Consider effectiveness and tolerability when choosing therapy

Use the decision pathway for PBS-listed treatment selection for management of confirmed osteoporosis and corticosteroid-induced osteoporosis.1-10

Assess potential adverse effects against benefits when choosing between medicines.

Bisphosphonates and denosumab are generally safe and well tolerated; however, some rare adverse effects have been reported with long-term use.

Guidelines recommend ensuring adequate calcium and vitamin D levels before starting osteoporosis medicines in order to maximise their anti-fracture efficacy.1-2,9

Minimise risk of upper gastrointestinal adverse effects in patients taking bisphosphonates

Oral bisphosphonate use is associated with increased incidence of upper gastrointestinal (GI) adverse effects (eg, oesophagitis, gastritis) compared with placebo.1-2,11 Evidence for an association between bisphosphonate use and risk of oesophageal cancer is conflicting.3,9,12-13

To minimise the risk of upper GI adverse effects, advise patients to take oral bisphosphonates in the morning prior to fooda and to remain upright for at least 30 minutes afterwards.1

a Enteric-coated risedronate can be taken with or without food. 

Assess cardiovascular risks prior to starting strontium ranelate, raloxifene or calcium supplements

Cardiovascular adverse events have been associated with strontium ranelate (eg, myocardial infarction [MI] and venous thromboembolism [VTE]),14-15 raloxifene (eg, deep vein thrombosis [DVT], pulmonary embolism [PE], and stroke),16-17 and calcium supplements (eg, MI and stroke).18-19 Assess the risk of cardiovascular disease before and during therapy.9 Patients should be reviewed every 6 months.20

Due to safety concerns, the TGA issued a safety alert for strontium ranelate in 2014, restricting its use to patients unable to use other medicines for osteoporosis.20 In August 2016, strontium ranelate was delisted from the PBS.

Ensure patients maintain good dental hygiene while taking bisphosphonates

Osteonecrosis of the jaw (ONJ) is a rare complication of intravenous bisphosphonates, seen mostly in patients with bone metastatic malignancies.21-22 The risk of ONJ with oral bisphosphonates or denosumab tends to be much lower with the doses used for osteoporosis.3,9,23 Advise patients to maintain good dental hygiene and to stop bisphosphonate treatment if ONJ is confirmed.1-2

Stop bisphosphonate therapy if an atypical femoral fracture occurs

The absolute risk of atypical femoral fracture (AFF) with long-term use of bisphosphonates or denosumab is very low.24 The overall benefit in preventing hip fractures with bisphosphonates greatly outweighs the risk of AFF.3 Consider AFF if the patient develops pain in the thigh, hip or groin.9 If AFF is confirmed, stop bisphosphonate therapy and check for contralateral AFF.9

Monitor treatment response and review therapy to encourage adherence

Approximately 40% of people taking osteoporosis medicines do not meet levels of adherence needed to obtain full benefit from their treatment.25

Use BMD measurements to monitor treatment response

Therapeutic response can be monitored by measuring BMD at the lumbar spine and hip.1 Obtain BMD measurements 2 yearsb after commencing therapy or 1–2 years after therapy changes significantly.1

Guidelines recommend measuring BMD prior to starting long-term corticosteroids and at least once a year for the first few years of therapy, in patients taking prednisolone (≥ 5 mg/day) or equivalent.c,1

Review diagnosis and treatment regimen if BMD losses greater than 3%–5% per year are observed in a patient taking osteoporosis medicines.2

Evaluate medicine effectiveness and adherence, or investigate for underlying causes of osteoporosis if:

  • unexpected fractures occur (usually more than one fracture event)2
  • a decrease in height of more than 2–3 cm is documented since last examination2,26
  • the patient experiences acute back pain, which may be a symptom of a new fracture.2

b In cases of severe osteoporosis, BMD measurements can be obtained 1 year after commencing therapy.

c DXA is only MBS-subsidised for patients taking ≥ 7.5 mg/day prednisolone or equivalent for longer than 4 months and is restricted to 1 service only in a period of 12 consecutive months.

Manage modifiable risk factors to improve bone health

Modifiable risk factors should be addressed in all postmenopausal women and older men to reduce fracture risk (see Table 1).1-3,9


Table 1: Modifiable risk factors for osteoporosis
Lifestyle factor Recommendations
Calcium intake

Consider calcium supplementation if the recommended calcium intake cannot be achieved through diet:1-2,9,27

  • calcium citrate 2.38 g (elemental calcium 500 mg)
  • calcium carbonate 1.5 g (elemental calcium 600 mg).
Vitamin D levels

Advise patients who are vitamin D deficient (< 50 nmol/L) to take vitamin D supplements.1

Maintain serum 25-hydroxyvitamin D (25-OH D) levels at ≥ 50 nmol/L (at end of winter or early spring) for the general population or ≥ 75 nmol/L in people diagnosed with osteoporosis.1-2,9 

Exercise 
A combination of high-intensity, weight-bearing and muscle-strengthening exercise is recommended, aiming for 4–6 times per week for 30–40 minutes per session.1-2
Alcohol intake 
Encourage patients to reduce alcohol consumption to moderate levels; that is, ≤ 2 standard drinks per day.1-2
Smoking 
Encourage and advise patients to stop smoking.1-2 Refer to smoking cessation guidelines for Australian general practice for interventions and preventive health strategies.2,28
Risk of falls 
Reduce the risk of falls by recommending individualised fall reduction strategies: improving vision, patient education, medicines review, exercise programs focusing on strength and balance, assistive devices, treatment of postural hypotension and reduction in environmental hazards.1-2
Healthy weight and BMI 
Encourage patients to maintain a healthy weight and BMI (body mass index).1-2

GP-mediated patient resources for osteoporosis such as the Bone Health Action Plan can help encourage discussion about modifiable risk factors with patients being treated with osteoporosis medicines.

Date published:15 Oct 2015

Expert reviewers

  • Associate Professor Vasi Naganathan, Centre for Education and Research on Ageing, University of Sydney. Ageing and Alzheimer's Institute, Concord Hospital, Sydney, NSW.
  • Dr Simon Vanlint, General Practitioner and Clinical Senior Lecturer, University of Adelaide, Adelaide, SA.

References

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  2. Royal Australian College of General Practitioners. Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. Melbourne: RACGP, 2010. [Online] (accessed 30 April 2015).
  3. Scottish Intercollegiate Guidelines Network. Management of osteoporosis and the prevention of fragility fractures. A national clinical guideline. Edinburgh: SIGN, 2015.
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