My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I review the NICE Clinical Knowledge Summaries (CKS) “Osteoporosis - prevention of fragility fractures” looking at both scenarios assessment and management, last updated in April 2023. I have summarised the guidance from a Primary Care perspective.

By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The NICE GP YouTube Channel: NICE GP - YouTube 

The summary on Osteoporosis - prevention of fragility fractures can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Assessment” can be found here:

·     https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/assessment/

The CKS “Osteoporosis - prevention of fragility fractures: Scenario: Management” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/management/

The “Osteoporosis - prevention of fragility fractures: Prescribing information” can be found here:

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/calcium-colecalciferol-vitamin-d3-preparations/

·      https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/prescribing-information/bisphosphonates/

To calculate dietary calcium intake, see the National Osteoporosis Foundation chart:

·      https://www.nof.org/patients/treatment/calciumvitamin-d/steps-to-estimate-your-calcium-intake/

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]   

• Music provided by Audio Library Plus  

• Watch: https://youtu.be/aBGk6aJM3IU 

Free Download / Stream: https://alplus.io/halfway-through 

Transcript 

Hello everyone and welcome. I am Fernando Florido, a GP in the United Kingdom.

Today, we'll be reviewing the NICE Clinical Knowledge Summaries (CKS) on “Osteoporosis - prevention of fragility fractures” looking at two scenarios, assessment and management, both updated in April 2023. I have summarised the guidance from a Primary Care perspective and I have put links in the episode description.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

If you prefer a video format, there’s also a YouTube version of these episodes. The link is in the episode description.

Please stay until the end, as I'll be sharing fictitious clinical cases created by chat GPT that will illustrate how the guideline is applied in real-life situations.

So, with that said, let's dive in!"

The video has three parts, assessment, management and prescribing information.

• Osteoporosis is characterised by low bone mass and increased bone fragility and it is asymptomatic until a fracture occurs.
• A fragility fracture is a fracture following a fall from standing height or less, typically in the wrist, spine, and hip. Vertebral fractures may occur spontaneously
• Risk factors for osteoporosis include:
• Female sex.
• Increasing age.
• Menopause.
• Oral corticosteroids.
• Smoking and excess alcohol.
• Previous fragility fracture and Parental history of hip fracture
• Inflammatory arthropathies, such as rheumatoid arthritis and
• Body mass index of less than 18.5 kg/m2.

How should we assess a person for fragility fracture risk?

• First, we need to exclude other causes like:
• Metastatic bone disease
• Multiple myeloma
• Osteomalacia and
• Paget's disease and
• Also exclude secondary causes of osteoporosis like:
• Endocrine conditions such menopause, hypogonadism, diabetes mellitus, and hyperthyroidism.
• Inflammatory arthropathies such as rheumatoid arthritis.
• Gastrointestinal malabsorption like in Crohn's disease, ulcerative colitis, coeliac disease, and chronic pancreatitis. 
• Chronic conditions like chronic liver disease and COPD and
• We will then assess for vitamin D deficiency and inadequate calcium intake, especially if they are over 65 years, not exposed to much sun and with a dietary calcium intake of less than 700 mg/day. There are online calculators to estimate dietary calcium and the link is in the episode description.
• We will also assess risks of falls. 
• We will offer a DXA scan without calculating the fragility fracture risk to those:
• Over 50 years of age with a history of fragility fracture.
• Younger than 40 years of age who have a major risk factor for fragility fracture.
• And we will consider starting drug treatment without a DXA scan in vertebral fractures
• We will normally assess the fracture risk first, then depending on the result, we will do a DEXA scan and then depending on the scores, we will consider treatment. So,

·      For all other people with risk factors, we will calculate the 10-year fragility fracture risk prior to a DXA scan, using online assessment calculators such as QFracture® (the preferred one) or FRAX®.

·      If using FRAX®, we must know that it underestimates the risk of:

• Oral steroids
• A history of fragility fractures. 
• And smoking and alcohol excess.

Now that we have completed the assessment, how should we interpret a fragility fracture risk score?

• People at high risk have a QFracture score of 10% or greater or are in the red zone of FRAX.
• People at intermediate risk have a QFracture score close to but below 10% or are in the orange zone of FRAX.
• People at low risk have a QFracture score below 10% or are in the green zone of FRAX.

And how should we manage fragility fracture risk scores?

• If at high risk, we will arrange a DXA scan and:
• offer drug treatment if the T-score is -2.5 or lower. 
• If the T-score is greater than -2.5, we will modify risk factors, treat any underlying conditions, and repeat the DXA, usually within 2 years.
• If at intermediate risk with risk factors we will arrange a DXA scan and offer drug treatment if the T-score is -2.5 or lower.
• If at low risk of fragility fracture, we will not arrange a DXA scan and we will offer lifestyle advice and follow up within 5 years.

What drug treatments are recommended?

• We will prescribe a bisphosphonate (first line in primary care are alendronate 10 mg once daily or 70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly) if the T-score is -2.5 or less.
• We will consider biphosphonates if taking oral steroids equivalent to prednisolone 7.5 mg daily or more for 3 months or longer.
• All the bisphosphonates are licensed for use in postmenopausal women. However, only daily alendronate and weekly risedronate are licensed for use in men.
• If an oral bisphosphonate is not possible, we will refer to secondary care for consideration of other options such as zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide. 
• If the dietary calcium intake is adequate (700 mg/day), we will prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.
• If calcium intake is inadequate:
• We will prescribe the same dose of vitamin D with at least 1000 mg of calcium daily. 
• Or for elderly people who are housebound or living in a nursing home, we will prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily. 
• We will consider HRT for younger postmenopausal women 

What lifestyle information and advice should we give?

• We will advise exercise, a balanced diet, stop smoking and drink alcohol within recommended limits.
• We will also give appropriate patient education. 

How should we follow up a person at risk of fragility fracture?

• After bone-sparing treatment we will ask about adverse effects, in particular:
• Upper GI, such as dyspepsia or reflux. These are common initially and often improve with time.
• Symptoms of atypical fracture, including new onset hip, groin, or thigh pain. If this occurs, stop treatment, and arrange an X-ray of the femur.
• For those taking steroids we will continue bisphosphonates and/or calcium and vitamin D until corticosteroids have stopped, then we will reassess the osteoporotic risk.
• For all other people, we will review the need for bisphosphonates after 3–5 years.
• If they remain at high risk, we will continue alendronic acid for up to 10 years, and risedronate for up to 7 years for those:
• over 75
• or with a previous hip or vertebral fracture.
• In other people, we will arrange a DXA scan and we will consider:
• continuing treatment if the T-score is less than -2.5. We will then reassess every 3–5 years.
• Stopping treatment if the T-score is greater than -2.5 and reassess after 2 years.

We are now going to look at the prescribing information on calcium and Vit D supplements and biphosphonates

Although for further information we will check the British national Formulary or BNF.

Some of the contraindications for calcium and vitamin D preparations are:

• Hypercalcaemia
• Hyperparathyroidism.
• Current renal stone disease.
• CKD stage 4 or 5.
• An allergy to peanuts or soya — soya oil-free products are available

Some of the interactions of calcium and vitamin D preparations include:

• digoxin, thiazides and steroids, as well as
• impaired absorption with a number of drugs, including bisphosphonates, so a period of time needs to be left before taking them.

Some of the contraindications bisphosphonates include:

• Low calcium, vitamin D or parathyroid dysfunction — these should be treated before starting it.
• Severe CKD
• Being unable to be upright for at least 30 minutes, or if there us delay in oesophageal emptying (such as stricture or achalasia) — to reduce the risk of oesophageal reactions. 

Adverse effects of bisphosphonates include:

• Musculoskeletal pain and gastrointestinal symptoms including oesophageal reactions.
• Osteonecrosis of the jaw and of the external auditory canal and atypical stress fractures

Interactions with bisphosphonates include:

• An increased risk of gastrointestinal irritation with nonsteroidal anti-inflammatory drugs.
• Decreased absorption of the bisphosphonate with calcium supplements and antacids, as well as with food and drinks. A minimum of 30 minutes should be left between them.

Routine bisphosphonate advice is as follows:

• They should be taken on an empty stomach.
• They should be swallowed whole with at least 200 mL of water while in an upright position and must not lie down for at least 30 minutes.
• If a dose is missed:
• For daily preparations, they should skip that day and continue the next day as usual. They should not take a double dose.
• For weekly preparations, they should take it on the day that it is remembered and continue on the usual weekly day but two tablets should not be taken on the same day.
• We should inform about possible side effects, including symptoms of atypical fracture (such as hip, groin, or thigh pain) and of osteonecrosis of the jaw (such as jaw pain, swelling, and redness).
• We should advise them to have any necessary dental work done before starting bisphosphonates and to have regular dental check-ups and good oral hygiene thereafter.

 Now that we have reviewed the guideline, let’s look at three clinical cases that illustrate some of the concepts that we have discussed. I have used Chat GPT to generate these random patients.

Clinical case 1

The first patient is

John Smith is a 60-year-old man who develops a Colle’s fracture after tripping over and falling while walking his dog.

How should he be assessed?

Firstly, given that the fracture happened after falling from standing height we can state that John has sustained a fragility fracture.

Considering that he is over 50 with a history of fragility fracture, we should arrange a DXA scan without calculating the fragility fracture risk.

We should also consider alternative diagnoses and screening. We will arrange general blood tests which, according to our clinical judgement, could include the following: male hormones to screen for hypogonadism, vitamin D levels to check for osteomalacia, ESR, CRP and RF to check for inflammatory arthropathies, HbA1c to screen for diabetes, TFTs to check for hyperthyroidism, PTH levels to check for hyperparathyroidism, and LFT’s to screen for chronic liver disease. We will also consider looking for evidence of malignancy including, for example, immunoglobulin electrophoresis, calcium and urinary Bence Jones protein to screen for multiple myeloma. We could also look at X-rays and the alkaline phosphatase, to screen for Paget’s disease of the bone. Finally, depending on the clinical situation, we could screen for conditions causing malabsorption such as checking faecal calprotectin for Crohn’s disease and antigliadin antibodies or tissue transglutaminase antibodies (tTGA) for coeliac disease.

We will also assess risks of falls and calcium intake.

We will consider treatment depending on the DXA scan result. However, if he had been found to have a vertebral fracture instead of a Colle’s fracture, drug treatment would be considered even without a DXA scan.

Clinical case 2

The second patient is

Patient Name: Jane Thompson Age: 62

Medical History: Hypertension, Type 2 diabetes, asthma, and a TIA 5 years ago.

Risk Factors: Family history of osteoporosis, sedentary lifestyle, and history of smoking (quit 5 years ago) following her TIA

Routine blood tests are normal, including vitamin D and calcium. Her eGFR is 65 and she is otherwise asymptomatic.

She comes to see you because she is concerned because her mother had a hip fracture and was diagnosed as having osteoporosis when she was 60.

What further steps should we take?

Before considering a DXA scan to make a diagnosis, we should calculate Jane’s Fragility Fracture Risk and based on her risk factors, the QFracture score is 11.7%. This puts her in the high-risk category.

Since Jane is at high risk, we should arrange a DXA scan to assess her bone mineral density. If the T-score is -2.5 or lower, drug treatment should be offered. If the T-score is greater than -2.5, risk factors and any underlying conditions should be managed, and a repeat DXA scan should be scheduled within 2 years.

Jane's T-score is -2.8 and osteoporosis is diagnosed.

How should we manage her?

1.    Because the T score is less than -2.5 she should have a bisphosphonate: For example Alendronate 70 mg once weekly can be prescribed as the first-line treatment for osteoporosis.

2.    We will assess Jane's dietary calcium using online calculators and we conclude that her intake is adequate.

3.    Jane is not exposed to much sun and she should be given vitamin D Supplementation: so, she will be prescribed 10 micrograms (400 international units) of vitamin D without calcium.

What other advice should we give her?

Jane should be given advice on:

1.    Exercise: engage in weight-bearing exercises, ideally for at least 30 minutes per day.

2.    Balanced Diet: Jane will be encouraged to follow a well-balanced diet rich in calcium and vitamin D sources, including dairy products, leafy greens, and fortified foods.

3.    Smoking Cessation: As Jane has a history of smoking, she will be advised to continue to refrain from smoking.

4.    Alcohol Intake: Jane will be advised to limit her alcohol consumption within recommended guidelines.

5.    Patient Education: Jane will be provided with appropriate patient education materials and resources to enhance her understanding of osteoporosis.

Clinical Case 3

Name: Sarah Johnson

Age: 68

Medical History: Hypertension, GORD (gastroesophageal reflux disease) and osteoporosis, diagnosed after a vertebral fracture seen on an x-ray.

Risk Factors:

1.    Sedentary lifestyle

2.    History of smoking (quit 10 years ago)

3.    Family history of osteoporosis (mother had a hip fracture)

Medication:

1.    Alendronic acid (bisphosphonate) - 70 mg once weekly for the past 5 years

2.    Calcium and vitamin D supplements - 1000 mg calcium and 800 IU vitamin D daily after having found that her dietary calcium and sun exposure are insufficient.

eGFR (estimated glomerular filtration rate): 60 mL/min/1.73m²

How should she be followed up?

1.    We should review side effects: Sarah experienced dyspepsia and occasional reflux during the initial months of starting alendronic acid. However, these symptoms improved over time with continued treatment.

2.    We should always beware of atypical fracture symptoms: And we note that after 3 years of being on alendronic acid, Sarah started experiencing new onset pain in her right thigh and hip. Suspecting an atypical fracture, she was advised discontinuing the medication and arranged an X-ray of her femur to evaluate the possibility. A diagnosis of hip osteoarthritis was made and bisphosphonate treatment was restarted.

3.    Because she has had alendronic acid for 5 years, we should review the need to continue with Bisphosphonate treatment. She could have a DXA scan to assess bone density and response to treatment. However, because Sarah had a previous vertebral fracture, she should be advised to continue alendronic acid for up to 10 years regardless.

4.    Sarah underwent a DXA scan at 5 years, which revealed a T-score of -2.8, indicating a continued need for treatment.

In conclusion, the management of osteoporosis and fragility fractures requires a comprehensive approach that addresses both the underlying causes and the patient's individual risk factors. We have discussed the importance of detection and diagnosis, the assessment of fracture risks, management strategies, and regular reviews.

Please keep in mind that this is only a summary and my interpretation of the guideline.

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye