1. Osteoporosis Lucy Cowdrey 4 th November 2009

2. What is it?

3. Diagnosis “Osteoporosis is a loss of bone density sufficient to cause an increased risk of fracture” – GP Notebook Diagnosed when: -2.5 SD or below on DEXA scan Can be assumed in women over 75 years

4. Why does it matter? 180,000 osteoporosis-related fractures / yr in England and Wales 70,000 hip fractures 25,000 vertebral fractures 41,000 wrist fractures Osteoporotic fractures cost NHS £1.7 billion annually Personal cost 50% after hip # unable to live independently 20% die within 6 months

5. Who gets it? Strongest risk factors? Age Female sex Family history

6. Other risk factors Caucasian Early menopause Low BMI Smoking & probably alcohol Sedentary lifestyle >3/12 corticosteroid use ?Depo-provera

7. Associated conditions Anorexia Chronic liver disease Chronic kidney disease Coeliac disease Hyperparathyroidism IBD Rheumatoid arthritis

8. Should we test for it?

9. When to test : (National Osteoporosis Guideline Group 2008)

10. FRAX calculator Assesses 10 year risk of # www.shef.ac.uk/FR AXwww.shef.ac.uk/FR AX National Osteoporosis society also recommend testing if receiving steroids for >3/12

11. General advice? Stop smoking Adequate calcium intake Exercise

12. Should we prescribe calcium / vitamin D? Dietary calcium is as effective as pharmacologically-derived Intake of 1000mg Ca / day leads to 24% reduction hip # No evidence that Vit D required in active people <65 years >65 – need intake of 10µg (400IU) / day Some uncertainty Evidence for dose-dependent relationship Always consider prescribing in housebound individuals NICE – supplementation should be considered in women who may be deficient

13. Here comes the science…

14. Specific dietary advice? 3-4 portions of the following = 1000mg calcium 200ml milk 1 pot yoghurt 30g hard cheese 200g portion macaroni cheese 60g sardines 170g cheese & tomato pizza 4 slices white bread 1 bowl calcium-rich cereal with milk

16. When should we use bisphosphonates? NICE (Oct 2008) Alendronate is first line Use risedronate or etidronate if intolerant 70+ women With independent risk factor With indicator for low BMD With confirmed osteoporosis 65-69 women With independent risk factor AND confirmed osteoporosis Postmenopausal women <65 With independent risk factor AND indicator for low BMD AND confirmed osteoporosis

17. Independent clinical risk factors (NICE) Parental history of hip fracture Alcohol intake of 4+ units / day Rheumatoid arthritis

18. Indicators of low BMD (NICE) BMI <22 Ankylosing spondylitis Crohns disease Prolonged immobility Untreated menopause

19. Other drugs in primary prevention Main SE bisphosphonates is oesophageal reactions CI: achalasia, oesophageal stricture Strontium an alternative if intolerant Raloxifene (SERM) not a treatment option for primary prevention

20. Secondary prevention NICE (2008) Alendronate 1 st line Risedronate or etidronate if intolerant 2 nd line – strontium or raloxifene 3 rd line - teripatide

21. Summary Consider Ca / Vit D in housebound patients or if poor dietary intake Consider DEXA scan depending on 10yr risk Consider bisphosphonates if risk factors or indicators for low BMD Check if elderly patients have been discharged on bisphosphonates following #

22. References! Primary Prevention Ostoporosis (TA160) NICE October 2008 Secondary prevention (TA161) NICE October 2008 National Osteoporosis Guideline Group 2008 – Guideline for diagnosis and management osteoporosis Management of Osteoporosis (71) SIGN 2003 Prevention of Nonvertebral Fractures With Oral Vitamin D and Dose Dependency (Arch Int Med) Mar 2009 GPnotebook!