Initial Pathway for DEXA Referral and Treatment for Fracture Risk Reduction in Postmenopausal Women and Men Age 50 or Above

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1 Initial Pathway for DEXA Referral and Treatment for Fracture Risk Reduction in Postmenopausal Women and Men Age 50 or Above 2 or > vertebral fractures Low trauma fracture In past 5 years Risk Factors (table1) Calculate Qfracture or FRAX 10 year risk (table 2) DEXA is not required to prescribe treatment for osteoporosis if multiple vertebral fractures, it is however useful when possible as a baseline DEXA Qfracture or FRAX 10 year fracture risk 10% or more T-score -2.5 or less No Treat as per treatment pyramid (tables 3 & 4) Yes Reassure

2 DEXA Referral Criteria for initial assessment Low trauma fracture in past 5 years - Peripheral or vertebral Current or planned oral corticosteroid use >3months and age 65 years or less (if age 65 or above treat with bisphosphonate for duration of steroid then stop no DEXA required). Qfracture 10 % or above - Measure Qfracture if risk factors for osteoporosis but no low trauma fracture or steroid use Key to when to refer for DEXA Table 1 Peripheral fractures - referred via fracture liaison service Vertebral fractures managing clinician to exclude myeloma or metastatic disease, refer for DEXA and prescribe bisphosphonate whilst result awaited. Refer for DEXA at time of starting steroid If steroid dose 30mg or above for greater than 4 week prescribe bisphosphonate at time of commencing steroid Opportunistic case finding UK Validated Fracture Risk Assessment Tools Qfracture SIGN risk calculator of choice to assess baseline risk in those without low trauma fracture. FRAX Underestimates risk when used without DEXA as a baseline. Can be used to reassess risk on treatment. Table 2 NB - FRAX and QFracture underestimate risk in high risk groups eg. previous vertebral or multiple fractures and is only required for DEXA referral in those who have not sustained a low trauma fracture in the last 5 years. Lateral Morphometry Views of the spine taken at time of DEXA to assess for presence of vertebral fractures. Useful for those not known previously to have had low trauma fracture as may tip risk as to requiring treatment. Lower radiation than spinal x-ray. Request DEXA plus morphometry if no fractures but height loss, kyphosis or back pain and no recent spinal x-rays. (Doubles scanning time therefore not performed in all)

3 Treatment Pyramid for Women Teriparatide 20mg subcutaneously per day for 2 years. Subcutaneous Denosumab 60mg every 6 months long term or Intravenous Zoledronic Acid 5mg infusion per year for 3 years. Oral Ibandronate 150mg per month, Oral Raloxifene 60mg per day. Oral Alendronic Acid 70mg or Risedronate 35mg per week, HRT postmenopausal woman < age 60 years. Table 3 Key to Treatment Pyramid 1 st line treatment 2 nd line treatment if intolerant or unable to take 1 st line Parenteral treatments refer osteoporosis clinic Hospital prescription only refer osteoporosis clinic

4 Treatment Pyramid for Men Teriparatide 20mg subcutaneously per day for 2 years Intravenous Zoledronic Acid 5mg infusion per year for 3 years Oral Ibandronate 150mg per month. Oral Alendronic Acid 70mg or Risedronate 35mg per week. Key to Treatment Pyramid Table 4 1 st line treatment 2 nd line treatment if intolerant or unable to take 1 st line Parenteral treatments refer osteoporosis clinic Hospital prescription only refer osteoporosis clinic

5 Calcium and Vitamin D Note All the pivotal studies of bisphosphonates co-prescribed calcium and vitamin D supplementation. Absorption reduces with age and frailty. The benefit of combined calcium and vitamin D supplements in patients receiving treatment for osteoporosis is likely to outweigh risk unless contraindication or dietary excess. Vitamin D deficiency may take longer to replete if bisphosphonates prescribed prior to correction. For those receiving treatment for Osteoporosis co-prescription of combined calcium and vitamin D supplements is required if older age, less active, house bound on high dose steroid on other drugs that reduce absorption such as anti-convulsants coeliac disease or other malabsorption syndromes biochemical deficiency or poor diet (correct deficiency prior to treatment with bisphosphonate with Stexerol D3 2 x 25,000 units per week for 6 weeks) if poor general health or uncertainty that diet satisfactory - assessment can be aided by use of calcium calculators such as Preparations recommended Theical D3 1 tablet per day Adcal D3 2 caplets twice a day 1 tablet twice a day Calfovit D3 1 sachet per day For those who are < age 75, fit and active without comorbidities with good dietary calcium but at risk of vitamin D deficiency recommend vitamin D3 without calcium Preparations recommended Stexerol D units per day or 25,000 units per month Valupak D units per day (available otc) Invita D3 25,000 units per month(1 ampule per month) This document is for guidance if additional advice is required contact anne.drever@nhs.net