Osteoporosis9th January 2013

Dr Julian Tomkinson

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’

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

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.

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

Osteoporosis (‘porous bones’)

‘a progressive systemic skeletal disease characterised by reduced bone mass/density and micro-architectural deterioration of bone tissue’

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

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

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

Risk Factors for fragility fracture

• Age

• Low BMD

• Parental history of hip fracture.

• Alcohol intake of four or more units per day.

• Rheumatoid arthritis.

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/m2) 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 hyperparathyroidismHyperthyroidism

Osteogenesis imperfecta

Caucasian or Asian origin

Post transplantation

Chronic renal failure

Presentation

• Fracture – still need to be aware of and recognise fragility fractures

• Case finding

Case finding 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).

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

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

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

Referred for DEXA SCAN

Case continued

Scan shows T score -2.3 hip and -2.5 spine

Wedge fracture seen at T10

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.

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.

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.

Secondary prevention - T-score treatment threshold for second-line treatment in patients with previous fragility fracture[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 arthritis

    No fracture risk factors

1 fracture risk factor

2 fracture risk factors

50-54 Refer for DEXA Not recommended -3.0 -2.5

55-59 Refer for DEXA -3.0 -3.0 -2.5

60-64 Refer for DEXA -3.0 -3.0 -2.5

65-69 Refer for DEXA -3.0 -2.5 -2.5

70-74 Refer for DEXA -2.5 -2.5 -2.5

75 and over

DEXA may not be required

(see any local guidelines)

-2.5 -2.5 -2.5

Primary prevention - T-score treatment threshold for second-line treatment in patients without previous fragility fracture[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 arthritis

    No fracture risk factors

1 fracture risk factor

2 fracture risk factors

65-69 Refer for DEXA Not recommended -3.5 -3.0

70-74 Refer for DEXA -3.5 -3.0 -2.5

75 or older

Refer for DEXA unless over 75

and 2 risk factors

-3.0 -3.0 -2.5

Calcium & Vitamin D

Examples:

Adcal-D3®, Adcal-D3® DissolveCacit D3®Calceos®Calcichew D3®, Calcichew D3 Forte®Calfovit D3®Kalcipos-D®Natecal D3®Sandocal®

BisphosphonatesExamples:AlendronateRisedronateEtidronateIbandronatePamidronateZoledronate

Fracture classWomen with

existing vertebral fracture

Women without vertebral fracture and T score <−2.5

Any radiologic vertebral 8 29

Any clinical 13 11

Any nonvertebral 21 12

Hip 46 66

Numbers Needed To Treat (NNT)

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’

Treatment holidays

Stop after 3-5 years?

Safety Issues

Osteonecrosis of the jaw

rare with oral bisphosphonates good oral hygiene should be

encouraged

Atypical femoral fractures

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)

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.

Other Medications:

Strontium (dual action bone agent DABA)

Raloxifene (selective estrogen receptor modulator (SERM)

Teriparatide (recombinant PTH)

Denosumab (monoclonal antibody)

Possible other benefits

Bisphosphonates may have anti-cancer properties, particularly reducing the incidence

of post-menopausal breast cancer

1. Letter comes into docman:

Mrs Nora Olivia Fletcher age 77 Admitted: Orthopaedics via A&E Diagnosis: Sub-capital fracture of left hip Treatment: Thompson’s hemi-arthroplasty left hip Complications: Developed pneumonia post operatively.

Treated with IV antibiotics and improved

Discharge: To intermediate care Medication: Bisoprolol 2.5mg daily Aspirin 75mg daily Atrorvastatin 10mg daily Ramipril 5mg daily Prednisolone 7.5 mg daily Nitrolingual spray as needed

Case 2

Previous history from notes: Problems Polymyalgia rheumatic 2013 Angina 2006 Cholecystectomy 2000 Current medication Bisoprolol 2.5mg daily Aspirin 75mg daily Atrorvastatin 10mg daily Ramipril 5mg daily Prednisolone 7.5 mg daily Nitrolingual spray as needed Allergies Penicillin – severe rash Other Weight 60kg Height 165cm BMI 22.0 Ex-smoker – cigarettes stopped 2006 Alcohol 24 units per week 2006

Frax calculation

Frax calculation

 10 year probability of fracture

Major osteoporotic 31%

Hip Fracture 18%

Suggests refer for Dexa scan

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.

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

References

http://www.shef.ac.uk/FRAX/ (FRAX)

http://www.qfracture.org/ (QFRACTURE)

http://www.patient.co.uk/doctor/osteoporosis

http://www.sign.ac.uk/pdf/qrg71.pdf (SIGN GUIDE)

http://www.nice.org.uk/guidance/ (NICE GUIDE)

http://www.nos.org.uk/ (Osteoporosis Society)

Fracture Risk Reduction with Alendronate in Women with Osteoporosis: The Fracture Intervention Trial http://jcem.endojournals.org/content/85/11/4118.full