Osteoporosis

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
• gt3/12 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 gt3/12

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
  lt65 years
• gt65 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
(No Transcript)
16
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 lt65
• With independent risk factor AND indicator for
  low BMD AND confirmed osteoporosis

17
Independent clinical risk factors (NICE)

• Parental history of hip fracture
• Alcohol intake of 4 units / day
• Rheumatoid arthritis

18
Indicators of low BMD (NICE)

• BMI lt22
• Ankylosing spondylitis
• Crohns disease
• Prolonged immobility
• Untreated menopause

19
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

20
Secondary prevention

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

21
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

22
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!