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Osteoporosis

Osteoporosis. Dr Heinrich Van Wyk GP Registrar 27 October 2007. YOUR AGENDA. Introduction/ My Agenda. Definition, T’s & Z’s Diagnosis and Risk Assessment Treatment/ Fracture prevention Monitoring Referral. Definitions. Disease characterised by Low bone mass

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Osteoporosis

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  1. Osteoporosis Dr Heinrich Van Wyk GP Registrar 27 October 2007

  2. YOUR AGENDA

  3. Introduction/ My Agenda • Definition, T’s & Z’s • Diagnosis and Risk Assessment • Treatment/ Fracture prevention • Monitoring • Referral

  4. Definitions • Disease characterised by • Low bone mass • Micro architectural deterioration • Consequent increased fragility and fracture risk • WHO defines by • T-score • Z-score ?????

  5. T-scores Normal Osteopenia Osteoporosis Established osteoporosis Z-scores >-1 SD -1SD to -2.5SD < -2.5 SD <-2.5 + one or more fragility fracture As for T’s but SD for same age population Definitions

  6. So What is a Fragility fracture???? • Result of • Force • Not ordinarily cause fracture • i.e. • Force equivalent to standing height or lower

  7. Diagnosis • DEXA Scanner • Dual Energy X-ray Absorptiometry • Dual Energy • 70 kVp (Al filter) alt 140 kVp (Cu Filter) or • 80 kVp with no then cerium or samarium filter • X-ray = Pencil beam • Absorptiometry • Scintilationcounter • Output to computer + magic = RESULT

  8. Risk Assessment • Risk factors for osteoporosis • Risk factors for fragility fractures • Risk factors for falls • Secondary causes

  9. Group Work

  10. Strongest female > 60 y/o FH Diagnosis Kyphosis Low trauma # > 50y Other significant Caucasian/ Asian BMI < 19 kg/m² 2° Amenorrhoea >1y Smoking Low Calcium diet Low Vit D (sun) Sedentary/ low mob Height loss/ kyphosis Radiol Osteopenia/ vertebral collapse Corticosteroids Risk factors for osteoporosis

  11. Risk factors for fragility fractures • Osteoporosis • Falls • Previous fragility fracture • Key risk factors for hip # • Previous # <50 y old • Maternal hip fracture • Current smoker • Low BMI

  12. Risk factors for falls • Tendency to fall increase with age • Risk factors • History of falls • Gait problems • Balance problems • Mobility impairment • Fear • Visual impairment • Cognitive impairment • Urinary incontinence • Home hazards • Risk increase as number of risk factors increase

  13. Endocrine Poorly controlled thyrotoxicosis ♂ hypogonadism 1° hyperparathyroidism Malabs/ nutritional Inflam bowel disease Chronic liver disease Coeliac Anorexia Vit D deficiency Drugs Phenytoin Phenobarb Over Rx with Thyroxine Corticosteroids (!) DMPA Others RA Myeloma Renal disease Secondary causes

  14. Questions so far

  15. Treatment/ Fracture Prevention • Prevention of fracture • Primary • Secondary • Glucocorticoid induced • Treatment • Lifestyle advice • Assess and manage falls risk • Drugs (Primary vs Secondary) • 1st line • 2nd line • Men

  16. Lifestyle Intervention • Diet • Calcium 700mg- 1000mg daily • 1 pint milk + 60g hard cheese or 1 pot yoghurt or 60g sardines • Vit D 400IU daily >65y (only achievable by supplement) • 4oz cooked salmon or mackeral or • 6oz tuna (canned in oil) or • 3 oz sardines (canned in oil) • Exercise • Tailored to individual • Low impact weight bearing • Walking • High intensity strength targeting hip, spine, wrist muscles • Balance/ gait training if high risk of falls • Smoking cessation • Alcohol • Avoid excessive • Evidence scanty • Sun • 15-20 min twice a week April to October

  17. Risk of Falls • Who • Present for medical attention because of a fall • Report recurrent falls in the past year • Demonstrate abnormalities of gait/ balance. • How • Skill and experience • Usually specialist setting • Multifactorial • individualised

  18. Drugs: Primary Prevention • T-score • RCP/ BTAS recommendations • >-1.0 • reassure • -1.0 to -2.5 • lifestyle advice • <-2.5 • Consider drug treatment

  19. Drugs: Primary Prevention • Oral Bisphosphonates • Alendronate/ etidronate/ risedronate • Less frequent dosing better compliance • Raloxifene • Selective estrogen receptor modulator • HRT • See BNF for latest licensed HRT • Risk/ benefit complex • Not first line

  20. Drugs: Secondary Prevention • Age • ≥ 75y • Treat without DEXA • 65-74y • DEXA scan • Treat if T <-2.5 • Delay to DEXA likely: treat immediately until results available • <65y • DEXA • Treat if • T≤ -3.0 or • T< -2.5 with additional risk factors

  21. Drugs: Secondary Prevention • Oral bisphosphonates • Alendronate • Etidronate • Ibandronate • Risedronate • Alternatives if CI or not tolerating • Raloxifene • Strontium • IV ibandronate • PTH (teriparatide) • Secondary care • Intolerance/ unsatisfactory response to bisphos AND • Extremely low BMD or • Low BMD + > 2 fractures + other risk factors • Calcium Vit D adjunct

  22. Drugs: Glucocorticoid induced prevention • Exposure ≥ 3months at any dose • ≥ 65y and/ or previous fracture • Treat • < 65y • DEXA (unless delay then Rx immediately) • T >0 • Reassure • T<-1.5 • Treat • ONLY Bisphosphonates are licensed

  23. Calcium and Vitamin D • Monotherapy • Elderly women in nursing homes only • Adjunct therapy • Recommended by NICE with all Rx • UNLESS • confident adequate dietary intake • Vit D replete • Dose depends on diet • Ca 600mg – 1.2 g • Vit D 400-800 IU

  24. Men • Consider referring all men • Not necessary if • clear risk factors • all screening tests available in primary care • Exclude 2° causes • Assess falls risk • Lifestyle advice • Treatment best initiated following specialist advice

  25. Drugs: Men • Little evidence on Rx in men • Alendronate 10mg OD • only licensed drug • 70mg once weekly similar efficacy but unlicensed • Other bisphosphonates • None licensed • Expert opinion Risedronate reasonable alternative • Vit D and Calcium as for women

  26. Monitoring • How long to treat • Likely indefinitely • Little evidence on stopping and fracture risk or BMD • Monitoring • 1st after 3 moths then 6 monthly • Height • Medicine compliance • SE’s check • Further falls assessment • Previous fracture • Repeat DEXA or refer • If further fracture occur after 12m fully compliant Rx

  27. Refer • Diagnostic difficulty • Intolerance/ CI to oral Rx • Acute painful vertebral fracture • Secondary osteoporosis req further Ix • Potential use of PTH

  28. YOUR AGENDA MY AGENDA

  29. References/ Comprehensive guidance • CKS • Osteoporosis- Treatment (and prevention of fragility fractures) • NICE • Technology appraisal 87 • e-Guidelines • Consensus guideline on the management of osteoporosis in post-menopausal women • Guidelines for the prevention and management of glucocorticoid induced osteoporosis • RCP • BTAS

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