Bone health in focus

The Irish Osteoporosis Society held its 2024 Annual Medical Conference recently, featuring a varied range of presentations from expert speakers and updates in many key areas of bone health. Priscilla Lynch reports

The Irish Osteoporosis Society (IOS) 2024 Annual Medical Conference for health professionals was held virtually on Saturday 19 October. The well-attended conference featured a varied range of presentations from expert speakers on topical issues relating to osteoporosis.

 Prof Moira O’Brien, President of the Society, expressed her delight that attendees gained valuable updates across multiple areas of bone health, helping to deepen their awareness of the importance of osteoporosis prevention, early detection, and evidence-based treatment.

She also highlighted the importance of clinicians thoroughly investigating the underlying causes of bone loss in patients, rather than attributing it solely to factors like menopause or chemotherapy. She added that stress is a significant risk factor.

“Very high stress levels, for example, affect the hormones and can cause bone loss.”

Denosumab

Dr Kevin McCarroll, Consultant Physician and Geriatrician, Bone Health Unit, St James’s Hospital, Dublin, gave a detailed presentation on the use of denosumab in osteoporosis. Denosumab is a human monoclonal antibody for the treatment of bone loss in severe osteoporosis, which is administered via injection every six months. It has been shown to be very effective and safe for long-term use (10 years plus).

There is evidence that denosumab discontinuation causes rapid bone loss within one year and increases the risk of multiple vertebral fractures, particularly among those with existing vertebral fractures. Reports indicate that vertebral fractures after denosumab discontinuation can occur as early as six months after the last injection.

Dr McCarroll said it is key that patients and healthcare providers schedule the six-monthly injections and have a recall system in place to make sure that denosumab is not missed. While there is increasing awareness of the risk of rebound bone loss and vertebral fractures on stopping denosumab, not all GPs or patients are aware of this, he noted.

“Bisphosphonates are the only osteoporosis therapy compatible with a ‘drug holiday’, and drug holidays need to be monitored closely. Osteoporosis is a chronic condition,” Dr McCarroll emphasised.

Therefore, it is vital that osteoporosis patients and primary care practitioners are made aware that “denosumab is not a suitable therapy for a drug holiday” and “it should not be stopped unless there is a good reason”.

A careful plan is required to manage withdrawal (for example, the need for two or maybe three zoledronic acid infusions).

“Make sure fracture risk is low if stopping; ideally T-score ≥-2.0, and no recent fractures.” He added that if a patient experiences a vertebral fracture while on denosumab, it does not mean treatment failure: “Do not switch therapies.”

In such cases, he advised attendees to consider adding teriparatide.

Concluding, Dr McCarroll reported that a new agent, romosozumab, which is a dual action anabolic and antiresorptive, is on the way and could also be used with denosumab.

Exercise

A guide to treating patients with vertebral fractures was the title of a presentation by Ms Ciara Shields, a Chartered Physiotherapist and a Clinical Specialist in Musculoskeletal Physiotherapy at IONA Physiotherapy in Drumcondra, Dublin. Ms Shields noted that vertebral fractures are frequently missed and remain undiagnosed (only 30 per cent being detected), causing considerable pain and loss of function in patients. Sacral fractures of the lower back are even more underdiagnosed, she told the meeting.

Ms Shields advised against prolonged bed rest in patients recovering from such fractures and outlined how she treats these patients with balance and strength exercises. She cautioned against certain yoga poses due to fracture risk and stressed the need for a multidisciplinary approach to managing patients’ pain.

Diet concerns

Ms Orla Walsh, Registered Dietitian, spoke about the importance of ensuring adequate calcium intake in the diet alongside vitamin D to help protect against osteoporosis.

She said that three portions of dairy a day are recommended for adults and up to five in older adults. Ms Walsh added that magnesium and vitamin K are also important.

Ms Walsh noted that plant-based dairy alternatives are not nutritionally similar to dairy products and may lack fortification and people need to be more aware of this.

She also discussed lactose intolerance, which she said is rarer than people think, with a huge variation in severity of symptoms and ability to tolerate lactose.

“People with issues have greater tolerance for lactose if consumed in mixed meals.” She added that many dairy products, such as most cheeses, do not contain lactose.

Ms Walsh said a body mass index (BMI) of under 21 is another risk factor. She also noted alcohol, caffeine, and smoking are other important risk factors for poor bone health, while exercise, sleep, and reducing stress are important protective factors.

Patient perspective

This year’s patient perspective was delivered by Ms Annette Costello, who was diagnosed with a progressive non-treatable neurological condition in 2006 and now uses a wheelchair.

She shared her challenging personal experience of trying to find a radiology department in Dublin that could provide a hoist transfer from her electric wheelchair to a DXA scanner. It took significant efforts to do so, with her original GP referral in early October 2023, only finally leading to a DXA scan in June 2024.

Her story highlighted the inadequate provision of these services despite there being a statutory obligation to prevent discrimination based on disability.

“There is a clear need to make DXA scanning more convenient and fully accessible for wheelchair users including those of us living with muscle wasting conditions,” she said.

Bone health and the menopause

Dr Sinead Hussey, Clinical Lead for Women’s Health in Centric Health, Raheny, Dublin, spoke about bone health through the menopause, and the usage of various osteoporosis therapies. Women have roughly twice the lifetime risk of an osteoporotic fracture when compared to men. Bone loss is accelerated during perimenopause and menopause as oestrogen levels decrease. One-in-two women older than 50 years will sustain an osteoporotic-related fracture in their lifetimes.

Dr Hussey pointed to the high prevalence of osteopaenia and undiagnosed fractures in older women. This highlighted the need to be more vigilant with this patient population in assessing their osteoporosis risk factors, carrying out tests and DXA scans, and adequately treating them to prevent fractures, according to her presentation.

Key risk factors for osteoporosis in menopausal women include prior fracture without major trauma after age 50 years, being aged >65 years, having a low BMI <21, a family history of osteoporotic fracture, early menopause, having a medical disease or condition associated with bone loss, excessive alcohol consumption (>three units per day), smoking, long-term glucocorticoid therapy, secondary osteoporosis, and height loss from kyphosis.

Dr Hussey also discussed the use of hormone replacement therapy (HRT) in helping prevent osteoporosis in post-menopausal women. She quoted Irish College of GPs, British Menopause Society, and North American Menopause Society guidance and data in this area.

HRT may be required for women who have an early menopause below the age of 45 years, as well as where there has been surgical removal of ovaries, chemotherapy, hormone therapy and radiotherapy. Certain risk factors may trigger osteoporosis in this population, which include unhealthy lifestyle habits, family history, chromosomal abnormalities, and certain autoimmune conditions.

Vitamin D deficiency

Also speaking during the conference, Prof Bernard Walsh, Director of the Mercer’s Unit at St James’s Hospital, Dublin, and Trinity College Dublin, addressed the issue of vitamin D deficiency in a comprehensive presentation. He noted that vitamin D insufficiency (<50nmol/l) and deficiency (<30nmol/l) remain high in Ireland. Prof Walsh added it is also a significant issue in hot countries due to inadequate sunlight exposure.

He cited a number of studies on the role of vitamin D deficiency in muscle weakness and increased falls risk and how supplementation can address this issue. Prof Walsh said that consideration should be given to national public health strategies to mandate for food fortification to address this widespread deficiency. “Without this, vitamin D deficiency and insufficiency will remain widespread worldwide.”

Other speakers

Ms Anne Power, Advanced Nurse Practitioner in Chronic Disease Management, Wexford Residential Intellectual Disability Service, discussed alternative bone health screening for people with an intellectual disability. She noted that while DXA scans remain the gold standard, for some patients, including those with intellectual disabilities, they can be unsuitable or difficult to use. She advocated the use of Echolight, a non-invasive portable diagnostic and monitoring device, which does not produce ionising radiation and is easy to use.

Ms Aoife Ní Eochaidh, Chartered Physiotherapist, Clinical Specialist Physiotherapist, Women’s and Men’s Health and Continence, Bon Secours Consultants Clinic, Galway, spoke about pelvic organ prolapse and urinary incontinence.

There were also a number of oral research presentations during the conference.