Osteoporosis - Standard Treatment Guidelines

Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines Osteoporosis. Following are the major recommendations :

Case Definition:

Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density that is 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by DXA; the term "established osteoporosis" includes the presence of a fragility fracture. The disease may be classified as primary type 1, primary type 2, or secondary. The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis or senile osteoporosis occurs after age 75 and is seen in both females and males at a ratio of 2:1. Finally, secondary osteoporosis may arise at any age and affects men and women equally. This form of osteoporosis results from chronic predisposing medical problems or disease.

Incidence of Condition In Our Country

The exact incidence of osteoporosis in India is not known .However ,according to one study,approximately 6-7 crores of Indian population is suffering from osteopenia / osteoporosis.

Differential Diagnosis

Differential diagnosis of Osteoporosis include

1.Multiple myeloma

2. Osteomalacia

3. Chronic kidney disease

4. Primary hyperparathyroidism

5. Metastatic bone malignancy

6. Vertebral deformities

Prevention And Counselling

a. Risk factors for Osteoporosis includes following

1. Prior fragility fracture


2. Female gender


3. White ancestry


4. Old age


5. Low BMI


6. Loss of height


7. Sec amenorrhoea


8. Primary hypogonadism


9. Smoking


10. Excessive alcohol use


11. Prolonged immobilizatioin


12. Low calcium intake


13. Vit D defficiency


14. Glucocorticoid excess


15. Corticosteroid use


16. Hyperthyroidism


17. Heparin use


18. Anticonvulsant use


19. Weight loss

b. Prevention Change in life style, diet, exercise. Amongst the various risk factors for osteoporosis modifiable risk factors can be modified to prevent development of osteoporosis. Medications to prevent development of osteoporosis.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

SITUATION 1: At Secondary Hospital / Non Metro situation : Optimal standards of Treatment in situations where technology and resources are limited

Clinical diagnosis:

Osteoporosis itself doesn’t have any symptom.

Symptoms develop once the fragility fracture occurs. Symptoms develop according to the site of fracture. Pain may or may not be there due to osteoporotic fracture. Vertebral compression fracture at times may present with neural symptoms.

Investigations:

1. Plain X-ray of spine


2. Dual energy X ray absorptiometry (DXA) BMD


3. Renal function test


4. Calcium


5. Albumin


6. Phosphorus


7. Urinary calcium level

Standard Operating Procedure

In Patient

Surgery

• Vertebroplasty


• Open surgical spinal stabilization

Out Patient

supplementation and bracing

1.Pain control

• Bed rest


• Analgesics


• Brace

2. Antiresorptive agents

• Bisphosphonates


• Estrogen analogs


• Raloxifen


• Calcitonin

3. Bone anabolic agent

• Teriparatide


• Calcium salts


• Sodium fluoride

4. Nutrition

• Calcium


• Vitamin D


• Vitamin K

5. Exercise

• Aerobics


• Weight bearing


• Resistance exercise

6. Orthosis

• Spinal orthoses

7. Long term Osteoporosis prophylaxis

Day Care: Injectable medication

Referral criteria:

SITUATION 2: At Super Specialty facility in Metro Location where higher end technology is available

Clinical diagnosis:

Osteoporosis itself doesn’t have any symptom.

Symptoms develop once the fragility fracture occurs. Symptoms develop according to the site of fracture. Pain may or may not be there due to osteoporotic fracture. Vertebral compression fracture at times may present with neural symptoms.

Investigations:

1. Plain X-ray of spine


2. Dual energy X ray absorptiometry (DXA) BMD


3. Renal function test


4. Calcium


5. Albumin


6. Phosphorus


7. Urinary calcium level


8. QCT (quantitative computer tomography)


9. Quantitative Ultrasound


10. Biochemical markers of bone resorption (increased urinary excretion of C- telopeptides)


11. Vit D level


12. Testosterone level


13. Urinary free cortisol


14. Serum protein electrophoresis

Standard Operating Procedure

In Patient

Surgery

• Vertebroplasty


• Open surgical spinal stabilization


• Vertebroplasty


• Kyphoplasty

Out Patient

supplementation and bracing

1.Pain control

• Bed rest


• Analgesics


• Brace

2. Antiresorptive agents

• Bisphosphonates


• Estrogen analogs


• Raloxifen


• Calcitonin

3. Bone anabolic agent

• Teriparatide


• Calcium salts


• Sodium fluoride

4. Nutrition

• Calcium


• Vitamin D


• Vitamin K

5. Exercise

• Aerobics


• Weight bearing


• Resistance exercise

6. Orthosis

• Spinal orthoses

7. Long term Osteoporosis prophylaxis

8. Other agents

• RANKL inhibitors


• Strontium ranelate

Day Care: Injectable medication

WHO DOES WHAT? AND TIMELINES

Doctor

Early diagnosis and appropriate treatment. Counsel the patient for prevention and dietary advice.

Nurse

Counselling the patient

Technician

Appropriate bracing manufacturing and application of braces Physiotherapy

Resources Required For One Patient / Procedure (Patient Weight 60 Kgs)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi