Treatment and management of osteoporosis

Diagnosing osteoporosis

Diagnosis of osteoporosis requires an assessment of bone mineral density (BMD). The most commonly used technique is a specialised X-ray known as a 'Dual energy X-ray Absorptiometry (DXA) scan' to determine bone mineral density (BMD) in the hips and spine (IOF 2017). Scan results are expressed as T-scores which compare a person's BMD with the average of young healthy adults (Table 1).

Table 1: Diagnosing osteoporosis using bone density testing

 

Normal

Osteopenia

Osteoporosis

T-Score

1 to –1

–1 to –2.5

–2.5 or lower

Source: WHO Study Group 1994.

Preventing and managing osteoporosis

Osteoporosis is largely a preventable disease. The goal of the prevention and treatment of osteoporosis is to maintain bone density and reduce a person’s overall fracture risk (RACGP 2018).

Quality of life can be severely compromised for people with osteoporosis, particularly if they fall and sustain a fracture. Wrist and forearm fractures may affect the ability to write, type, prepare meals, perform personal care tasks and manage household chores. Fractures of the spine and hip can affect mobility, making activities such as walking, bending, lifting, pulling or pushing difficult. Hip fractures, in particular, often lead to a marked loss of independence and reduced wellbeing.

Primary prevention of osteoporosis involves supplementing diet to get sufficient calcium and vitamin D, and behaviour modification such as regular weight-bearing and resistance exercise, keeping alcohol intake low and not smoking, and fall reduction strategies (RACGP 2018).

There is a diverse range of medicines available for osteoporosis management, so treatment selection is guided by a number of factors including sex, “menopausal status, medical history, whether it is for primary or secondary fracture prevention, patient preference and eligibility for government subsidy” (Bell et al. 2012).

Oral and intravenous bisphosphonates, and subcutaneous denosumab injections are among the recommended first-line pharmacological therapy for both males and females with osteoporosis (RACGP 2018). These medicines “slow bone loss, improve bone mineral density and reduce fracture rates” (RACGP 2018). Bone building drugs, such as daily teriparatide (RACGP 2018) and monthly romosozumab injections, are reserved as second-line treatments when first-line treatments fail.   

Hospitalisation for osteoporosis

People with osteoporosis can be hospitalised for a range of reasons, including minimal trauma fractures. These fractures can occur from a minor bump, fall from a standing height or an event that would not normally result in a fracture if the bone was healthy.

Minimal trauma fractures generate substantial costs to the community, including with direct costs in terms of hospital treatment. Data from the National Hospital Morbidity Database (NHMD) show that in 2017–18 there were 6,838 hospitalisations with a principal diagnosis of osteoporosis for people aged 50 and over. The hospitalisation rate for people with osteoporosis was greatest for people aged 85 and over (Figure 1). Among individuals 50 years and above, the hospitalisation rate was higher in females than in males (122 compared with 41 per 100,000 persons in 2017-18).

Figure 1: Rate of hospitalisation for osteoporosis, people aged 50 and over, by age and sex, 2017–18

The vertical bar chart shows that in 2017–18, the age-adjusted hospitalisation rate (per 100,000 population) for the principal diagnosis of osteoporosis was greater for females than males. The hospitalisation rate increased with age and was highest in people aged 85 and over for both males (180) and females (463). Hospitalisation rates were lowest in people aged 50–54 (11 for males, 17 for females).

Source: AIHW National Hospital Morbidity Database (Data table).

Minimal trauma fractures

Minimal trauma fractures may be the result of osteoporosis, which is commonly undiagnosed prior to a fracture. A range of other factors, such as high bone turnover, low body weight and a tendency to fall, also increase minimal trauma fracture risk. As osteoporosis is not common before the age of 50, minimal trauma fractures occurring in people age 50 or over are more likely to be a result of osteoporosis.

In 2017–18:

  • there were 93,321 hospitalisations for minimal trauma fractures in people aged 50 and over
  • the hospitalisation rate for minimal trauma fractures in people aged 50 and over was higher in females (1,576 per 100,000 people) than in males (650 per 100,000).
  • of all hospitalisations for minimal trauma fractures for people aged 50 and over, 34% were for people aged 85 and over
  • the most common fracture sites were the hip (32%), the forearm (13%) and lumbar spine and pelvis (13%) (Figure 2).

Figure 2: Hospitalisations following minimal trauma by fracture site, people aged 50 and over, 2017–18

Figure 2 shows that hip fractures were the most common site for a minimal trauma fracture in hospitals (29,541 hospitalisations), followed by other sites (19,064 hospitalisations), lumbar spine and pelvis (12,332 hospitalisations), forearm (11,726 hospitalisations), lower leg including ankle (10,348 hospitalisations), and shoulder and upper arm (10,310 hospitalisations).

Source: AIHW National Hospital Morbidity Database (Data table).

Minimal trauma hip fractures

Minimal trauma hip fracture is one of the most serious and debilitating outcomes of osteoporosis (Ip et al. 2010). In 2015–16, there were an estimated 18,700 new hip fractures among Australians aged ≥45 years—a crude (age-specific) rate of 199 fractures per 100,000 population (AIHW). Treatment of this type of fracture invariably requires hospitalisation, may require surgery, and may be a source of ongoing pain and disability. These fractures are a considerable burden to individuals, the community and the Australian health system due to their high cost (Watts et al. 2013).

In 2017–18:

  • there were 29,541 hospitalisations for minimal trauma hip fracture among people aged 50 and over
  • the rate of hospitalisation for minimal trauma hip fracture among people age 50 and over was more than twice as high for females (480 per 100,000 people) compared with males (226 per 100,000) (Figure 3)
  • hospitalisation rates for minimal trauma hip fracture were highest in those aged 85 and older (2,566 per 100,000 people, compared with 16 per 100,000 people aged 50–54).

Figure 3: Rate of hospitalisations for minimal trauma hip fractures, people aged 50 and over, 2017–18

The vertical bar chart shows the age-adjusted hospitalisation rates (per 100,000 population) for minimal trauma hip fracture increased with age and were highest among people aged 85 and over for both males (1,902) and females (2,973).

Source: AIHW National Hospital Morbidity Database (Data table).