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OSTEOPOROSIS An update

OSTEOPOROSIS An update. May 2012. Osteoporosis. Df : A progressive systemic skeletal disorder characterised by a low bone mass and micro-architectural deterioration of bone. T score of < -2.5 when measuring bone mineral density on DEXA scan (Dual –energy x-ray absorptiometry)

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OSTEOPOROSIS An update

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  1. OSTEOPOROSISAn update May 2012

  2. Osteoporosis • Df: A progressive systemic skeletal disorder characterised by a low bone mass and micro-architectural deterioration of bone. • T score of < -2.5 when measuring bone mineral density on DEXA scan (Dual –energy x-ray absorptiometry) • Osteopenia: T score -1 to -2.5.

  3. DEXA Scans • Z score- bone strength compared to other people in your own age • T score- compares bone density to that of a 25 year old. • Measures bone mineral density using central hip and/or spine DEXA scanning and is expressed in the number of standard deviations below peak bone mineral density.

  4. Why is it important? • 70,000 hip and 120,000 spine and 50,000 wrist # a yr due to osteoporosis . 1 • > 1/3rd of women sustain a # relating to osteoporosis. 2 • Costing NHS > 940 M a yr. 2

  5. Quick revision • Bone remodelling predominates 15-17 yrs (once longitudinal growth ceases) • Consists of: • bone dissolution/resorption by osteoclasts + • bone formation by osteoblasts • Adults, remodelling cycle is balanced so resorption = bone formation (90-130 days)

  6. However remodelling can become imbalanced so result in significant bone loss • Age-related bone loss starts in 40’s/50’s as a result of: • ↑ed bone breakdown by osteoclasts • ↓ed bone formation by osteblasts

  7. Risk Factors • Hormonal. • Late menarche, early menopause, long hx of oligomenorrhoea. • During menopause oestrogen deprivation ↑ed bone resorption, so→ bone loss. • Smoking • Excessive alcohol intake

  8. Lack of weight bearing exercise • Vitamin D deficiency • Glucocorticoid exposure. • ↓ Ca absorption, ↑ bone resorption, ↓ bone formation, thus → bone loss.

  9. Investigations • < 75 yrs DEXA scan 3 • Bloods: • FBC, ESR, TSH, U+E’s, bone and LFTs. • Consider checking serum paraproteins /urinary Bence Jones proteins to exclude other causes for # such as:

  10. Other possible causes of #: • Malignancy, • Osteomalacia, • Hyperparathyroidism 4

  11. If ≥ 75 yrs + DEXA clinically inappropriate clincial assessment is sufficient for diagnosis. 3

  12. Management Non-pharmacological Pharmacological

  13. Non-pharmacological • Diet. • 1000 mg Calcium daily intake for postmenopausal women →24 % reduction in hip #.5 • 1000 mg equivalent to 1 pint milk/50 g cheese/50 g sardines/1 pot of yogurt. • Avoid caffeinated products. Evidence inconclusive. • Regular exercise. Weight bearing exercise > 30 mins/day ↓# rate. 4

  14. Stop smoking. Pre-menopause leads to 25 % ↓# rate postmenopausal 4 • ↓alcohol consumption to < 21 units/wk male, <14 units/wk women 4

  15. Pharmaocological(NICE guidance)3 1. osteoporosis, no # 2. osteoporosis, already sustained #

  16. 1o prevention of osteoporotic # in PM women 1st line Alendronate 2nd line Risedronate and Etidronate 3rd line Strontium Ranelate 4th line Denosumab

  17. 2o Prevention of # in PM women who have sustained osteoporotic # 1st line alendronate 2nd line risedronate/etidronate 3rd line strontium ranelate/raloxifene 4th line teriparatide

  18. If there are contraindications, intolerances or side effects then the next line of treatment should be tried. • As an adjunct to treatment calcium and vitamin D supplementation should be considered in patients with a diagnosis of osteoporosis.

  19. Bisphosphonates • Alendronic acid/risedronate/etidronate • MOA: adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth + dissolution so ↓ the rate of bone turn over. 6 • Poorly absorbed.1-5 % of oral dose actually absorbed. 5

  20. Special instructions: • To be swallowed whole, with water while sitting or standing on an empty stomach 30 mins before breakfast. • Pt should then stand or sit upraight for at least 30 mins after taking the tablet. • Side effects: • oesophageal reactions- oesophagitis/ulcers/stricture/erosions.

  21. Alendronic Acid Dose:6 • Men 10 mg daily • Women • 70 mg OW if postmenopausal, • 10 mg daily if corticosteroid induced osteoporosis not on HRT.

  22. Strontium Ranelate • MOA: stimulates bone formation + reduces bone resorption. 6 • Special instructions: • Avoid food 2 hrs before and after taking in particular calcium- containing products • Side effects: severe allergic reactions such as drug rash with eosinophilia and systemic symptoms (DRESS). Signs: rash/fever/swollen glands/ ↑ WCC • Dose: 2 g OD.

  23. Raloxifene • MOA: SERM, beneficial effects on bone, but no effect on breast or endometrium. • CI: past VTE, endometrial carcinoma • Dose: 60 mg OD

  24. Teriparatide • MOA: recombinant fragment of parathyroid hormone. Increasing availability of Calcium. • Special instructions- only initiated by specialists experienced in the treatment of osteoporosis. • Dose: 20 mcg OD s/c

  25. Denosumab7 New NICE guidance • Tx option for the 10 prevention of osteoporotic # if the following apply: • Postmenopausal women at ↑ ed risk of # • Unable to comply with special instructions for administering alendronate/risedronate/etidronate • Intolerances or CI to the above • Can be used in pts who have a combination of T-score + age and no. of independent clinical risk factors for # (see nxt box)

  26. Independent risk factors: 1. Parental history of hip # 2. Alcohol intake ≥ 4 units per day 3. RA

  27. AKT Question • Which of the following is considered a second line option for the primary prevention of # in postmenopausal women? Select ONE option only. • Raloxifene • Adcal D3 + Risedronate • Teriparatide • Alendronic acid

  28. Answer • B is the correct answer. • A+C are used in secondary prevention • D is first line for primary prevention

  29. References •  Osteoporosis. An Information booklet. www.arc.org.uk Updated May 2007. • Royal College of Physicians. Clinical Guidelines for the prevention and treatment of osteoporosis. www.rcplondon.ac.uk/ • NICE guidance Oct 2008 http://www.nice.org.uk/nicemedia/live/11746/42486/42486.pdf • Oxford Handbook of General Practice. P568-569

  30. SIGN (Scottish intercollegiate guidelines network) guidelines for osteoporosis. http://www.sign.ac.uk/guidelines updated 2004. • BNF Chapter 6.6.2 p463. Bisphospahtes and other drugs affecting bone metabolism. • Denosumab for the prevention of osteoporotic fractures in fractures in postmenopausal women Nice Guidance, Oct 2010. http://www.nice.org.uk/nicemedia/live/13251/51329/51329.pdf

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