1. Update on Osteoporosis Dr Terence O’Neill Consultant Rheumatologist

2. 3 million people have osteoporosis in the UK. 80 000 hip / 50 000 wrist / 120 000 vertebra £1.7 billion per annum. Clinical / Public Health Impact

3. Risk of Future Fracture Klotzbuecher, 2000

4. 2001 Census

5. Projected Rise in Hip Fractures UK European Commission, 1998

6. Reduction in vertebral fractures Clodronate 0 0.2 0.3 0.4 0.5 0.6 0.7 Alendronate Ibandronate Risedronate Strontium Relative risk ALNCLODIBANRISSR 0.5

7. Risk Factor Case Finding Strategy +

8. Risk Factors Indications for BMD Low trauma # Steroids (oral) > 7.5mg /day – 3 mths Hypogonadism menopause < 45 yrs 2 nd amenorrhoea Radiologic osteopenia Comorbid diseases hyper PTH coeliac disease

9. Medical management of men and women aged 45+ years who have or are at risk of osteoporosis Frail, increased fall risk +/- housebound Risk factorsPrevious fragility fracture Investigations Measure BMD [DXA, hip +/- spine] NORMAL T score above -1 OSTEOPENIA T score –1 to –2.5 OSTEOPOROSIS T score below –2.5 Reassure Lifestyle advice Treat if previous fracture Lifestyle advice Offer treatment* Calcium + Vitamin D Falls risk: Assessment/advice and Consider hip protectors RCP, 1999

10. Limitations Bone Mineral Density Focus on T Score Out of Date

11. Risk Assessment Age Gender Prior Fracture (after age 50 years) Parental history of fracture Current Smoking Alcohol intake > 2 units / day Ever Corticosteroid use Secondary causes (e.g. RA)

12. T Score

13. http://www.shef.ac.uk/NOGG/

15. NOGG – November 2008 New Risk Assessment Tool ‘FRAX’ - Web Based No More T Scores !– 10 year fracture risk Thresholds for Treatment (web / tables) Advice on which treatment

16. http://www.shef.ac.uk/FRAX/ http://www.shef.ac.uk/NOGG OR

22. BMD 60yr70yr 80yr No. Risk Factors Women with No Prior #

25. NOGG - Treatment Alendronate If unable to take / intolerant Risedronate / Ibandronate / Strontium Raloxifene / Etidronate

26. What about NICE? After gestation of 6 years new technology appraisals published late 2008 TA160 : Primary prevention TA 161 : Secondary prevention

28. NICE 161– Secondary Prevention Alendronate (ALN) treatment of choice in post-menopausal women if T-score < – 2.5 Unable to take ALN – Risedronate (RIS) or etidronate (ETD) Unable to take RIS /ETD – Strontium / Raloxifene

32. * Age < 65 years + independent clinical risk factor for fracture + clinical risk of low BMD + T-score of < – 2.5 NICE 160– Primary Prevention * Age 65-69 yrs + independent clinical risk factor for fracture + T-score of < – 2.5

34. * Age 75 +yrs + 2 or more risk factors – no need for BMD NICE 160– Primary Prevention * Age 70+ yrs + independent clinical risk factor for fracture OR clinical risk of low BMD + T- score of < – 2.5

35. NICE 160/161 Difficult to use – copy of guidance to hand Restrictive : only few risk factors Unfair ALN first line therapy – Using NOGG many patients will be NICE compliant

36. Summary Osteoporosis is major health problem Effective therapies are available Challenge is targeting treatment – at risk NOGG / FRAX new approach to assessment of risk Use of NOGG should help target treatment to individuals at risk