The video version of this podcast can be found here:

·      https://youtu.be/tdY5bOFmzbg

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

This video refers to the clinical guideline by the National Osteoporosis Guideline Group. (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only. The information is based on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is below.

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

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

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

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE clinical guideline on osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/cg146

The Clinical guideline for the prevention and treatment of osteoporosis by the National Osteoporosis Guideline Group can be found here:

·      https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2024.pdf?v3

The NICE technology appraisal on Bisphosphonates for treating osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/ta464

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to review the treatment of osteoporosis, always focusing on what is relevant in Primary Care only.

I have based this episode on the clinical guideline by the National Osteoporosis Guideline Group. The link to it is the episode description.

Right, let’s jump into it.

We will start by saying that we need a strategy to decide who gets treated, which is what we call “intervention thresholds.”

We need to remember that the NICE guideline on assessing the risk of fragility fracture and Osteoporosis does not itself define fixed treatment thresholds. Instead, we are advised to follow local or national guidance when deciding when to treat. So, for the purpose of this video, I will explain the thresholds given by the National Osteoporosis Guideline Group.

Here the intervention threshold (for people under 70) is set at a fracture risk equivalent to a same-age woman who has already had a fracture. As people age, the threshold for treatment rises, so at the age 70 years and above, fixed thresholds are applied.

When FRAX is calculated we can get a result that shows low risk, intermediate risk, high risk and very high risk of a Major Osteoporotic Fracture.

If the fracture risk is low, we will offer lifestyle advice.

If a person’s calculated risk sits near that intervention threshold, then that is intermediate risk and we should consider a bone mineral density (BMD) measurement with DXA to refine the estimate. If after the bone mineral density result the risk is high, we move forward with treatment otherwise, we will reassess later.

If the fracture risk meets or exceeds the intervention threshold, that person is considered high risk and eligible for treatment.

If the risk is very high, for example if they have multiple risk factors — we may consider referral for more aggressive treatment.

Let’s now focus on the non-drug measures recommended for preventing and managing osteoporosis. They should be recommended for everyone, whether or not we eventually use drugs.

First — diet and nutrition, ensuring adequate calcium intake. Ideally this is achieved through food, but if needed, we can use supplements to reach recommended levels.

We should also make sure vitamin D is addressed. For people at risk of low vitamin D — for example, those with limited sun exposure, people who are housebound, or living in care homes — we should offer vitamin D supplementation.

Next —We should encourage regular weight-bearing and muscle-strengthening exercise, tailored to each person’s ability. This supports bone strength, maintains muscle mass, and helps prevent falls.

Speaking of falls — for those with osteoporosis or fragility fractures, or at risk of fracture, we must assess their fall risk. For patients identified as at risk of falling, we should offer an exercise programme to improve balance and muscle strength.

We must also address lifestyle factors. We should advise smoking cessation in smokers and recommend moderation of alcohol intake.

For all patients we should also screen for and manage other medical conditions that may contribute to bone fragility, such as endocrine problems, malabsorption, chronic illness or immobility.

Now let’s move on to the pharmacological treatment options for osteoporosis, based on the National Osteoporosis Guideline Group recommendations, and the NICE Technology Appraisal on Bisphosphonates for treating osteoporosis

There are several effective drug treatments available, but for most patients, bisphosphonates remain the first-line option. These include oral alendronic acid, risedronate and ibandronate, as well as intravenous zoledronic acid and ibandronate if recommended by a specialist.

How do bisphosphonates work?

Bisphosphonates slow down the rate of bone breakdown by inhibiting osteoclast activity. This helps stabilise bone density and reduces the risk of fractures.

What about risks and how do we minimise them?

Common side effects include gastrointestinal irritation with oral bisphosphonates, and muscle or joint aches. Much rarer risks include atypical femoral fractures and osteonecrosis of the jaw. To minimise these, we ensure correct administration: oral tablets should be taken with a full glass of water on an empty stomach, with the patient remaining upright for at least 30 minutes. We also maintain good dental hygiene, have a dental check-up and complete major dental work before starting treatment where possible, and reassess the need for long-term therapy at appropriate intervals.

Alongside bisphosphonates, denosumab is another established anti-resorptive option. If we use denosumab, we must plan from the start how we will eventually stop or switch treatment, because stopping it abruptly without follow-up therapy can lead to rebound bone loss and an increased risk of vertebral fractures.

For patients at the highest fracture risk, we should seek specialist input. These patients may benefit from anabolic, or bone-forming treatments such as romosozumab, or other anabolic or sequential regimens.

Now let’s look at how we manage osteoporosis treatment over time, that is, the long-term strategy.

First: when we start a drug treatment for osteoporosis — for example a bisphosphonate or denosumab — we need a clear plan for how long that treatment should continue, how we’ll monitor it, and when we’ll reassess risk.

For oral bisphosphonates, we generally treat for at least five years and for intravenous bisphosphonates, at least three years.

In patients at higher risk — for instance people over 70, or those who’ve had hip or vertebral fractures, or patients on high-dose steroids — longer treatment might be needed. Also, if they sustain a further fragility fracture while on treatment, we will also keep going.

In lower-risk patients, after five years of oral bisphosphonates (or three years of IV bisphosphonates), we may consider a treatment pause for 18 to 36 months, depending on individual risk.

Second: we must reassess fracture risk periodically. This means that we should repeat the fracture risk assessment if the patient has a new fracture, regardless of when the treatment started.

If we paused treatment, we should re-assess the fracture risk after 18 months to 3 years — depending on individual circumstances.

Third: some situations require special consideration.

• In people starting long-term glucocorticoids (for example ≥ 7.5 mg prednisolone daily for 3 months or more), we should begin bone-protective therapy immediately — we don’t wait for a DXA scan.
• For patients receiving hormone therapy that impacts bone — for instance androgen-deprivation therapy in men or aromatase inhibitors in women — we should manage fracture risk proactively, often also with bone-protection from the start.

And finally, fourth: after a fragility fracture or in people at high or very high fracture risk, treatment should start promptly, because the risk of re-fracture is often greatest soon after the first event.

So that is it, a review of the treatment of osteoporosis.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.