2024
Osteoporosis has been defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass (the average of young healthy adults) (National Institute for Health and Care Excellence (NICE) 2023). The condition occurs when there is an imbalance in the bone remodelling process and bone resorption exceeds bone formation. The imbalance between osteoclast (bone clearing) and osteoblast (bone forming) activity results in low bone mass and changes to the bone microarchitecture (thinning or loss of trabeculae and cortical thinning), which increases the risk of fracture (Gregson et al 2022, NICE 2023). The disease process is often asymptomatic until a fracture occurs (NICE 2023).
It has been estimated that osteoporosis affects over 30 million people, mostly women, in Europe (including the UK), however this is likely to be an underestimate due to underdiagnosis (Adami et al 2022). Osteoporosis is a global public health issue which is likely to increase over the next ten years due to the ageing population (Adami et al 2022).
This article discusses fragility fractures and some of the causes of osteoporosis and details a multifaceted approach to the identification and management of the condition in primary care.
The risk of sustaining a fracture increases with advancing age, predominately due to declining skeletal strength and an increased likelihood of falls. In adults, osteoporosis can result in what is termed fragility fractures, or osteoporotic fractures, which occur as a result of a fall from standing height or from a force applied to the bone which would not typically result in a fracture in healthy bones (Morin et al 2023). Common sites of fragility fractures include the hip, wrist and spine, although they can also occur in other bones (National Osteoporosis Guideline Group UK (NOGG) 2021, NICE 2023). Curtis et al (2022) reported that in 2019 there were about 4.3 million new fragility fractures in the UK, Switzerland and the European Union, the equivalent of around 11,705 fractures per day, or 487 per hour, with an estimated 248,487 deaths causally related to fractures. The collective cost of new and existing fragility fractures and pharmacological interventions totalled €56.9 billion.
Fractures caused by osteoporosis can be debilitating (NICE 2019a) and are associated with reduced life expectancy (NICE 2017, Morin et al 2023), reduced quality of life and loss of autonomy (Morin et al 2023). Fragility fracture of the hip results in permanent disability in approximately 50% of cases and is fatal in approximately 20% of cases (NICE 2023). The mortality rate of such fractures is higher in men than in women (Björnsdottir et al 2022). In the UK, hip fractures related to osteoporosis result in 1.8 million hospital bed days per year and incur approximately £1.1 billion in hospital costs, which does not include the substantial costs associated with social care (Office for Health Improvement and Disparities (OHID) 2022).
In England and Wales, over one in three women and one in five men will sustain one or more fragility fracture in their lifetime (NICE 2023). However, approximately half of all fragility fractures occur in people who do not meet the diagnostic threshold for osteoporosis based on the BMD score (Kanis et al 2023). It is therefore important to recognise that while BMD is an essential factor in assessing fracture risk, it is not the only determinant. A lack of comprehensive risk assessment may lead to undertreatment in people at high risk of sustaining a fragility fracture (Kanis et al 2023). It is also important to note that men are commonly under-evaluated and undertreated for osteoporosis, despite experiencing worse outcomes than women after sustaining a fragility fracture (Björnsdottir et al 2022, Morin et al 2023).
• Primary health care professionals are well placed to identify individuals at risk of osteoporosis and fragility fractures and to address the identified risks through lifestyle modifications and calcium and vitamin D supplementation
• Pharmacological treatment for the management of osteoporosis includes antiresorptive therapy, which inhibits osteoclast activity, and anabolic (bone forming) therapy
• Before discussing pharmacological treatment options, healthcare professionals should consider the patient’s understanding of osteoporosis and why pharmacological management may be required
• Providing accessible, patient-centred information enables informed decision-making and reduces the treatment burden
Osteoporosis can be classified as primary or secondary (Diab and Watts 2013):
• Primary osteoporosis refers to the bone loss that occurs due to age-related changes or factors not related to another pathology, such as post-menopausal decline in oestrogen levels.
• Secondary osteoporosis is caused by underlying medical conditions, side effects of certain medicines and/or lifestyle factors.
There are several non-modifiable risk factors for developing osteoporosis, including sex, age, ethnicity and a parental history of osteoporosis (NOGG 2021). Women are at greater risk of developing the condition than men due to declining oestrogen levels following the menopause, as oestrogen regulates bone metabolism (Liang et al 2022). Men typically have a lower risk of developing osteoporosis and associated fragility fractures than women, as they have an approximate 20% higher peak bone mass and an approximate 30% larger bone area (Björnsdottir et al 2022). However, hypogonadism (that is, decreased functional activity of the testes), including that caused by androgen deprivation therapy for prostate cancer, is a risk factor for development of osteoporosis in men (Björnsdottir et al 2022, Li et al 2023). White people and people of Asian heritage are also noted to have a high risk of fragility fracture due to low bone density and mass (Aibar-Almazán et al 2022).
Heavy alcohol use can suppress osteoblast activity and stimulate osteoclastic action, thereby reducing the production of new bone matrix and increasing the risk of developing osteoporosis (Gaddini et al 2016). Consuming three units or more of alcohol per day is associated with an increased fracture risk (Gregson et al 2022), while alcohol misuse can increase the risk of falls due to impaired balance and coordination (NICE 2019b).
The presence of a coexisting health condition and use of certain medicines can result in malabsorption or suboptimal use of nutrients and/or directly affect the bone mineralisation process. Examples of such health conditions include (NICE 2023):
• Endocrine disease, such as diabetes mellitus, hyperparathyroidism and hyperthyroidism.
• Rheumatological conditions, such as rheumatoid arthritis.
• Gastrointestinal conditions, such as Crohn’s disease, ulcerative colitis and coeliac disease.
• Chronic liver disease.
• Chronic obstructive pulmonary disease.
• Chronic kidney disease.
• Immobility and a body mass index (BMI) of less than 18.5kg/m2.
In relation to medicines, glucocorticoids are a known risk factor for developing osteoporosis and increase the risk of bone loss and subsequent fragility fractures in a dose-dependent manner (NOGG 2021). According to the American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis, the most significant rate of bone loss occurs during the initial three to six months of glucocorticoid treatment, with a peak incidence of fragility fractures at 12 months (Humphrey et al 2023). The guideline recommends that fracture risk is assessed in individuals who are prescribed glucocorticoid treatment for over three months as soon as possible after beginning treatment.
Other medicines which affect fracture risk include thiazolidinediones, anti-Parkinson’s, antipsychotics, benzodiazepines, histamine type 2 (H2) receptor agonists and proton pump inhibitors (Gregson et al 2022).
Most fragility fractures that occur in the community are in individuals who do not have a diagnosis of osteoporosis, as defined by a BMD score (Kanis et al 2023). Kanis et al (2023) emphasised the importance of differentiating between thresholds for diagnostic purposes and thresholds for intervention. Gaps in treatment occur where those who may be at risk of fractures are not receiving appropriate treatment or strategies to reduce the risk (Curtis et al 2022).
Fracture liaison services have been established in some NHS hospital trusts to systematically identify individuals with low-impact fractures and facilitate further assessment and treatment to reduce the risk of future fracture (Royal Osteoporosis Society 2022). There is a need to develop a similar approach in primary care to enable proactive identification of individuals who would benefit from fracture prevention measures. One UK randomised controlled trial that explored the cost-effectiveness of screening older women in primary care settings demonstrated that screening 1,000 patients prevented nine hip fractures and 20 non-hip fractures over the patients’ remaining lifetime (mean 14 years) compared with usual management (Söreskog et al 2020). In addition, the screening arm of the study saved £286 in treatment costs and gained 0.015 quality adjusted life years per patient, compared with usual treatment (Söreskog et al 2020).
NICE (2017, 2023) recommends that fracture risk is calculated for all women aged 65 years and over and for all men aged 75 years and over, and in women aged 50-64 years and men aged 50-74 years with known risk factors, such as use of systemic glucocorticoids, secondary causes osteoporosis, a history of falls or a family history of hip fracture.
QFracture (www.qfracture.org) and FRAX (fracture risk assessment tool) (frax.shef.ac.uk/FRAX/) are validated fracture risk assessment tools used to estimate the ten-year probability of sustaining a major osteoporotic fracture; each tool measures different risk factors and produces different risk outcomes so cannot be used interchangeably (NICE 2017). The QFracture and FRAX tools are helpful in guiding interventions, but may underestimate risk for patients taking very high doses of glucocorticoids (>30mg/day) and do not adequately address risk factors such as frailty, history of falls or multiple fractures (Humphrey et al 2023).
Vertebral osteoporotic fractures can happen spontaneously or through undertaking daily activities such as bending or lifting. As vertebral fractures may be asymptomatic, between 50% and 70% are undiagnosed (NICE 2023). Vertebral fractures are a predictor of hip fracture (Royal Osteoporosis Society 2024a), therefore early detection and intervention are vital to prevent further fractures.
Vertebral fractures can be identified in primary care by differentiating back pain and deformity from other causes (Curtis et al 2022). This type of fracture can cause physical changes over time, such as loss of height and alterations in spinal posture. An exaggerated thoracic kyphosis (forward curvature of the spine) caused by a vertebral fracture can impede activities of daily living; in severe cases it can cause gastrointestinal problems and breathing difficulties, therefore the patient may require referral to specialist services, such as physiotherapy or orthopaedic surgeons, for further assessment and management (NICE 2023).
X-rays and computerised tomography scans may be used to confirm the presence of vertebral fractures. Non-osteoporotic pathologies that should be considered include osteomalacia (softening of the bones, often due to prolonged deficiency of vitamin D), Paget’s disease of the bone, multiple myeloma and metastatic bone disease (NICE 2023).
Assessment of BMD is undertaken using a dual-energy X-ray absorptiometry (DXA) scan, typically of the spine, hip or forearm as these areas are prone to fracture. The DXA scan results provide a T-score, which compares the individual’s BMD to that of a healthy young adult, and a Z-score, which compares the person’s BMD to others in the same age group (NOGG 2021).
It is important to consider other health conditions which cause low BMD and treat these accordingly (NOGG 2021, Gregson et al 2022). Investigations should therefore start with a detailed clinical history and physical examination, including assessment of height and thoracic kyphosis, and may include the following laboratory tests (NOGG 2021, Gregson et al 2022):
• Full blood count.
• Erythrocyte sedimentation rate or C-reactive protein levels.
• Serum calcium, albumin, phosphate, alkaline phosphatase and liver function (low phosphate or low alkaline phosphatase may indicate the presence of an underlying metabolic bone disease).
• Serum 25-hydroxy vitamin D.
• Thyroid function.
Individuals who have sustained a fragility fracture should be referred to a fracture liaison service for assessment of the fracture and falls risk and for further investigation, treatment and monitoring (NOGG 2021). Prompt treatment is required to reduce the risk of further fractures.
Primary health care professionals are well placed to systematically identify individuals at risk of developing osteoporosis and fragility fractures and to address the identified risks through lifestyle modifications, including falls prevention strategies and advice regarding calcium and vitamin D supplements. Nurses can use resources such as the Royal Osteoporosis Society leaflet Healthy Living for Strong Bones (https://strwebprdmedia.blob.core.windows.net/media/s3qmugrt/healthy-living-leaflet-december-2019.pdf) when providing patient education.
Lifestyle modifications may include smoking cessation and moderate alcohol intake as well as increased physical activity (Björnsdottir et al 2022), as mechanical loading of bone stimulates osteoblastic activity. Resistance and impact exercises are recommended to maximise bone strength, however for individuals with vertebral fractures or multiple low-trauma fractures impact exercises should be equivalent to brisk walking (Brooke-Wavell et al 2022).
Falls are a significant risk factor for fractures. The cause of a fall is often multifactorial involving, for example, impaired physical function, environmental hazards and the side effects of some medicines (NICE 2019b). Pre-emptive action can reduce the risk of falls and thus reduce the risk of sustaining a fracture.
Patients may not volunteer information about falls they have sustained; it is important, therefore, that the nurse asks the patient directly to gain information such as the number, characteristics, context and consequences of any falls they have sustained and that they assess the predisposing risks (Montero-Odasso et al 2022).
Components of a multifactorial risk assessment may include assessing for hazards in the home (NICE 2019b) and observing the person’s gait and balance (OHID 2022). The World Falls Guidelines Task Force recommends that older adults with a low risk of falls should be offered information on falls prevention and exercise for general health; those at intermediate risk should be offered targeted exercises or a referral to physiotherapy to improve balance and muscle strength; and those at high risk should have personalised interventions informed by a multifactorial risk assessment (Montero-Odasso et al 2022). Regular exercise, particularly activities that improve strength, balance and flexibility, can reduce the number of falls in older people living at home (Sherrington et al 2019). The nurse should emphasise the importance of continuing exercise and/or physiotherapy to maintain any gains made through engaging in these activities.
The risk of falls can also be reduced by addressing underlying medical conditions such as hypotension or visual impairment (OHID 2022). In addition, the nurse should consider the potential adverse effects of medicines which may increase the risk of falls, such as sedatives, diuretics and anticholinergics (Moles et al 2023).
An adequate calcium intake is required to maintain bone mass and strength, while adequate intake of vitamin D is needed to aid the absorption of calcium (Liang et al 2022). Low serum calcium levels (hypocalcaemia) may cause an increase in parathyroid hormone, which stimulates the osteoclasts to resorb bone and release calcium (Liang et al 2022). Ensuring adequate calcium intake prevents the mobilisation of calcium from the bones to serum calcium and is therefore considered an important part of the strategy to promote bone health. Where possible, calcium intake should be achieved through dietary means, as supplements can cause side-effects such as renal calculi and constipation (Scottish Intercollegiate Guidelines Network 2021).
Where calcium intake is sufficient (700mg/day) but sunlight exposure is inadequate, a daily supplement of 10 micrograms of vitamin D should be prescribed; where calcium intake is insufficient, a daily supplement of 10 micrograms of vitamin D and at least 1,000mg of calcium should be prescribed; in patients with insufficient calcium who are housebound, such as those living in nursing and residential care, this should be 20 micrograms daily along with 1,000mg of calcium (NICE 2023).
Treatment options for the management of osteoporosis can be broadly divided into antiresorptive therapy, which inhibits osteoclast activity, and anabolic (bone forming) therapy (Morin et al 2023). Although there is insufficient economic evaluation of the management of osteoporosis in men, one systematic review identified that the intervention thresholds and cost-effectiveness were similar in men and women (Li et al 2023).
Bisphosphonates inhibit bone resorption by preventing the release of cytokines that activate osteoclasts (Liang et al 2022). Treating individuals with bisphosphonate therapy has been associated with a reduction of 20-30 vertebral fractures, ten non-vertebral fractures and three hip fractures per 1,000 people, compared with those who did not receive bisphosphonate therapy (Morin et al 2023). Where generic options are available, treatment should be initiated using the least expensive, considering costs of administration, dosage and cost per dose (NICE 2019a). The NOGG (2021) recommends the use of oral alendronate (alendronic acid) or risedronate sodium, or intravenous (IV) zoledronate as the most cost-effective pharmacological interventions.
Although bisphosphonates are usually well tolerated, common side effects include gastrointestinal symptoms, such as dyspepsia and nausea, musculoskeletal pain and, less commonly, oesophagitis, oesophageal strictures, ulcers and erosions (NICE 2019a, 2023). Rare side effects include osteonecrosis of the jaw or external auditory canal (NICE 2023).
Bisphosphonates have low bioavailability due to low gastrointestinal absorption, however NICE (2019a) has reported that oral bisphosphonates are cost effective for those with at least a 1% fracture risk and that IV bisphosphonates are cost-effective in individuals with at least a 10% fracture risk. Absorption may be optimised by advising patients how to take the medicine correctly, which is on an empty stomach, with water and waiting a further 30 minutes before eating or taking other medicines (NICE 2023). To promote adherence, healthcare professionals should ask patients about any adverse effects and determine whether they have followed the advice on how to take the medicines during a medicine review (NICE 2017). Where patients are unable to take or tolerate oral bisphosphonates, IV treatments should be considered. Treatment regimens may need to be adjusted and/or a referral made to specialist osteoporosis services for advice if the patient experiences issues such as inability to adhere to the treatment requirements or experiences adverse side effects (NOGG 2021).
When a patient is on long-term bisphosphonate therapy, their response to treatment should be considered to determine whether it should be continued (NICE 2017). Fracture risk and use of bisphosphonates should be reviewed every three years for those taking zoledronic acid and every five years for those taking alendronate, ibandronate and risedronate (NOGG 2021). However, it is recommended that treatment is continued for those aged over 75 years, who have a history of hip or vertebral fractures or who have sustained a fragility fracture during the treatment period or who are taking glucocorticoids (NOGG 2021, NICE 2017).
When bisphosphonates are not suitable, due to contraindications or low tolerance, alternative options such as denosumab or raloxifene hydrochloride may be considered (NOGG 2021, NICE 2023). Selective oestrogen receptor modulators (SERMs) such as raloxifene inhibit bone resorption (increasing bone density) and reduce the risk of vertebral fractures in post-menopausal women (Liang et al 2022). Denosumab is a monoclonal antibody that prevents receptor activator of nuclear factor kappa-B ligand (RANKL) on osteoclasts, which leads to inhibition of bone resorption (Liang et al 2022). Denosumab may be used in post-menopausal women, and in men with an increased risk of fractures (NOGG 2021).
Denosumab is administered six monthly as a subcutaneous injection (NICE 2010) and may be given in primary care where there is a shared care agreement that outlines the responsibilities of prescribing and administering between the specialist service and primary care setting (Royal Osteoporosis Society 2024b). Discontinuation of denosumab results in increased bone turnover exceeding pre-treatment levels resulting in rapid reduction of BMD and, in some cases, multiple vertebral fractures (Tsourdi et al 2021). Therefore, the NOGG (2021) recommends the use of IV zoledronate for six months after the last injection of denosumab.
Anabolic treatment is more effective in preventing fractures than bisphosphonates, although it is restricted for use only in those with a very high risk of fractures or in those unable to tolerate bisphosphonates (NOGG 2021, Händel et al 2023). Romosozumab is a monoclonal antibody which can be used to treat severe post-menopausal osteoporosis in people at very high risk of fracture and who have had a fracture of the spine, hip, forearm or humerus within the previous 24 months, but is contraindicated in people with a history of myocardial infarction or stroke (NICE 2022).
Intermittent use of low-dose parathyroid analogues can promote osteogenic activity (Liang et al 2022). Teriparatide, a synthetic form of parathyroid hormone, can be used as a first-line treatment for men aged 50 years and older who are at very high risk of fracture or in post-menopausal women with very high risk of fracture (NOGG 2021).
Romosozumab is approved for treatment for 12 months and teriparatide is approved for treatment for 24 months (NOGG 2021). Following completion of anabolic treatments, subsequent use of antiresorptive therapy is recommended (NOGG 2021).
Before discussing pharmacological treatment options, healthcare professionals should consider the patient’s understanding of the condition and why pharmacological management may be required. This may help to identify any misconceptions about osteoporosis the patient may have and can support an informed and collaborative decision-making process between the patient and the healthcare team. Providing accessible, patient-centred information enables informed decision-making and reduces the treatment burden (Paskins et al 2022).
Information should be communicated clearly in a way the patient can understand and should address any concerns, such as potential adverse effects of the treatment (Ralston et al 2022). It is also important that patients are made aware of alternative treatment options and understand that they can choose not to undergo treatment. This will ensure that patients have a comprehensive understanding of treatment options and that they are empowered to select an option most suited to their needs and circumstances (Ralston et al 2022). Medicine reviews can create an opportunity to deprescribe unnecessary medicines (Moles et al 2023).
Osteoporosis typically remains asymptomatic until fractures occur, which emphasises the importance of proactive identification of the condition as well as preventive risk assessment and treatment. Primary health care professionals are well placed to support patients at risk of sustaining fragility fractures through identification of osteoporosis, fracture risk assessment and risk reduction interventions, provision of education and medicines review. Approaches to managing osteoporosis include lifestyle modifications, calcium and vitamin D supplementation, and pharmacological interventions to improve bone quality. Routine medicine reviews can be used as an opportunity to emphasise the need for adherence to medicine regimens.
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