Osteoporosis

IMPORTANT INFORMATION FOR OSTEOPOROSIS PATIENTS

Date of Advice June 19th 2023

New Patients

It is likely that the reason for your GP referral to our Osteoporosis service is to consider an injectable treatment (such as zoledronic acid or denosumab) to protect your bones. Unfortunately, our ability to provide these treatments remains slightly delayed compared to pre-pandemic waiting times. Consequently, some patients are at the risk of not being on any bone protection for a period of time.

Therefore, we would ask you to contact your GP for advice on alternative treatments in the meantime. This is particularly important if you have already tried a tablet treatment such as alendronic acid (alendronate), and this did not agree with you.

The Royal Osteoporosis Society provides a lot of information which you may find helpful https://theros.org.uk/

Some alternative medications for you and your GP to consider:

If intolerant to alendronic acid tablets (mainly digestive symptoms), please consider:

Soluble version of alendronate (Binosto)-men and women
Weekly Risedronate(35mg)-men and women
Monthly Ibandronate(150mg)-women only
Consider adding gastric protection (eg omeprazole or ranitidine)

If there is a contraindication to, or intolerance of oral bisphosphonates, please consider:

HRT: in young postmenopausal women with low thrombotic risk, particularly if menopausal symptoms present. Avoid if history of any gynaecological malignancy (suspected or confirmed).

NOGG 2021 guidance is an excellent resource and covers all of the commonly asked questions regarding osteoporosis assessment and management https://www.nogg.org.uk/full-guideline

Referrals for a bone mineral density test (DXA)

Our DXA service is running as normal again. Given the ongoing backlog due to the pandemic and recent staffing issues, waiting times will be slightly longer than usual.

Please refer via ICE. Ideally a repeat DXA should be carried out on the same DXA machine as the patient's previous test. It is very helpful to us if you can specify where their previous DXA was carried out (it is important to note that we have two DXA machines at Bristol Royal Infirmary - one in the Radiology department and the other in the Rheumatology department. As a result there are two ways to request a DXA via ICE; through Radiology and through referrals - Rheumatology adult DXA referral).

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1 in 2 women and 1 in 5 men over the age of 50 will break a bone. 3 million people in the UK are estimated to have osteoporosis. This condition can also rarely affect children.

The osteoporosis service at University Hospitals Bristol provides a specialised service for osteoporosis and rarer metabolic bone disorders and aims to help clinicians identify those people most at risk of low impact fractures (broken bones) and then manage them appropriately with a combination of education, physical therapy and drugs.

Our multidisciplinary team is led by Dr Matt Roy, consultant rheumatologist. The team is supported by an osteoporosis specialist nurse (Mr Ronu Roy), a rheumatology registrar, DXA technicians, therapies team and clinic co-ordinators.

We have access to a full set of laboratory services including serum bone turnover markers. We have a Hologic Horizon A DXA scanner which is able to perform a vertebral fracture assessment (VFA). There is a Hologic Discovery A DXA scanner in our Radiology department.

What we offer

Patients at relatively high risk of fragility fracture can be referred for a DXA scan by their GP. This can be done via an ICE referral. The reports are all written or checked by a consultant and provide clinical advice for the referrer.

More complex patients, or those that have not tolerated oral therapies, may be referred for an outpatient assessment. According to need, some of these patients may be suitable for the "one-stop" osteoporosis clinic where a clinician will review the patient with the results of a scan carried out immediately beforehand, in the department. To refer a patient to the osteoporosis clinic, please send a written referral via the eRS system.

Regional advice is also available if there are any queries regarding drug holidays and duration of treatment. This information can be found on the Remedy BNSSG osteoporosis webpage remedy pathway (bnssgccg.nhs.uk)

Parenteral therapies

Although initial drug treatment is usually oral medication, sometimes this is unsuitable and alternatives are required. These may include:

Zoledronic acid: Patients receive this intravenous bisphosphonate therapy on our specialised day case unit. This particular medication is usually given on a 12 - 18 month basis. To find out more about this treatment, click here:

Osteoporosis treatments: zoledronic acid (theros.org.uk)

Denosumab: This is given by six-monthly subcutaneous injections for patients at high risk of fracture. The first injection is given in our department, with further doses administered in general practice. Click here for shared care guidance:

Royal Osteoporosis Society | Denosumab (theros.org.uk)

Teriparatide: This anabolic drug is administered as a daily subcutaneous injection over a two year period. It is available for patients at high risk of fracture who fulfil NICE criteria https://www.nice.org.uk/guidance/TA161/chapter/1-Guidance

Romosozumab:This is a new injectable treatment available for post-menopausal women at high risk of fracture and who have already had a recent fracture (within last 24 months). This is given as a sub-cutaneous injection once monthly for 12 months.

Osteoporosis treatment: Romosozumab (theros.org.uk)

Patient Education

The team provides a patient education program for patients with osteoporosis, or at increased risk of fracture, who want to learn more about the condition. This is led by our osteoporosis nurse specialist Ronu Roy, senior physiotherapist and occupational therapist and is run over a 6-week period covering all aspects of the condition including exercise. The aim of the sessions is to provide people with the information and tools to help them manage their condition effectively. Patients will also have the chance to meet other people with the same condition and share their experiences.

Bone Health for Older People (BHOP) Service

The BHOP service is a partnership between the care of the elderly team and the rheumatology unit. The aim is to significantly reduce the risk of patients with fragile bones who have had a low trauma fracture having another.

The Fracture Liaison Service (FLS) is led by Dr Emma-Kate Reed and Dr Rachel Bradley, both consultant geriatricians, supported by two specialist FLS nurses. Together they run a Bone Health for Older People (BHOP) clinic focusing on frail older patients who have osteoporosis and are at high risk of falling.

Childhood Osteoporosis

Dr Christine Burren is a paediatric endocrinologist with a special interest in osteoporosis in childhood. She leads a regional service for patients with complex or severe osteogenesis imperfecta (OI). In addition, Dr Burren takes consultant to consultant referrals for children with, or suspected to have osteoporosis. Dr Burren is based at Bristol Royal Hospital for Children, Paul O'Gorman Building, Upper Maudlin St, Bristol, BS2 8BJ.

The rheumatology unit carries out scans in children which are reported by Dr Burren. Patients that have attended the regional OI service transition to be followed up in the adult osteoporosis clinic with Dr Matt Roy.

How to access our services

We accept local and regional referrals from both primary and secondary care for adults considered to be at increased fracture risk.

GPs, consultants or specialist healthcare professionals may refer patients to the osteoporosis clinic (suitable for complex cases, or for patients who are at high fracture risk and unable to tolerate first line oral therapies - a scan will not normally be carried out within 2 years of any prior measurement) via an eRS referral.

GPs wishing to arrange a DXA scan for their patients can do so through the ICE referral system. The scan will then be triaged to be performed either in the Radiology or Rheumatology department DXA scanner. This will be partly dependent on whether or not the patient has had a previous scan with us before.

If a patient is >75 and they are not known to our Rheumatology service, we would recommend referral to the Bone Health for Older People (BHOP) Service at Bristol Royal Infirmary.

Useful links

Remedy BNSSG osteoporosis guidance remedy pathway (bnssgccg.nhs.uk)

Fracture Risk Assessment Tool (FRAX) https://www.shef.ac.uk/FRAX/tool.jsp

The Royal Osteoporosis Society https://theros.org.uk/

Calcium calculator https://www.osteoporosis.foundation/educational-hub/topic/calcium-calculator

Healthtalk online http://www.healthtalk.org/peoples-experiences/bones-joints/osteoporosis/topics

NHS UK https://www.nhs.uk/conditions/osteoporosis/

NICE guidance assessing the risk of fragility fracture https://www.nice.org.uk/guidance/cg146

Patient information on medication related osteonecrosis of the jaw (MRONJ) https://www.sdcep.org.uk/media/hefd1mjp/sdcep-mronj-information-for-osteoporosis-patients.pdf