The RACGP guideline has been updated in the areas of risk assessment, therapeutic options and supplementation recommendations.
Early diagnosis of osteoporosis and fracture prevention have been highlighted as the priorities in the updated 2024 Royal Australian College of General Practitioners and Healthy Bones Australia guideline.
Widespread screening is still not recommended but clinical risk factor assessments should be conducted for postmenopausal women and men over the age of 50 who have had a fracture from minimal trauma or who have one or more major risk factor for minimal trauma fracture.
There is an increased risk of refracture within 24 months of a fracture, and it’s a crucial period for the assessment of bone health and intervention.
To help prevent subsequent fractures and recognise patients at high risk of their first fracture, the guidelines are now encouraging the use of absolute fracture risk assessment tools, such as FRAX.
When the FRAX risk for major osteoporotic fracture is 10% or greater, the patient should be referred for DXA bone density testing.
Early osteoanabolic therapy should be considered for patients with imminent or very high fracture risk. For those with a vertebral or hip fracture with no history of significant trauma, a presumptive diagnosis of osteoporosis can be made to prompt early intervention.
Strontium ranelate has been removed as a therapeutic option due to excess cardiovascular mortality.
Romosozumab, a sclerostin inhibitor, has been added as it leads to a marked increase in bone mineral density. However, the TGA issued an alert to avoid its use in individuals with previous myocardial infarction or stroke, due to one trial showing a small increase in cardiovascular events.
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“As always, its use requires discussion with the individual patient regarding risk and benefit, especially as the same ageing population at risk of poor bone health is also at increased risk of adverse cardiovascular events,” the authors noted.
Oral supplements have been recommended only for those with deficiencies.
The guidelines acknowledge that there is good evidence that calcium and vitamin D supplementation are beneficial for maintaining long term bone health and muscle function, but state that supplementation will likely only reduce fracture risk when given in combination to patients who are deficient.
Calcium supplementation may lead to increased risk of renal calculi, constipation and bloating. The target daily intake rises from 1000mg to 1300mg for women aged over 50 and men aged over 70.
If oral vitamin D supplementation is required, a daily 800-1000IU dose is usually sufficient.
The guidelines also suggest a daily protein intake of 1-1.2g/kg body weight should be recommended to frail, institutionalised individuals, especially those receiving bone‐protective therapy. The authors cite a Melbourne study which showed an 11% reduction in falls risk, a 48% reduction in hip fractures, and a 30% reduction in all fractures from improving dietary calcium and protein intake in institutionalised older adults.
