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Guidelines for Strategies to Prevent and Treat Osteoporosis

These are based on the  ‘Clinical Guidelines for Strategies to Prevent and Treat Osteoporosis’ published  Royal College of Physicians. 

Prevention of osteoporosis

  Population strategies

Population-based programmes for osteoporosis prevention, such as increasing levels of exercise, smoking cessation and improving levels of calcium and vitamin D in the diet have obvious benefits in terms of general health. There is evidence that increasing calcium intakes eg in young females can increase bone density. There is however no evidence of a direct link between such intervention and prevention of fractures in the long term. Bone health messages should be included in general health promotion activities.

Lifestyle measures

Target all those with a risk of developing osteoporosis.

• Stop smoking.
• Avoid excessive alcohol intake.
• Regular weight-bearing exercise.
• Avoid immobility.
• Avoid excessive dieting and exercise resulting in amenorrhoea.
• Maintain adequate reference nutrient intakes of calcium and Vitamin D

1 pint of semi-skimmed milk or 4 ounces of cheddar cheese contain 700-800mgs of calcium. If these levels cannot be achieved with diet alone (as is likely with vitamin D requirements in those not exposed to sunlight), consider supplements.

Exercise

• Weight-bearing physical activity (walking) and strength training can increase bone mass in those at risk of osteoporosis, but the amount required has not been established, and effects may be small and persist only for the period of activity.
• In patients with osteoporosis, although there is little effect in increasing bone mass, carefully managed exercise programmes may decrease the risk of further fractures by improving well-being, muscle strength and postural stability.
• Physiotherapy and postural advice can help chronic pain.

Hip protectors

Wearing hip protectors may decrease the risk of hip fractures particularly in the elderly residential population. (Supplier details are available from the National Osteoporosis Society.)

Drug therapy options for prevention

• HRT
• Tibolone
• Bisphosphonate
• Calcium and vitamin D

See drug therapy section below for more details of how to use these therapies. Further therapies such as raloxifene (a selective oestrogen receptor modulator) are under evaluation and if appropriate further guidance will be issued.

Treatment of established osteoporosis

  Management of fragility fractures

All primary healthcare teams should have a system for ensuring that every patient who suffers a possible fragility fracture is investigated for osteoporosis, and where appropriate treated to prevent further fractures. These people are at very high risk of suffering future fractures.

• Ensure prompt referral for orthopaedic surgical management unless vertebral fracture.
• Ensure adequate analgesia, allowing early mobilisation to prevent further bone loss.
• It is not necessary to confirm the diagnosis of osteoporosis by DXA since if one such low impact fracture has already occurred then a clinical diagnosis can be made. Exclude secondary causes and initiate long-term therapy to prevent further bone loss.
• Provide patients with further sources of information (see end).

Consider:

• hydrotherapy or physiotherapy if pain or disability persists
• IM calcitonin three times weekly for short term use (up to 3 months) for analgesic effect on vertebral fractures if other analgesic is ineffective.

Drug therapy options for treatment

• Calcium and vitamin D
• Bisphosphonates
• Strontium
• sub cut PTH

See drug therapy section below.

• HRT is an effective therapy for prevention and treatment of osteoporosis but for post menopausal women oover 50 taking it for 5 years, the risks outweigh the benefits. However for women with an early menopause and  at risk of osteoporosis and without contraindications, the benefits may outweigh the disadvantages.

Bisphosphonates

• Cyclical etidronate is licensed for the prevention and treatment of osteoporosis. It prevents bone loss at the lumbar spine and decreases the risk of further vertebral fracture; one epidemiological study suggests a reduction in limb fractures including hip. It is also licensed for corticosteroid-induced osteoporosis.
• Alendronate arrests further bone loss and decreases the risk of fractures at all sites.
• Alendronate may cause oesophageal ulceration; it must be taken with a full glass of water, and the patient must remain upright for 30 minutes after each dose.
• Absorption of bisphosphonates is poor; etidronate must be taken at the mid-point of a 4 hour fast; alendronate must be taken at least 30 minutes before food, drink or oral medication.
• Also consider risedronate, or i.v  zoledronate.

Calcium and vitamin D

There is increasing evidence that 800 i.u. of vitamin D with 1g of calcium is the appropriate dose in the osteoporotic.