Direct medical costs from fragility fractures to the UK healthcare economy were estimated at £1.8 billion in 2000, with the potential to increase to £2.2 billion by 2025. It is therefore important for primary care clinicians to be aware of osteoporosis and the importance of prevention of fragility fractures.

Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis leads to nearly nine million fractures annually worldwide,1 and over 300,000 patients with fragility fractures present to hospitals in the UK each year.2

Fragility fractures are those occurring from trauma that would not usually cause a fracture, such as a fall from standing height. Fragility fractures are usually due to osteoporosis and are important because they increase morbidity for the patient due to pain and long-term disability and increase the likelihood of death.

Osteoporotic fragility fractures tend to occur in the spine, forearm (Coles fracture) in the fifties, wrist, spine and pelvis fractures in the sixties and seventies and hip fractures in the eighties (Figure 1). Vertebral fractures are often silent and are only found incidentally on X ray; however, they are a pointer to osteoporosis and if identified and treated, can prevent the progression to hip fracture that occurs a number of years later once the patient is at risk of falling.

People who have suffered a first fragility fracture are at a double risk of suffering from a second fracture. Often the patient will present with decreasing height, which can be the only sign of silent vertebral fractures.

Hip fracture nearly always requires hospitalisation, is fatal in 20% of cases and permanently disables 50% of those affected; only 30% of patients fully recover. Projections suggest that, in the UK, hip fracture incidence will rise from 70,000 per year in 2006 to 91,500 in 2015 and 101,000 in 2020.3

Direct medical costs from fragility fractures to the UK healthcare economy were estimated at £1.8 billion in 2000, with the potential to increase to £2.2 billion by 2025 and with most of these costs relating to hip fracture care.4 There are also indirect costs to the patient and their families such as productivity loss by patients and families who may need to care for a patient. It is therefore important for primary care clinicians to be aware of osteoporosis and the importance of prevention of fragility fractures.

Osteoporosis management in primary care is not always a priority and the care of people with osteoporosis can be improved by the use of a fracture liaison nurse to identify people at risk and optimise treatment.5

Fracture prevention can be termed primary or secondary. Primary prevention refers to patients who have never sustained a fracture and secondary care refers to those who have already had a fracture. Care often falls down when the significance of the first fracture is missed and the risk of osteoporosis and further fractures is not calculated. Fracture liaison nurses enable this to happen much more effectively by case finding and treating people at risk of further fractures.

Osteoporosis indicators are now included in the quality and outcomes framework (QOF), but are only recording information about the management of patients who have sustained a fragility fracture. Primary prevention is not included.

Figure 1: International Osteoporosis foundation. www.osteoporosis.org.nz

Assessing fracture risk

Guidance from NICE6 has suggested that fracture risk should only be assessed in certain populations. The risk of fragility fracture is commoner in women and is commoner in older patients. The risk of osteoporosis rises steeply after the menopause in women because of the loss of the protective effect of circulating oestrogen.

Therefore NICE have suggested that the risk of fracture should be assessed in:

  • All women over 65 years of age
  • All men over 75 years of age.

Fracture risk should also be assessed in women under 65 years of age and men under 75 years of age, with certain additional risk factors which are:

  • Previous fragility fracture
  • Current use or frequent recent use of oral or systemic glucocorticoids
  • History of falls
  • Family history of hip fracture
  • Other causes of secondary osteoporosis such as vitamin D deficiency (see below)
  • Low body mass index (BMI) (less than 18.5kg/m2)
  • Smoking
  • Alcohol intake of more than 14 units per week for women and more than 21 units per week for men.

Causes of secondary osteoporosis include:

  • Endocrine: hypogonadism (in either sex) including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy; hyperthyroidism; hyperparathyroidism; hyperprolactinaemia; Cushing’s disease; diabetes
  • Gastrointestinal: coeliac disease; inflammatory bowel disease; chronic liver disease; chronic pancreatitis; other causes of malabsorption
  • Rheumatological: rheumatoid arthritis; other inflammatory arthropathies
  • Haematological: multiple myeloma; haemoglobinopathies; systemic mastocytosis
  • Respiratory: cystic fibrosis; chronic obstructive pulmonary disease
  • Metabolic: homocystinuria, chronic renal disease and immobility (due for example to neurological injury or disease).

There is no point assessing fracture risk in patients under 50 years of age unless they have major risk factors such as high dose steroid therapy.

It is also worth remembering that having osteoporosis alone is not the only reason why people sustain a fracture. There is also a risk of falls from other comorbidities such as Parkinson’s disease. Therefore, falls prevention is a large part of fragility fracture prevention and most hospitals or community geriatric services will have a Falls Service that identifies patients at risk of falling and treats them with physiotherapy and exercise classes to improve their musculoskeletal fitness.

Within a consultation, assessment of fracture risk has been made much easier with the use of online tools or decision-aids. There are two commonly used ones in the UK and these are:

Most GP computer systems have these tools uploaded to the system so that they can be used quickly within a consultation.

Both will provide a risk of osteoporotic fracture. The FRAX system uses guidance from the National Osteoporosis Guidance Group (NOGG) to calculate whether the patient needs treatment or not, which is helpful.

FRAX was developed by the World Health Organisation (WHO) for assessing fracture risk in women and men taking into account several risk factors as listed above. Also the femoral neck bone mineral density (BMD) can be used to calculate the risk if this is available, but risk can be assessed without BMD as well.

FRAX was developed using data from Europe, Asia and the USA and validated in 11 countries. Whereas, Q-fracture was designed using UK data and the list of risk factors differs slightly from those in the FRAX tool and includes asthma, risk of falls, other long-term conditions such as diabetes and the use of certain medications such as triyclic anti-depressants, so is more comprehensive.

Q-fracture produces a 10-year risk of hip fracture and also other major osteoporotic fractures such as wrist and spine. However, it does not give guidance on when to start treatment (ie. the treatment threshold), whereas FRAX will give a treatment threshold, or advise measurement of BMD in borderline cases to help make a decision about treatment.

There is also a slight difference in the age ranges covered by each tool; FRAX can be used in the age range 40-90 years, Q-fracture from 30-84 years.

The GP or practice nurse can therefore be faced with a dilemma over whether to start treatment for osteoporosis. If there is doubt, then referral for BMD assessment and the opinion of a metabolic bone specialist or rheumatologist may be required.

It is also important to understand that BMD should not be requested until a fracture risk assessment is done first, using one of the tools described.

Many BMDs are requested without first assessing the other risk factors and comorbidities and this wastes resources. Treatments for osteoporosis have risks as well as benefits and there may be harm in treating a patient with low bone density who is not at risk of falling or sustaining a fracture.

Bone mineral density

Bone mineral density is measured using dual X ray densitometry (DXA); osteoporosis is defined as a BMD less than 2.5 standard deviations below the mean, which is expressed as a T score. A T score of -2.8 means that the patient has a BMD 2.8 standard deviations below the mean.

Osteopenia is defined as a BMD between 1.5 and 2.5 standard deviations below the mean (T score between -1.5 and -2.5). Osteopenia is important as a possible precursor to osteoporosis.

Treatment of osteoporosis

If a patient is at high risk of fracture as assessed by FRAX or Q-fracture or another risk tool, NICE7 advise measuring BMD (although the NOGG guidance suggests treating high risk patients without measuring BMD).

If at high or intermediate risk or with a T score less than -2.5, then current NICE guidance suggest starting a bone-sparing therapy in the form of a bisphosphonate. Low risk patients should be advised about lifestyle measures and have a BMD repeated in two years. In all patients, lifestyle measures should be suggested in addition to drug therapy.

Lifestyle measures

It is important to advise the patient to:

  • Take regular exercise (tailored to the person) to improve muscle strength. Encourage:
  • Walking, especially outdoors, as this will increase exposure to sunlight, increasing vitamin D production
  • Strength training (such as weight training) of different muscle groups (for example hip, wrist, and spine)
  • A combination of exercise types, for example balance, flexibility, stretching, endurance, and progressive strengthening exercises
  • Eat a balanced diet as this may improve bone health
  • Stop smoking if needed, as it is a risk factor for fragility fracture. For more information, see the Clinical Knowledge Summaries (CKS) topic on smoking cessation
  • Drink alcohol within recommended limits, as alcohol is a dose-dependent risk factor for fragility fracture. See the section on safer drinking limits in the CKS topic on alcohol.
  • Provide the person with sources of information and support:
  • The National Osteoporosis Society provides support and information to people affected by osteoporosis, and works to improve public understanding of osteoporosis.
  • Healthtalkonline has a large collection of videos and transcripts of people’s experiences of health and illness, including osteoporosis. There are also short articles for people with osteoporosis and the general public.
  • NHS Choices has a health encyclopaedia, which has a printable article on osteoporosis.

Also attend to any risk factors such a glucocorticoid usage and reduce the dose to the lowest possible level, address smoking and alcohol intake.

Advice from the Royal College of Physicians helps clinicians to decide when to prescribe bone-sparing therapy in patients on steroids.8

Vitamin D

Vitamin D is required for calcium and phosphate metabolism and is therefore important for musculoskeletal health. Vitamin D is synthesised in the skin following exposure to ultraviolet light. Some is absorbed from the diet, but sun exposure is the most important source in the body. During winter months, exposure can be limited in the UK and also if the skin is covered, this prevents adequate synthesis of vitamin D.

The Scientific Advisory Committee on Nutrition (SACN) produced recommendations on vitamin D intake in 2016. It recommends:

  • The serum level of vitamin D (serum 25(OH)D should not fall below 25nmol//l at any time of the year in order to protect musculoskeletal health.
  • An intake of 10microg/day or 400IU/day of vitamin D is recommended for the UK population aged four years and above. This is the average amount needed by 97.5% of the population to maintain a serum 25 (OH)D concentration of equal to or greater than 25nml/l.

A patient lacking vitamin D will develop osteomalacia; in children the same condition is known as rickets. Osteomalacia is a condition where skeletal bones are softer than usual due to a lack of both bone mineralisation from calcium and phosphate. The bone matrix is made up of collagen fibres, which are normally mineralised with calcium and phosphorus to make a strong bony structure. When vitamin D is low, this mineralisation cannot occur to its full extent and bones are softer and more prone to fracture.

In osteomalacia, the measured bone density may be normal, but the bones are not as strong as they should be.

The SACN guidelines have been developed to prevent osteomalacia in the population. Taking vitamin D supplements will not prevent or treat osteoporosis, but will prevent osteomalacia in a patient who has osteoporosis or is at risk of osteoporosis, and anyone else for that matter.

Calcium

If the patient eats a diet low in calcium, less than 700mg/day, prescribe supplements:

  • Prescribe 10 micrograms (400 international units) of vitamin D with at least 1000mg of calcium daily.
  • Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000mg of calcium daily for elderly people who are housebound or living in a nursing home.

The calcium calculator (https://www.iofbonehealth.org/calcium-calculator) is a useful resource for patients to estimate their daily calcium intake.

  • If the person’s calcium intake is adequate (700mg/day), prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.
  • Also consider prescribing HRT in women who have had a premature menopause.

Prescribing bisphosphonates

NICE recommends alendronate 10mg once daily or 70mg once weekly, or risedronate 5mg once daily or 35mg once weekly, if there are no contraindications and after appropriate counselling.

Bisphosphonates should be taken on an empty stomach, before food and often before breakfast. They should be taken with plenty of water and taken when standing to promote passage down the oesophagus.

The dose of bisphosphonates should be reduced in patients with renal impairment.

Common side effects with bisphosphonates are indigestion and reflux, especially if the dosing instructions are not followed.

Patients often stop taking the drugs but do not tell their doctor due to side effects so it is important to be vigilant about compliance. The commonest reason for bisphosphonates not working is poor compliance.

Osteonecrosis of the jaw

Bisphosphonates have the potential to cause osteonecrosis of the jaw. This is an area of dead bone in the jaw, which has persisted for more than eight weeks. There is no consensus about the incidence of osteonecrosis of the jaw, however, risk is increased with more than three years of treatment, more potent intravenous bisphosphonates, and higher doses (such as those used in managing cancer).

All patients should be advised to have a dental assessment before treatment starts; any existing dental problems such as decay or infection can increase the likelihood of osteonecrosis and should be attended to before treatment.

There is also a small risk of atypical femoral fractures with long-term bisphosphonate use. The annual absolute risk of atypical femur fractures is reported as 11 per 10,000 person years of bisphosphonate.9 Recommendations suggest that bisphosphonate treatment is reviewed at five years.10,11

Sometimes, a break from treatment is recommended (a drug holiday). More specific advice is included in the BMJ article; 10 minute consultation on bisphosphonates beyond five years.12 Each patient must be assessed on their specific risk factors for continuing treatment and any comorbidities, which have occurred in the time since treatment began (such as further fragility fractures).

Further advice from specialist care may be necessary. Adverse effects of oral bisphosphonates include:

  • Gastrointestinal (most common)—nausea, dyspepsia, mild gastritis, and abdominal pain. They are more likely to occur in the first month of treatment.
  • Bone, joint, and/or muscle pain (common)
  • Oesophageal reactions (uncommon)— oesophagitis, oesophageal ulcers, oesophageal strictures, and oesophageal erosions.
  • Osteonecrosis of the external auditory canal (very rare).

Treatments other than bisphosphonates

If oral bisphosphonates are not tolerated, then specialist referral is recommended to undertake BMD testing and assess for other treatments. Other options available are zoledronic acid (intravenous bisphosphonate); raloxifene, a selective oestrogen receptor modulator that works like HRT, but without the oestrogen related side effects; denosumab, a monoclonal therapy, which inhibits osteoclasts (cells which break down bone), and teriparatide, a synthetic analogue of parathyroid hormone.

Case study

Jennifer attends your practice with obesity and diabetes; she is 67 years of age and a smoker. She is not very active, and her mother had a hip fracture at the age of 72 years who died six months later.

1. Would you check Jennifer’s fracture risk at this point in time?

Yes. As part of her annual chronic disease review, it would be a good idea to assess her fragility fracture risk using FRAX or Q-fracture.

2. What other lifestyle parameters would you like to know about?

Alcohol consumption and whether Jennifer has rheumatoid arthritis. Does Jennifer have a previous fracture or steroid therapy? Height and weight are also required.

She drinks more alcohol than the recommended safe amount; weight is 96kg, height is 170cm. She has not had a BMD assessment.

3. Using FRAX, her risk is deemed intermediate. What should you do now?

Refer her for BMD assessment. In the meantime, give lifestyle advice about the smoking, alcohol and lack of exercise. Her diet is not very rich in calcium so also prescribe a calcium and vitamin D supplement.

4. Her BMD is actually very good, so is there any indication for bisphosphonate treatment at the current time?

No, but it is sensible to check her fracture risks in two years time and offer advice about lifestyle interventions.

Summary

In primary care we should be thinking about osteoporosis in all patients over 55 years of age. Osteoporosis can cause fragility fractures that are a cause of mortality and morbidity; anyone sustaining a fragility fracture should be assessed for osteoporosis and treated as necessary. They should also be referred for a falls assessment.

QOF records the secondary prevention measures for osteoporosis in those who have sustained a fracture.

A risk assessment should be performed in those at risk of fragility fracture; FRAX or Q-fracture are good decision aids and refer for bone density assessment if recommended by the tool assessment. Assess lifestyle measures and offer advice on major risk factors such as smoking, alcohol and BMI.

Treat osteoporosis with calcium and vitamin D as necessary and a bone-sparing agent; bisphosphonates are recommended as first-line treatment. In addition, assess the need for continuing treatment in those who have been on bisphosphonates for five years or more.

Conflict of interest: I am a consultant for Versus Arthritis (formerly Arthritis Research UK). I am a Senior Lecturer at Keele University

References

  1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006; 17(12):1726–33
  2. British Orthopaedic Association. The care of patients with fragility fracture. British Orthopaedic Association, 2007
  3. Department of Health. Hospital Episode Statistics. 2006. Available from: http://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=192 (accessed 10/11/18)
  4. Burge RT, Worley D, Johansen A, et al. The cost of osteoporotic fractures in the UK: projections for 2000-2020. Journal of Medical Economics 2001; 4(1-4):51-62
  5. Chan T, de Lusignan S, Cooper A, Elliott M. Improving Osteoporosis Management in Primary Care: An Audit of the Impact of a Community Based Fracture Liaison Nurse. PLoS One 2015; 10(8): e0132146
  6. https://www.nice.org.uk/guidance/cg146/evidence/osteoporosis-fragility-fracture-full-guideline-186818365 (accessed 10/11/18)
  7. http://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenario:1 (accessed 10/11/18)
  8. http://shop.rcplondon.ac.uk/products/glucocorticoid-induced-osteoporosis-guidelines-for-prevention-and-treatment?variant=6364571205 (accessed 10/11/18)
  9. Schilcher J, Koeppen V, Aspenberg P, Michaëlsson K. Risk of atypical femoral fracture during and after bisphosphonate use. N Engl J Med 2014; 371: 974-6
  10. Compston J, Bowring C, Cooper A, et al. National Osteoporosis Guideline Group. Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013. Maturitas 2013; 75: 392–96
  11. Scottish Intercollegiate Guidelines Network (SIGN). Management of osteoporosis and the prevention of fragility fractures SIGN publication no. 142. SIGN, 2015
  12. Paskins Z, Warburton L. 10 minute consultation. Bisphosphonates beyond five years. BMJ 2016; 352: i264

Louise Warburton

Senior lecturer in General Practice, GP with a special interest in Rheumatology and Musculo-skeletal Medicine

louise.warburton1@nhs.net