1. OSTEOPOROSIS Dr Annie Cooper Consultant Rheumatologist Royal Hampshire County Hospital Winchester

2. Plan Normal bone What is osteoporosis? Who gets it? How common is it? How do we diagnose it? How do we monitor it? What can we do to prevent it?

3. Building bone consolidation growth aging

4. Normal development

5. Determinants of bone health Genetic – 70% Age Sex hormones status Vitamin D Weight bearing exercise

6. What is osteoporosis? Osteoporotic boneNormal young bone Progressive loss of bone Affects all of the skeleton Causes thin, fragile bones which break easily

7. Commonest bones broken due to osteoporosis Wrist

8. Commonest bones broken due to osteoporosis Backbone

9. Commonest bones broken due to osteoporosis Hip

10. Number of Fractures Cooper & Melton, 1992

11. 400 500 560 175 360 600 160 375 4260 hip fractures ~12,800 non-hip fragility fractures Current local status: fractures figures 2009

12. 180,000 osteoporosis-related fractures 2 million bed days Social and hospital care costs £1.8 billion Fractures associated with increasing mortality Hip: relative mortality rate 4.4 Vertebrae: relative mortality rate 2 to 12 1 in 3 women over 50 will sustain a vertebral fracture Demographic time bomb - aging population Why bother? Annual figures - England & Wales, 2008

13. Who Gets It? everyone over the age of 35! women after the menopause those with certain medical conditions those taking certain medicines

14. Who is at risk? previous low trauma (fragility) fracture –up to 20% ↑in fracture rate after 1 year menopause <45 / oestrogen deficiency prednisolone for 3 months or more FH, especially parental hip fracture smoker, low BMI (<22kg/m 2 ) height loss 2” since age 25 >3 units alcohol/day secondary causes of osteoporosis rheumatoid arthritis, ankylosing spondylitis

15. How Common is it? 1 in 3 women 1 in 5 men

16. Bone Measureme nt Dual-energy X-ray Absorptiometry (DXA) T score -1 to -2.5 = osteopenia <-2.5 = osteoporosis <-2.5 + # = severe osteoporosis

17. Fracture Risk - age related bone quality 10 year probability of fracture (%) T -score Kanis JA et al, Osteoporosis Int 2001: 12:989-995

18. FRAX™ Tool for assessing 10 year risk of fracture Easy, quick & simple Available on internet –www.sheffield.ac.uk/FRAX – Google / App Aims to identify those where DXA useful Linked to NOGG

19. FRAX™ www.shef.ac.uk/FRAX Easy, quick & simple Identifies those who need further assessment

20. NOGG National Osteoporosis Group Guidance 2008

21. How do we monitor it? Check height Repeat DXA scan ON THE SAME MACHINE –generally after 2 years Special urine tests (research)

22. Who to treat & with what? Maintaining bone health –maximise peak bone mass –‘sensible’ lifestyle no smoking healthy diet moderate alcohol intake regular weight bearing exercise Treat those at risk of fracture –previous fracture (cf TIA) –current steroids –think FRAX™!

23. What can we do to help ourselves? Regular weight bearing exercise Vitamin D (sunshine vitamin!) Balanced diet Not just calcium & vitamin D! Essential Protein Iron, magnesium Trace minerals Vitamins e.g. B12

24. Give up/moderate…. Smoking Excess alcohol Unhealthy lifestyle

25. Beware Falls Degree of trauma? Reaction to the fall? A specialist, multidisciplinary falls service Public health strategies Exercise , diet , smoking  Community strategies E.g pavements, adequate lighting etc Individual prevention Identifying those at high risk

26. Treatment Vitamin D 800 IU/day Normal dietary calcium (800-1000 mg/day) Drug treatments: 50% ↓ risk of new fractures Bisphosphonates PTH Strontium ranelate Denosumab SERM’s (HRT)

27. Treatment Treatments Vitamin D 800 IU/day Normal dietary calcium (800-1000 mg/day) Supplements poorly tolerated Replace when needed.... Too much may not be good for you!

28. Summary Raise awareness of osteoporosis –previous fracture –steroids –(2” height loss since age 25) Refer for DXA Treat when necessary –Most treatments reduces fracture risk by 50%