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Update on Osteoporosis

Update on Osteoporosis. Dr Terence O’Neill Consultant Rheumatologist. Clinical / Public Health Impact. 3 million people have osteoporosis in the UK. 80 000 hip / 50 000 wrist / 120 000 vertebra £1.7 billion per annum. Risk of Future Fracture. Klotzbuecher, 2000. 2001 Census.

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Update on Osteoporosis

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  1. Update on Osteoporosis Dr Terence O’Neill Consultant Rheumatologist

  2. Clinical / Public Health Impact • 3 million people have osteoporosis in the UK. • 80 000 hip / 50 000 wrist /120 000 vertebra • £1.7 billion per annum.

  3. Risk of Future Fracture Klotzbuecher, 2000

  4. 2001 Census

  5. Projected Rise in Hip FracturesUK European Commission, 1998

  6. Relativerisk 0.7 Alendronate 0.6 0.5 Ibandronate 0.4 Risedronate Strontium 0.3 0.2 0 ALN CLOD IBAN RIS SR Reduction in vertebral fractures 0.5 Clodronate

  7. Case Finding Strategy Risk Factor +

  8. Risk Factors Indications for BMD • Low trauma # • Steroids (oral) > 7.5mg /day – 3 mths Hypogonadism menopause < 45 yrs 2nd amenorrhoea • Radiologic osteopenia • Comorbid diseases hyper PTH coeliac disease

  9. Medical management of men and women aged 45+ years who have or are at risk of osteoporosis Frail, increased fall risk +/- housebound Risk factors Previous fragility fracture Investigations Measure BMD [DXA, hip +/- spine] OSTEOPENIA T score –1 to –2.5 OSTEOPOROSIS T score below –2.5 NORMAL T score above -1 Lifestyle advice Offer treatment* Lifestyle advice Treat if previous fracture Reassure Lifestyle advice Calcium + Vitamin D Falls risk: Assessment/advice and Consider hip protectors RCP, 1999

  10. Limitations • Bone Mineral Density • Focus on T Score • Out of Date

  11. Age Gender Prior Fracture (after age 50 years) Parental history of fracture Current Smoking Alcohol intake > 2 units / day Ever Corticosteroid use Secondary causes (e.g. RA) Risk Assessment

  12. T Score

  13. http://www.shef.ac.uk/NOGG/

  14. NOGG – November 2008 New Risk Assessment Tool ‘FRAX’- Web Based No More T Scores !– 10 year fracture risk Thresholds for Treatment (web / tables) Advice on which treatment

  15. http://www.shef.ac.uk/FRAX/ OR http://www.shef.ac.uk/NOGG

  16. Women with No Prior # 60yr 70yr 80yr No. Risk Factors BMD

  17. NOGG - Treatment • Alendronate • If unable to take / intolerant Risedronate / Ibandronate / Strontium Raloxifene / Etidronate

  18. What about NICE? • After gestation of 6 years new technology appraisals published late 2008 • TA160 : Primary prevention • TA 161 : Secondary prevention

  19. NICE 161– Secondary Prevention • Alendronate (ALN) treatment of choice in post-menopausal women if T-score < – 2.5 • Unable to take ALN – Risedronate (RIS) or etidronate (ETD) • Unable to take RIS /ETD – Strontium / Raloxifene

  20. NICE 160– Primary Prevention * Age < 65 years + independent clinical risk factor for fracture + clinical risk of low BMD + T-score of < – 2.5 * Age 65-69 yrs + independent clinical risk factor for fracture + T-score of < – 2.5

  21. NICE 160– Primary Prevention * Age 70+ yrs + independent clinical risk factor for fracture OR clinical risk of low BMD + T-score of < – 2.5 * Age 75 +yrs + 2 or more risk factors – no need for BMD

  22. NICE 160/161 • Difficult to use – copy of guidance to hand • Restrictive : only few risk factors • Unfair • ALN first line therapy – Using NOGG many patients will be NICE compliant

  23. Summary • Osteoporosis is major health problem • Effective therapies are available • Challenge is targeting treatment – at risk • NOGG / FRAX new approach to assessment of risk • Use of NOGG should help target treatment to individuals at risk

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