Osteoporosis

Overview

See the CKS guidelines on Osteoporosis (1) which provides useful information on management in primary care and advice on when to refer.

See the following pages for further advice:

• BNSSG formulary - for advice on bisphosphonates.
• When to start Osteoporosis Treatment 2023
• BNSSG Osteoporosis Clinic Referral Guidance - for advice on indications for referral from local rheumatologists and the APMOC team (Dec 2023)
• Osteoporosis drug holidays - latest BNSSG advice.

• Referral for DEXA scanning can be sent via ICE.  Details can be found under Rheumatology on the BNSSG Service Guide.  Only patients who are NICE compliant will be accepted. 

• Fracture Liaison Service - details are available in the Care of the Elderly section of Remedy.
• Osteoporotic Vertebral Fracture - advice on how to refer for vertebroplasty in patients with recent vertebral fracture.

Before Referral

Management in Primary Care

Most patients with osteoporosis can be managed in primary care using lifestyle advice and oral bisphosphonates. Vitamin D supplements (with calcium if indicated) should be given with bisphosphonates - see CKS managment of osteoporosis  

Please also see the BNSSG Formulary for further details on medication.

The BNSSG Osteoporosis Clinic Referral Guidance gives advice on indications for referral developed by local rheumatologists and the APMOC team (Dec 2023).

Advice and Guidance

Waiting times for outpatient clinics may be long. Clinicians are advised to consider requesting advice and guidance prior to referral. See options below:

• Rheumatology - advice and guidance via eRS- available at NBT, UHB and Weston
• Bone Health and Osteoporosis for Older People (BHOOP) - advice and guidance via eRS - available at NBT for older patients (>75)

Investigations prior to Referral

If referral to a secondary care service is required then please ensure that the following bloods have been done prior to referral. This will help the clinic provide the most appropriate advice on the patients first visit. If these results are not available then this can lead to avoidable additional clinic appointments and delays to treatment:

• FBC
• U and E
• Calcium
• Vitamin D - please start treatment for vitamin D deficiency if this is indicated.
• HbA1c
• LFT
• TFT

Referral

Referrals for secondary care Osteoporosis clinics can be made to:

NBT 

• Rheumatology osteoporosis clinic via eRS for patients <75 or not clinically frail
• Bone Health and Osteoporosis for Older People (BHOOP) via eRS (Geriatric medicine) for patients >75 or clinically frail, for patients with a recent hip fracture, to consider second line or injectable treatments, complex treatment decisions. Clinics available at Southmead and Cossham Hospital
• (Please note that advice and guidance for Rheumatology and BHOOP via eRS is also available).

UHBW Bristol 

• Rheumatology osteoporosis clinic via eRS (RAS service) for patients <75
• Bone Health for Older People (BHOP) via eRS (geriatric medicine - metabolic bone disease). This clinic is particularly suitable for patients >=75 or if a patient has a history of hip of other fragility fracture and there is a contraindication to the use of oral bisphosphonates or difficulty with concordance and a second line injectable therapy could be useful. 
• (Please note that advice and guidance for Rheumatology via eRS is also available).

UHBW Weston

• General Rheumatology via eRS. Please note that WGH also offer Bone Health for Older People via the General Rheumatology service. 
• (Please note that advice and guidance for Rheumatology via eRS is also available).

If referring a North Somerset patient to Bristol please confirm they are willing to travel. The same services are available at WGH.

Pregnancy associated osteoporosis

Pregnancy-associated osteoporosis (PAO) is a rare condition where bones break easily, around the time a woman gives birth. It most commonly affects bones in the spine, or occasionally in the hip.

These broken bones usually happen during the birth or in the next 8 to 12 weeks – and usually  affect a woman's first pregnancy (2).

The condition should be especially considered in women presenting with new onset back pain in pregnancy or the postpartum period (3).

Management

Appropriate acute management of any suspected fracture.

Check osteoporosis bloods as above and correction of vitamin D or calcium deficiency. 

Give lifestyle advice on diet and exercise to reduce osteoporosis risk.

Follow up should be by referrral to osteoporosis clinic via eRS as above to discuss appropriate management (such as bisphosphonates) to reduce risk of fractures and give advice about future pregnancies. 

A patient information leaflet is available on the Royal Osteoporosis Society website.

(2) Pregnancy associated osteoporosis (PAO) (theros.org.uk)

(3) Pregnancy-associated osteoporosis: a UK case series and literature review - PubMed (nih.gov)

Resources

(1) Osteoporosis - prevention of fragility fractures | Health topics A to Z | CKS | NICE

Romosozumab

Romosozumab is a RED drug which can be prescribed in Secondary Care. Regional Guidelines are used to carry out Cardiovascular Risk Assessment before prescribing Romosozumab. If the patient’s risk is found to be raised and they are not on adequate pharmacological management of hypertension and/or cholesterol they will be asked to contact their GP to discuss this. The advice is to target systolic BP <130 mmHg and LDL-Cholesterol <2.6 mmol/L or non-HDL-Cholesterol <3.4 mmol/L.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.