Osteoporosis Dr Heinrich Van Wyk GP Registrar 27 October 2007

YOUR AGENDA

Introduction/ My Agenda Definition, T’s & Z’s Diagnosis and Risk Assessment Treatment/ Fracture prevention Monitoring Referral

Definitions Disease characterised by –Low bone mass –Micro architectural deterioration –Consequent increased fragility and fracture risk WHO defines by –T-score Z-score ?????

Definitions T-scores –Normal –Osteopenia –Osteoporosis –Established osteoporosis Z-scores –>-1 SD – -1SD to -2.5SD – < -2.5 SD fragility – < one or more fragility fracture –As for T’s but SD for same age population

So What is a Fragility fracture???? Result of –Force –Not ordinarily cause fracture i.e. –Force equivalent to standing height or lower

Diagnosis DEXA Scanner –Dual Energy X-ray Absorptiometry Dual Energy –70 kVp (Al filter) alt 140 kVp (Cu Filter) or –80 kVp with no then cerium or samarium filter X-ray = Pencil beam Absorptiometry –Scintilation counter –Output to computer + magic = RESULT

Risk Assessment Risk factors for osteoporosis Risk factors for fragility fractures Risk factors for falls Secondary causes

Group Work

Risk factors for osteoporosis Strongest –female –> 60 y/o –FH Diagnosis Kyphosis Low trauma # > 50y Other significant –Caucasian/ Asian –BMI < 19 kg/m² –2° Amenorrhoea >1y –Smoking –Low Calcium diet –Low Vit D (sun) –Sedentary/ low mob –Height loss/ kyphosis –Radiol Osteopenia/ vertebral collapse –Corticosteroids

Risk factors for fragility fractures Osteoporosis Falls Previous fragility fracture Key risk factors for hip # –Previous # <50 y old –Maternal hip fracture –Current smoker –Low BMI

Risk factors for falls Tendency to fall increase with age Risk factors –History of falls –Gait problems –Balance problems –Mobility impairment –Fear –Visual impairment –Cognitive impairment –Urinary incontinence –Home hazards Risk increase as number of risk factors increase

Secondary causes Endocrine –Poorly controlled thyrotoxicosis – ♂ hypogonadism –1° hyperparathyroidism Malabs/ nutritional –Inflam bowel disease –Chronic liver disease –Coeliac –Anorexia –Vit D deficiency Drugs –Phenytoin –Phenobarb –Over Rx with Thyroxine –Corticosteroids (!) DMPA Others –RA –Myeloma –Renal disease

Questions so far

Treatment/ Fracture Prevention Prevention of fracture –Primary –Secondary –Glucocorticoid induced Treatment –Lifestyle advice –Assess and manage falls risk –Drugs (Primary vs Secondary) 1 st line 2 nd line Men

Lifestyle Intervention Diet –Calcium 700mg- 1000mg daily 1 pint milk + 60g hard cheese or 1 pot yoghurt or 60g sardines –Vit D 400IU daily >65y (only achievable by supplement) 4oz cooked salmon or mackeral or 6oz tuna (canned in oil) or 3 oz sardines (canned in oil) Exercise –Tailored to individual –Low impact weight bearing Walking High intensity strength targeting hip, spine, wrist muscles –Balance/ gait training if high risk of falls Smoking cessation Alcohol –Avoid excessive –Evidence scanty Sun –15-20 min twice a week April to October

Risk of Falls Who –Present for medical attention because of a fall –Report recurrent falls in the past year –Demonstrate abnormalities of gait/ balance. How –Skill and experience –Usually specialist setting –Multifactorial –individualised

Drugs: Primary Prevention T-score RCP/ BTAS recommendations –>-1.0 reassure –-1.0 to -2.5 lifestyle advice –<-2.5 Consider drug treatment

Drugs: Primary Prevention Oral Bisphosphonates –Alendronate/ etidronate/ risedronate –Less frequent dosing better compliance Raloxifene –Selective estrogen receptor modulator HRT –See BNF for latest licensed HRT –Risk/ benefit complex –Not first line

Drugs: Secondary Prevention Age ≥ 75y –Treat without DEXA 65-74y –DEXA scan –Treat if T <-2.5 –Delay to DEXA likely: treat immediately until results available <65y –DEXA –Treat if T≤ -3.0 or T< -2.5 with additional risk factors

Drugs: Secondary Prevention Oral bisphosphonates –Alendronate –Etidronate –Ibandronate –Risedronate Alternatives if CI or not tolerating –Raloxifene –Strontium –IV ibandronate –PTH (teriparatide) Secondary care Intolerance/ unsatisfactory response to bisphos AND –Extremely low BMD or –Low BMD + > 2 fractures + other risk factors Calcium Vit D adjunct

Drugs: Glucocorticoid induced prevention Exposure ≥ 3months at any dose ≥ 65y and/ or previous fracture –Treat < 65y –DEXA (unless delay then Rx immediately) T >0 –Reassure T<-1.5 –Treat ONLY Bisphosphonates are licensed

Calcium and Vitamin D Monotherapy –Elderly women in nursing homes only Adjunct therapy –Recommended by NICE with all Rx –UNLESS confident adequate dietary intake Vit D replete –Dose depends on diet Ca 600mg – 1.2 g Vit D IU

Men Consider referring all men –Not necessary if clear risk factors all screening tests available in primary care Exclude 2° causes Assess falls risk Lifestyle advice Treatment best initiated following specialist advice

Drugs: Men Little evidence on Rx in men Alendronate 10mg OD –only licensed drug –70mg once weekly similar efficacy but unlicensed Other bisphosphonates –None licensed –Expert opinion Risedronate reasonable alternative Vit D and Calcium as for women

Monitoring How long to treat –Likely indefinitely –Little evidence on stopping and fracture risk or BMD Monitoring –1 st after 3 moths then 6 monthly Height Medicine compliance SE’s check –Further falls assessment Previous fracture –Repeat DEXA or refer If further fracture occur after 12m fully compliant Rx

Refer Diagnostic difficulty Intolerance/ CI to oral Rx Acute painful vertebral fracture Secondary osteoporosis req further Ix Potential use of PTH

YOUR AGENDA MY AGENDA

References/ Comprehensive guidance CKS –Osteoporosis- Treatment (and prevention of fragility fractures) NICE –Technology appraisal 87 e-Guidelines –Consensus guideline on the management of osteoporosis in post-menopausal women –Guidelines for the prevention and management of glucocorticoid induced osteoporosis RCP BTAS