AHPA Report on Osteoporosis – Overview of the Latest Evidence

Dr. Heather McDonald-Blumer presented this AHPA pre-course on treatment of osteoporosis. When considering the patient with osteoporosis, we must think about who is at risk of fracture and who has already had a fracture. An osteoporosis fracture is considered a fragility fracture if it occurs at standing height with minimal trauma. Locations for these fractures include the wrist, vertebra, hip, humerus, pelvis and rib. Excluded areas are the skull, metatarsals, and metacarpals. There is debate over whether to include the ankle.

Osteoporotic fractures are associated with increased mortality, reduced independence (especially with hip fractures), pain, postural changes and increased risk of future fractures. After wrist fracture, 14% will have a repeat fracture within 3 years. After hip fracture, 33% will re-fracture within 1 year and 50% will suffer another fracture within 5 years.

Vertebral fractures are important to consider for fall risk and fracture risk. Two thirds of all vertebral compression fractures do not cause pain. For fall risk, consider the height, vision, gait, quadriceps strength, and balance of the patient. For fracture risk, look at loss of height, kyphosis, percussion tenderness, rib to iliac crest distance and occiput to wall distance.

CAROC and FRAX scores both provide a 10-year fracture risk for a patient.

Pearls for the management of osteoporosis include:

• Avoid being too skinny, alcohol, caffeine, and smoking

• Use fall avoidance strategies such as hip protectors

• Prescribe weight bearing exercise

• Educate on calcium and vitamin D

  • Calcium 1200 mg/day, diet servings preferred e.g. 3 servings of dairy per day)

  • Vitamin D 800-2000 units per day, target blood level should be >75 mmol/L

• Bisphosphonates such as Fosamax, Actonel and Aclasta work well in men and women who are at moderate/high risk but should not be used in people who are unable to follow dosing protocols or who have esophageal disease, renal dysfunction, hypocalcemia, low vitamin D levels

• Denosumab (Prolia) is given as an injection every 6 months, and is used in idiopathic osteoporosis; it may be used in breast and prostate cancer as well as in chronic kidney disease

• Evista may only be used in women

• Calcitonin is no longer on the market

• Teriparatide promotes bone building for severely low BMD or recurrent fractures despite conventional treatment, but should not be used if there are risks of bone metastases

Osteoporosis medications may be stopped if they are no longer needed, there is an inadequate response, they are contraindicated (esophageal or kidney disease), there is bone pain, osteonecrosis of the jaw, atrial fibrillation or atypical femoral fractures.

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