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Osteoporosis

Osteoporosis. Lucy Cowdrey 4 th November 2009. What is it?. 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. Why does it matter?.

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Osteoporosis

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  1. Osteoporosis Lucy Cowdrey 4th 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/FRAX • 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

  15. 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

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

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

  18. 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

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

  20. 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 #

  21. 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!

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