Osteoporosis Definition Reduced bone density, which can be determined by a DXA scan Records a T-score, 0 being the mean average of healthy population Osteopenia is between -1 and -2.5 standard deviations from this mean Osteoporosis (OP) less than -2.5 Fragility fracture= Injury insufficient enough to break normal bone Primary Prevention= Detect patients at risk of OP, based on risks Secondary Prevention = Sustained a fragility fracture and found to have OP

Osteoporosis Statistics At 50y, 1 in 3 women and 1 in 5 men fracture in their remaining lifetime 50% of patients with an osteoporotic fracture will have another Secondary Prevention: 9-21 people need to be treated for 3y to prevent one spinal fracture (NNT) NNT to prevent one hip fracture over 3y is 48-91

Osteoporosis Primary Prevention FRAX tool helps decide which patients are offered a DXA scan Recommended in >50y and with standard risks factors (e.g. family history, alcohol excess, diabetes, rheumatoid, overactive thyroid etc.) Only assess risk in < 50y where significant risk factors (previous fragility fracture, menopause < 45y, kidney disease, oral steroid use, neurological disease including Parkinson’s, Multiple Sclerosis, Dementia, Stroke)

Osteoporosis Secondary Prevention >50y with a fragility fracture should be offered a DXA scan and receive treatment if OP confirmed (T score < - 2.5)

Osteoporosis Treatment Lifestyle Stop smoking, reduce alcohol, weight-bearing exercise, balance/stretches to reduce falls Supplements Calcium 750mg/day Vitamin D 400 units (prevention) 800 units (if deficient) e.g. use in osteopenia, repeat DXA every 3y   First line medication Oral bisphosphonate (alendronate or risedronate)

Osteoporosis Treatment Second line medication Intravenous (a “drip”) zoledronate or injection denosumab, if not tolerated or fracture on first line treatment Third line medication HRT, raloxifene Fourth line medication Strontium (but not in cardiovascular disease)

Osteoporosis Duration of Treatment Evaluate after 5y of use, limited evidence of further benefit. Bisphosphonates have a peak increase in bone density at 3y and can “stay” in the bone for up to 10 years. T-score not improved, continuing to fracture, still on oral steroids etc. then may use medication for 10 years

Osteoporosis Treating Without DXA Scan Option of treating without DXA scan in hip and spine fractures as the former carry a high risk of future fracture and the latter nearly always associated with OP   >75y with fragility fracture, acceptable to assume OP without a DXA scan

Osteoporosis Treatment Harms Bisphosphonates Gastric reflux (follow instructions) and yet omeprazole can make them less effective Oesophageal cancer, not proven Atypical thigh bone fracture, not proven Soften the jaw bone (osteonecrosis) rare but discuss with dentist Denosumab Watch calcium (drops) and kidney function on blood tests HRT Small risk blood clots, breast cancer, stroke

Osteoporosis Calcium Supplements Theoretical risk cardiovascular disease if too much calcium in diet (>1400mg/day) More pronounced risk if taking calcium alone, without vitamin D Increasing calcium in diet or with supplements did not show fracture prevention So, only supplement if a good indication

Any questions? Dr Guy Cunliffe – GP Partner from the Swan Medical Group