UHN/MSH Medical Consult Service
- We see many patients on the consult service who have been admitted with a hip
fracture or other low trauma fracture.
- The presence of a low trauma fracture in the elderly strongly suggests the diagnosis
of osteoporosis, although malignancy and metabolic causes need to be ruled out.
- Once these are ruled out, osteoporosis can be diagnosed and treatment started
irrespective of the bone mineral density.
- A low trauma fracture increases the risk of a future fracture by 1.5-9.5%. Those with
a hip fracture have an especially high rate of a second hip fracture (above 20%).
- There are effective treatments for secondary prevention of fractures in this high-risk
population. Even though we are usually consulted for a different reason, it is
important that the osteoporosis be addressed.
- History to look for any medications that may contribute to bone loss – Steroids,
heparin, antiseizure medication, androgen and estrogen deprivation therapies,
more recent evidence for PPIs, SSRIs, rosiglitazone
- Screening labs to rule out secondary causes of bone loss: Calcium, creatinine,
ALP (although this is often high after fractures), liver enzymes, TSH, serum
protein electrophoresis. PTH and vitamin D levels are useful in specific situations.
- Pathologic fracture secondary to malignancy must be ruled out – this requires
- Start elemental calcium 500 mg daily, increased to two or three times a day as
tolerated, or less depending on dairy intake.
- Start Vitamin D 1000 IU per day.
- Consider oral bisphosphonate therapy
- Alendronate 70 mg per week and Risedronate 35 mg per week have strong
evidence for reduction in vertebral and nonvertebral fracture risk.
- Cautions – risk of esophagitits and GI intolerance, so they must be taken on
an empty stomach, in the upright position with a large glass of water, 1 hour
prior to taking food or medications.
- This is difficult to achieve in hospital, so it is often necessary to start
bisphosphonates in rehab or at home. There is a printable form of the
consults website that you can give to patients so they can follow up with their
- If a patient is ambulatory and willing, a bone density study should be done as a
baseline, and so it can be followed to assess response to treatment. In less mobile
patients with a hip fracture, bisphosphonates can be used even if a bone density
study can not be done
- Patients can also be referred to the UHN osteoporosis program, 416-340-3890.
- There is recent evidence that IV zoledronic acid (Aclasta) 5 mg given once a
year, as compared to placebo, is similarly effective to oral bishosphonates in
reducing fractures, and in patients who have had a hip fracture it has been shown
to reduce mortality. It is not yet widely available to treat osteoporosis, but when it
is it will be a useful option for treating osteoporosis.
Osteoporosis management in the orthopedic patient
By: Lianne Tile
- Lyles KW, et al: Zoledronic Acid and Clinical Fractures and Mortality after Hip
Fractures. NEJM Nov 2007. 357;18: 1799-1809