Osteoporosis

Lucy Cowdrey4th November 2009

What is it?

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

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

Who gets it?

• Strongest risk factors?• Age• Female sex• Family history

Other risk factors

• Caucasian• Early menopause• Low BMI• Smoking & probably alcohol• Sedentary lifestyle• >3/12 corticosteroid use• ?Depo-provera

Associated conditions

• Anorexia• Chronic liver disease• Chronic kidney disease• Coeliac disease• Hyperparathyroidism• IBD• Rheumatoid arthritis

Should we test for it?

When to test: (National Osteoporosis Guideline Group 2008)

FRAX calculator

• Assesses 10 year risk of #

• www.shef.ac.uk/FRAX

• National Osteoporosis society also recommend testing if receiving steroids for >3/12

General advice?

• Stop smoking• Adequate calcium intake• Exercise

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 <65

years• >65 – 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

Here comes the science…

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

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 <65• With independent risk factor AND indicator for low BMD

AND confirmed osteoporosis

Independent clinical risk factors (NICE)

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

Indicators of low BMD (NICE)

• BMI <22• Ankylosing spondylitis• Crohns disease• Prolonged immobility• Untreated menopause

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

Secondary prevention

• NICE (2008)• Alendronate 1st line• Risedronate or etidronate if

intolerant• 2nd line – strontium or raloxifene• 3rd line - teripatide

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 #

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!