High risk groups 1–4

  • Early or post-menopausal women
  • Men > 50 years
  • Coeliac disease, hyperthyroidism, osteogenesis imperfecta or low testosterone
  • Family history of osteoporosis (OP) or hip fracture
  • History of minimal trauma fracture or falls
  • Vertebral fracture or height loss
  • People receiving hormone therapy for breast or prostate cancer
  • Those receiving antiepileptics, HIV treatments or long-term glucocorticoids
  • Lack of weight-bearing Physical activity and sleep or inactivity
  • Low body weight, mass and strength
  • Low calcium intake or vitamin D deficiency
  • Those that smoke cigarettes or drink excessive alcohol amounts
  • Chronic kidney disease or Diabetes

Referral 1,2,5

  • Refer to specialist if:
    • a recent vertebral fracture (within the last 2 years)
    • ≥ 2 vertebral fractures (ever)
    • Bone mineral density (BMD) T-score ≤ − 3.5
    • treatment with high dose glucocorticoids (≥ 7.5 mg/day of prednisolone or equivalent over 3 months)

1. What is osteoporosis? 1,4,5

  • Characterised by deterioration of bone tissue and mass leading to fragile bones and increased risk of minimal trauma fractures, usually from falls e.g. hip, forearm, humerus, shoulder, ankle, pelvis, vertebra and tibia
  • For those with OP, the lifetime risk of minimal trauma fracture > 60 years of age is 44% in women and 25% in men
  • Those who sustain a fracture are at greater risk of sustaining another fracture

2. Diagnosis of osteoporosis 1–5

  • Diagnosis is based on:
    • medical history and presence of risk factors
    • physical examination including height and spinal alignment
    • baseline laboratory tests e.g. FBC, ESR, Ca+, ACR, UEC, serum 25(OH)D, TFT
    • absolute fracture risk. See Resource 1. for calculators
  • Confirmed by BMD T-score as below:

Physical activity time guide

  • Thoracic and lumbar spine radiographs are also considered
  • Exclude other causes of bone fragility e.g. metastatic cancers, endocrine disorders

3. Management of osteoporosis 2,5

  • The goals of managing OP are to improve and maintain bone health so patients can lead active and injury free quality lives by:
    • addressing Lifestyle modifications
    • optimising and maintaining cognitive and physical function to independently perform daily activities
    • identifying and addressing comorbid conditions including:
      • Depression
      • Anxiety disorders
      • Diabetes
      • Chronic kidney disease
  1. Support patient self-management 1–3
    • Provide the patient with OP resources. See Resource 2.
    • Utilise community support services to reduce risk and support the patient to stay in their own home. See Resources 3. and 4.
    • Discuss continuity of treatment as any interruption results in loss of bone density and treatment benefits
    • Engaging our patients to identify barriers to adequate lifestyle modification and clinical adherence and develop goals to overcome those barriers
  2. Social-emotional support 1,2
    • See Social-emotional wellbeing
  3. Adequate calcium intake 1,4,5,7
    • Calcium helps to prevent OP and minimal trauma fractures
    • Adequate calcium intake is achieved by Diet and nutrition including:
      • fortified, low fat and soy milks
      • low fat yoghurts and cheeses
      • tinned fish
      • tofu
      • green vegetables
      • nuts and tahini
      • dried fruit
    • The recommended daily intake of calcium is 1000 mg for men 50–70 years and 1300 mg for women > 50 years and men > 70 years
  4. Physical activity 1,2,4,5,8
    • Regular weight bearing and strength training Physical activity and sleep is the most effective lifestyle behaviour to improve bone structure, muscle strength and balance
    • Encourage weight bearing, resistance training and strength activities for 30 minutes, 2–3 days/week, including:
      • cycling
      • (water) aerobics
      • yard and garden work
      • golf with no cart
      • swimming
      • tennis
      • stair climbing
      • hand or ankle weights
    • Be mindful of falls risk during exercise especially in combination with medicines
    • Refer to a physiotherapist or exercise physiologist to develop an exercise regimen or enrol in a strength and balance group
  5. Body weight 1,2,4,5
    • Low body weight doubles the risk of a hip fracture
    • Target a healthy body weight and waist circumference to maintain muscle mass while guarding against being under or overweight
    • See Diet and nutrition
  6. Adequate vitamin D 1,4–7
    • Vitamin D promotes absorption of calcium which maintains bone mineralisation and muscle function
    • Sufficient vitamin D is produced by exposure to sunlight:
      • in summer (UV level > 3): exposure of face, hands and arms for a few minutes before 10am and after 3pm most days of the week. Use skin protection
      • in late autumn and winter (UV level < 3):  any daytime outdoor activity with skin partly covered most days of the week
    • Monitor those with OP not able to maintain a serum vitamin D concentration > 50 nmol/L, including those:
      • with limited sun exposure
      • with naturally dark skin
      • who cover their skin (cultural or habitual clothing)
      • in residential care or housebound, particularly the elderly
      • who are disabled or chronically ill
      • with medical conditions or take medicines that interfere with vitamin D metabolism
    • Small amounts of vitamin D are obtained from Diet and nutrition e.g. fatty fish (salmon, sardine, herring and mackerel), liver, eggs and some fortified foods
  7. Alcohol reduction 1,2,4,5
    • Excessive alcohol intake impairs bone formation and increases risk of falls and fractures. See Alcohol reduction
  8. Smoking cessation 1,4,5
    • Smoking is associated with reduction in bone structure and strength and increases the risk of fractures.
    • Refer willing patients to a Smoking cessation program
  9. Falls prevention 1,2,4,5
    • Screen for individual falls risk. See Resource 6.
    • Review medicines and minimise sedatives especially benzodiazepines
    • Refer to a physiotherapist and exercise physiologist for a balance and strength and a falls prevention group
    • Refer to an occupational therapist to assess for home modification requirements to avoid slip and fall hazards

4. Medicines for osteoporosis 1,2,4,5

  • The benefit of calcium and vitamin D supplements for fracture reduction is low (except for institutionalised patients at risk of deficiency)
  • Ensure completion of dental assessments and procedures, and oral wounds are healed before commencing OP medicines to minimise jaw osteonecrosis risk
  • Encourage patients to maintain oral hygiene, dental check-ups, and report any dental pain or swelling, especially those on bisphosphonates or denosumab
  • Glucocorticoids reduce bone formation and calcium absorption, increasing fracture risk independent of BMD. Assess need for their use

Table 1. Calcium supplements for OP 1,4,5,7

Calcium carbonate

  • Only consider if dietary calcium intake is < 1300 mg/day
  • Can reduce absorption of some medicines e.g. thyroxine, tetracyclines, quinolones, bisphosphonate. Separate by at least 2 hours

Calcium carbonate 1.25–1.5 g (elemental calcium 500–600 mg) PO, daily with food

  1. Vitamin D 1,7
    • Measure baseline serum 25(OH)D level prior to initiating vitamin D, then reassess after 3 months. See Table 2.
    • Target serum 25(OH)D levels > 50 nmol/L. Continue to provide maintenance doses
    • Higher doses of 50–100 microgs (2000–4000 IU) per day may be required in some patients e.g. obese

Table 2. Supplements for vitamin D deficiency 4,6,7

 

Mild deficiency

(serum 25(OH)D concentration

30 to 49 nmol/L)

Moderate vitamin D deficiency

(serum 25(OH)D
concentration
12.5 to 29 nmol/L)

Severe vitamin D deficiency

(serum 25(OH)D concentration
< 12.5 nmol/L)

Colecalciferol

  • 25–50 microgs (1000–2000 units) PO, daily

OR

  • 175–350 microgs (7000–140000 units) PO, weekly
  • 75–125 microgs (3000–5000 units) PO, daily for 6–12 weeks

FOLLOWED BY

  • 25 to 50 microgs (1000–2000 units) PO, daily
  1. Antiresorptive (AR) medicines 1,2
    • AR medicines (bisphosphonates and denosumab) slow bone loss by inhibiting osteoclast function, improving BMD and reducing the risk of fractures
    • Patients should ensure adequate intake of calcium and vitamin D while on these medicines, however, calcium should be taken at a different time to ARs
    • ARs should be taken with caution in patients with renal disease
    • See Table 3.

Table 3. Medicines for OP (continued) 1,2,4

Table 3. Medicines for OP 1,2,4,5

Bisphosphonates

  • For men and women with a minimal trauma fracture
  • Contraindicated if unable to swallow or remain upright for 30 minutes
  • Long-term use increases risk of osteonecrosis of the jaw and atypical fracture of the femur
  • Musculoskeletal pain is common and can be severe and disabling
  • To minimise upper gastrointestinal side effects take in the morning on an empty stomach and remain upright for at least 30 minutes and avoid:
    • food, drink and medicines for 30 minutes
    • calcium salts, antacids or iron and magnesium supplements within 2 hours

Alendronate 70 mg PO wkly

Risedronate 35 mg wkly OR 150 mg mthly PO

Zoledronic acid 5 mg IV once a year (over 15 minutes). If eGFR < 35 mL/min avoid

Denosumab

  • Correct vitamin D deficiency before initiating as medicine can exacerbate hypocalcaemia
  • Avoid unplanned cessation as its benefits rapidly reverse increasing vertebral fracture risk

Denosumab 60 mg subcut 6 mthly

Teriparatide

  • Patient must have a T-score ≤ -3, two or more minimal trauma fractures and at least one fracture after 12 months of AR therapy
  • Initiated in consultation with a specialist

Teriparatide 20 microgs subcut daily for a max. of 24 months

Romosozumab

  • Reduces vertebral and hip fractures risk in postmenopausal women
  • Patient must have a T-score ≤ –3 and at least one fracture after 12 months of AR therapy
  • Initiated in consultation with a specialist

*Romosozumab 210 mg subcut (two 105 mg injections), once a month for 12 months

Raloxifene

  • Reduces vertebral fracture risk in women > 3 years postmenopause

*Raloxifene 60 mg PO daily

Tibolone

  • Reduces vertebral fracture risk in postmenopausal women typically < 60 years of age

*Tibolone 2.5 mg PO daily

*See LAM and PBS for medicine indications and restrictions

5. Cycle of care

Cycle of care summary for osteoporosis

Action

Dx

Frequency

Height

annually

BMI

6 mthly

Weight

6 mthly

Waist circumference

6 mthly

BP

6 mthly

Serum 25(OH)D levels

3 mthly after commencing vitamin D then annually

Carer education and support

Each visit as required

Smoking cessation

Each visit as required

Physical activity

Each visit as required

Diet and nutrition

Each visit as required

Social-emotional wellbeing

Each visit as required

Influenza, pneumococcal and COVID-19 vaccines

Recommended. See the Australian Immunisation Handbookfor schedule

Lifestyle modification

Each visit as required

Medicine review

3–6 mths after medicine initiation then annually

Bone mass density testing

Every 2 years

HW/RN review

Each visit

MO/NP review

6 mthly

Occupational therapist

As indicated

Physiotherapist

Exercise program or falls prevention group

Dental review

Annually and prior to commencing medicines

Specialist review

As indicated

Aged care services

As indicated

Falls risk assessment

Each visit

Balance and strength exercise program

As determined by allied health

6. References

7. Resources

  1. The Fracture Risk Assessment Tool [FRAX] and the Garvan Fracture Risk Calculator
  2. Healthy Bones Australia patient fact sheets
  3. All aged care services are available via myagedcare
  4. Medical Aids Subsidy Scheme (MASS)
  5. Queensland Government’s Individual falls risk screening and Stay on Your Feet Toolkit

Last updated: September 2024

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