1. Osteoporosis 9 th January 2013 Dr Julian Tomkinson

2. RCGP Curriculum 3.06 Women’s Health ‘ Be able to advise on prevention strategies relevant to women’ 3.20 Care of People with Musculoskeletal Problems ‘Awareness treatment of fragility fracture in osteoporosis’

3. NICE  Direct medical costs of fragility fractures to the UK healthcare economy estimated at £1.8 billion in 2000, with the potential to increase to £2.2 billion by 2025  Most of these costs relating to hip fracture care

4. QOF 2012  Producing a register of patients (a) aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; or (b) aged 75 years and over with a record of a fragility fracture after 1 April 2012  Ensuring that patients on the register who are aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, are treated with an appropriate bone-sparing agent  Ensuring that patients aged 75 years and over with a fragility fracture are treated with an appropriate bone-sparing agent.

5. Statistics  Approximately 14,000 people die per year from osteoporosis (greater than carcinoma of ovary, uterus and cervix put together)  Patients who sustain a vertebral fracture consult their GP, on average, 14 extra times in the year following it.  The mortality of hip fracture in older patients is 20% at three months

6. Osteoporosis (‘porous bones’) ‘a progressive systemic skeletal disease characterised by reduced bone mass/density and micro- architectural deterioration of bone tissue’

7. Osteoporotic (Fragility) Fracture Fractures that result from mechanical forces that would not ordinarily result in fracture (fracture caused by a force equivalent to the force of a fall from a standing height or less) Defined as fractures associated with low bone mineral density. Can affect spine, forearm, hip and shoulder fractures

8. Osteoporosis: hip BMD 2.5 SD or more below the young adult reference mean (T-score ≤-2.5) Severe osteoporosis: T-score ≤-2.5 PLUS fracture Low bone mass (osteopenia): T-score less than -1 but above -2.5 Normal: T-score ≥-1 Bone Mineral Density (BMD) WHO / IOF standards

9. Prevalence Prevalence of osteoporosis increases markedly with age (2% at 50 years to more than 25% at 80 years in women) NICE estimates there are 2 million women who have osteoporosis in England and Wales

10. Risk Factors for fragility fracture Age Low BMD Parental history of hip fracture. Alcohol intake of four or more units per day. Rheumatoid arthritis.

11. Risk factors for reduced BMD Female gender Corticosteroid therapy or Cushing's syndrome Ankylosing spondylitis Crohn's disease Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea Low body mass (<19 kg/m 2 ) and anorexia nervosa Poor diet (particularly if calcium- deficient) Malabsorption syndromes, eg coeliac disease. Post breast cancer treatment Prolonged immobilisation or a very sedentary lifestyle Smoking Primary hypogonadism (men and women) Primary hyperparathyroidism Hyperthyroidism Osteogenesis imperfecta Caucasian or Asian origin Post transplantation Chronic renal failure

12. Presentation Fracture – still need to be aware of and recognise fragility fractures Case finding

13.  If a fragility fracture occurs this should trigger bone density measurement (although in women aged ≥75 years osteoporosis can be assumed and first-line treatment initiated (alendronate) without (DEXA) scan if the clinician feels this is appropriate).  Patients with any risk factors above should be considered for DEXA scanning, particularly if there are one or more risk factors for fractures (family history, increased alcohol intake or rheumatoid arthritis).

14. Fracture risk calculators WHO risk calculator available (FRAX®) which calculates the ten-year probability of a major osteoporotic fracture For UK populations, the recent QFracture® score may be more appropriate for fracture risk assessment

15. Case study 66 year old lady presents concerned about the risk of her having osteoporosis: Mother of patient fell age 69 and fractured hip and died of complications of surgery (DVT and PE) Well lady with no significant past history documented Occasional backache Thinks may have lost 2cm in height. Drinks 2 large glasses of wine per day Calculated height 165cm weight 65kg = BMI 24.2

20. Diagnosis of osteoporosis centres on the assessment of BMD DEXA is regarded as the gold standard technique for diagnosis; the accuracy at the hip exceeds 90% Residual errors arise for various reasons Incorrect diagnosis of osteoporosis can be caused by osteomalacia, osteoarthritis or soft-tissue calcification

21. Referred for DEXA SCAN

22. Case continued  Scan shows T score -2.3 hip and -2.5 spine  Wedge fracture seen at T10

23. Other investigations  Consider the following screening blood tests, in patients suffering from osteoporosis, to identify treatable underlying causes:FBC and ESR,U&E, LFTs, TFTs, serum calcium, ALP  Testosterone/gonadotrophins in men.  Serum immunoglobulins and paraproteins, urinary Bence-Jones' proteins.

24. Management Treatment for osteoporosis should include not only drug treatment but also advice on:  Lifestyle  Nutrition  Exercise  measures to reduce falls  Ensure adequate calcium intake and vitamin D status, prescribing supplements if required.

25. Management Patients with osteoporosis (T-score -2.5 or worse) at any age:  Consider hip protectors and assessment of ongoing risk of falls.  Reduce polypharmacy, especially sedatives.  Ensure adequate calcium (0.5-1 g) and vitamin D (800 IU) - supplementation may be necessary.

26. Secondary prevention - T-score treatment threshold for second-line treatment in patients with previous fragility fracture [1]1 Age If T-score not available When alendronate not an option, treat with risedronate or etidronate at these values or worse [3] Risk factors = family history, alcohol >3 units/day or rheumatoid arthritis3 No fracture risk factors 1 fracture risk factor 2 fracture risk factors 50-54Refer for DEXA Not recommended -3.0-2.5 55-59Refer for DEXA-3.0 -2.5 60-64Refer for DEXA-3.0 -2.5 65-69Refer for DEXA-3.0-2.5 70-74Refer for DEXA-2.5 75 and over DEXA may not be required (see any local guidelines) -2.5

27. Primary prevention - T-score treatment threshold for second-line treatment in patients without previous fragility fracture [3]3 Age If T-score not available When alendronate not an option, treat with risedronate or etidronate at these values or worse [3] Risk factors = family history, alcohol >3 units/day or rheumatoid arthritisrisedronateetidronate3 No fracture risk factors 1 fracture risk factor 2 fracture risk factors 65-69Refer for DEXANot recommended-3.5-3.0 70-74Refer for DEXA-3.5-3.0-2.5 75 or older Refer for DEXA unless over 75 and 2 risk factors -3.0 -2.5

28. Calcium & Vitamin D Examples: Adcal-D3®, Adcal-D3® Dissolve Cacit D3® Calceos® Calcichew D3®, Calcichew D3 Forte® Calfovit D3® Kalcipos-D® Natecal D3® Sandocal®

29. Bisphosphonates Examples:  Alendronate  Risedronate  Etidronate  Ibandronate  Pamidronate  Zoledronate

30. Fracture class Women with existing vertebral fracture Women without vertebral fracture and T score <−2.5 Any radiologic vertebral 829 Any clinical1311 Any nonvertebral2112 Hip4666 Numbers Needed To Treat (NNT)

31. How to take bisphosphonates ‘You need to swallow the tablet with a full glass of water and sit upright for 30 minutes afterwards. This is because bisphosphonates can irritate your oesophagus’

32. Treatment holidays Stop after 3-5 years?

33. Safety Issues Osteonecrosis of the jaw  rare with oral bisphosphonates  good oral hygiene should be encouraged  Atypical femoral fractures

34. Safety Issues There may be a small increased risk in oesophageal cancer in individuals taking bisphosphonates (NNH 1000 over 5 years) (Importance of emphasising the correct way to take these tablets and encourage early reporting of adverse effects)

35. Safety Issues Calcium supplementation alone slightly increases the risk of non-fatal myocardial infarction but has no effect on stroke or mortality. This study is not applicable to combined calcium and vitamin D supplements.

36. Other Medications:  Strontium (dual action bone agent DABA)  Raloxifene (selective estrogen receptor modulator (SERM)  Teriparatide (recombinant PTH)  Denosumab (monoclonal antibody)

37. Possible other benefits Bisphosphonates may have anti-cancer properties, particularly reducing the incidence of post-menopausal breast cancer

38. Case 2

40. Frax calculation 10 year probability of fracture Major osteoporotic31% Hip Fracture18% Suggests refer for Dexa scan

41. Case 4  67 year old lady with hx of COPD sent by colleague for dexa scan. Never had fracture but had aches and pains and had several courses of steroids and antibiotics over winter and spring  Scan shows osteoporosis in neck of femur and in spine  Medication: salbutamol 2 puffs prn salmeterol 2 puffs bd, tiotropium one capsule inhaled daily. Citalopram 20mg daily.

42. Case 3  45 year old lady presents to surgery  No health issues, exercises 4 x per week, zumba and spin classes. Healthy diet, never smoked, minimal alcohol. Regular periods. No significant past medical problems.  Concerned as step mum recently suffered back pain and was found to have a compression fracture at T8. She has read about dexa scanning and has come to request one  BMI 22.9

43. References  http://www.shef.ac.uk/FRAX/ (FRAX) http://www.shef.ac.uk/FRAX/  http://www.qfracture.org/ (QFRACTURE) http://www.qfracture.org/  http://www.patient.co.uk/doctor/osteoporosis http://www.patient.co.uk/doctor/osteoporosis  http://www.sign.ac.uk/pdf/qrg71.pdf (SIGN GUIDE) http://www.sign.ac.uk/pdf/qrg71.pdf  http://www.nice.org.uk/guidance/ (NICE GUIDE) http://www.nice.org.uk/guidance/  http://www.nos.org.uk/ (Osteoporosis Society) http://www.nos.org.uk/  Fracture Risk Reduction with Alendronate in Women with Osteoporosis: The Fracture Intervention Trial http://jcem.endojournals.org/content/85/11/4118.full http://jcem.endojournals.org/content/85/11/4118.full