Osteoporosis

1. Osteoporosis

2. Definitionof osteoporosis NIH Consensus Development Panel on Osteoporosis. JAMA 2001;285:785–95 NICE TA 160 & 161, October 2008 Osteoporosis is defined as a skeletal disorder characterised by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primarily reflects the integration of bone density and bone quality NICE define osteoporosis as a T-score ≤ –2.5SD at the hip or spine Normal bone Osteoporotic bone

3. Who should we treat? ThinkRISK • Osteoporosis is a risk factor: • The outcome of importance is fractures • Fracture incidence significantly influenced by falls: • Also important to reduce these as well as improve bone strength • Treatment aimed at those at high risk of fracture: • Particularly clinical (as opposed to radiological) fractures of the hip and spine

4. Independent clinical risk factors (RF): Parental history of hip fracture Alcohol intake of >4 units per day Rheumatoid arthritis Indicators of low BMD (ILB): Low body mass index (<22 kg/m2) Medical conditions e.g. ankylosing spondylitis, Crohn’s disease, RA Prolonged immobility Untreated premature menopause Risk factors for fracture and patient assessmentNICE TA 160 & 161, October 2008 • Other factors of potential importance: • [ Age and gender (female > male), prior fracture ] • Long-term use of corticosteroids • Calcium and vitamin D consumption • Smoking history • Factors affecting the risk of falls • NICE TAs include primary and secondary prevention in post-menopausal women: • The future clinical guideline to advise on men and steroid-induced

5. Primary preventionNICE TA 160, October 2008 • Alendronate is recommended for women in the following groups: • Age >70 years with 1 RF or ILB, and confirmed osteoporosis • In women >75 years with ≥2 RF or ILB; a DEXA scan may not be required if the responsible clinician considers it to be clinically inappropriate or unfeasible • Age 65–69 years, with 1 RF, and confirmed osteoporosis • Age <65 years with 1 RF, and ≥1 ILB, and confirmed osteoporosis • Other therapies are recommended subject to patients meeting additional BMD and/or risk factor criteria: • Details of these requirements are given in tables in the guidance • Other therapies include risedronate, etidronate and strontium ranelate▼ • Raloxifene is not recommended

6. Secondary preventionNICE TA 161, October 2008 • Alendronate is recommended for women: • Who have sustained a clinically apparent osteoporotic fragility fracture and have confirmed osteoporosis • Aged ≥75 years; a DEXA scan may not be required if the responsible clinician considers it to be clinically inappropriate or unfeasible • Other therapies are recommended subject to patients meeting additional BMD and/or risk factor criteria: • Details of these requirements are given in tables in the guidance • Other therapies include risedronate, etidronate, strontium ranelate▼, raloxifene and teriparatide▼

7. Selecting treatmentsNICE TA 160 & 161, October 2008 • When the decision has been made to initiate treatment with alendronate, the preparation prescribed should be chosen on the basis of the lowest acquisition cost available: • Which is the generic 70mg once weekly formulation • Women who are currently receiving treatment with one of the drugs covered by this guidance, but for whom treatment would not have been recommended, should have the option to continue treatment until they and their clinicians consider it appropriate to stop • In deciding between risedronate and etidronate, and between strontium ranelate▼ and raloxifene, clinicians and patients need to balance the overall proven effectiveness profile of the drugs against their tolerability and adverse effects in individual patients • Osteoporosis treatments often have complex administration requirements and compliance with therapies is known to be poor

8. The place of calcium and vitamin DNICE TA 160 & 161, October 2008Bischoff-Ferrari, HA et al. JAMA 2005;293:2257–64Avenell A, et al. Cochrane 2005 • Recommended intake of calcium is 700–1200mg daily: • Foods rich in calcium include dairy products and green vegetables • Evidence-based doses of Vitamin D 700–800IU daily: • Daily exposure to natural sunlight April – October will provide required vitamin D • Foods rich in vitamin D include oily fish, meat, eggs and fortified breakfast cereals • Routine supplementation of calcium and vitamin D: • Only appears to be beneficial in reducing fracture rates in high risk populations, eg the institutionalised elderly • Community-dwelling, mobile populations do not appear to benefit • NICE recommend: • Calcium and/or vitamin D supplementation be considered alongside osteoporosis treatments unless clinicians are confident that women have an adequate calcium intake and are vitamin D replete

9. What does all that translate to? • Active policy for those who fall (to prevent further falls) • High-strength daily calcium (1g) and vitamin D (800IU) for the institutionalised frail elderly • BMD measurement in the young, worried well is rarely worthwhile • The benefit of osteoporosis treatment is related to the population baseline risk: • Primary prevention in high risk individuals (see NICE definitions) may be worthwhile • Bisphosphonates are cost effective in this group • Secondary prevention — people with an existing fragility fracture are high risk, and need consideration of drug therapy (± DEXA according to age) • The bisphosphonates alendronate and risedronate have the most evidence of effectiveness • Alendronate is first choice based on safety, effectiveness, cost and patient factors • Other treatments have roles in some circumstances

10. 3 (careful) steps to osteoporosis heaven • Focus on falls as well as fractures • Review medicines as part of an integrated approach • Treat risk • Treat RISK not BMD (cf CV disease) • Assess individual risks using NICE guidance • Use alendronate first line, if appropriate (do the 4 boxes above) • Newer drugs provide choice (but little else) • Address patient compliance issues • Bone protection for high-dose/long-term steroid users (oral and inhaled) • ‘High strength’ calcium and vitamin D for: • Those on osteoporosis treatment where optimal calcium and vitamin D intake cannot be assured • Mobile elderly in nursing/residential homes