Records a Tscore 0 being the mean average of healthy population Osteopenia is between 1 and 25 standard deviations from this mean Osteoporosis OP less than 25 Fragility fracture Injury insufficient enough to break normal bone ID: 916768
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Slide1
Osteoporosis
Reduced bone density, which can be determined by a DXA scan Records a T-score, 0 being the mean average of healthy populationOsteopenia is between -1 and -2.5 standard deviations from this meanOsteoporosis (OP) less than -2.5Fragility fracture= Injury insufficient enough to break normal bonePrimary Prevention= Detect patients at risk of OP, based on risksSecondary Prevention = Sustained a fragility fracture and found to have OP
Definition
Slide2Osteoporosis
At 50y, 1 in 3 women and 1 in 5 men fracture in their remaining lifetime50% of patients with an osteoporotic fracture will have anotherSecondary Prevention:9-21 people need to be treated for 3y to prevent one spinal fracture (NNT)NNT to prevent one hip fracture over 3y is 48-91
Statistics
Slide3Osteoporosis
FRAX tool helps decide which patients are offered a DXA scanRecommended in >50y and with standard risks factors (e.g. family history, alcohol excess, diabetes, rheumatoid, overactive thyroid etc.) Only assess risk in < 50y where significant risk factors (previous fragility fracture, menopause < 45y, kidney disease, oral steroid use, neurological disease including Parkinson’s, Multiple Sclerosis, Dementia, Stroke)
Primary
Prevention
Slide4Secondary Prevention
>50y with a fragility fracture should be offered a DXA scan and receive treatment if OP confirmed (T score < - 2.5)Osteoporosis
Slide5Osteoporosis
LifestyleStop smoking, reduce alcohol, weight-bearing exercise, balance/stretches to reduce fallsSupplementsCalcium 750mg/day Vitamin D 400 units (prevention) 800 units (if deficient) e.g. use in osteopenia, repeat DXA every 3y First line medication
Oral bisphosphonate (alendronate or
risedronate
)
Treatment
Slide6Osteoporosis
Second line medicationIntravenous (a “drip”) zoledronate or injection denosumab, if not tolerated or fracture on first line treatmentThird line medicationHRT
,
raloxifene
Fourth line medication
Strontium (but not in cardiovascular disease)
Treatment
Slide7Osteoporosis
Evaluate after 5y of use, limited evidence of further benefit. Bisphosphonates have a peak increase in bone density at 3y and can “stay” in the bone for up to 10 years.T-score not improved, continuing to fracture, still on oral steroids etc. then may use medication for 10 yearsDuration of Treatment
Slide8Osteoporosis
Treating Without DXA ScanOption of treating without DXA scan in hip and spine fractures as the former carry a high risk of future fracture and the latter nearly always associated with OP >75y with fragility fracture, acceptable to assume OP without a DXA scan
Slide9Osteoporosis
Bisphosphonates Gastric reflux (follow instructions) and yet omeprazole can make them less effectiveOesophageal cancer, not provenAtypical thigh bone fracture, not provenSoften the jaw bone (osteonecrosis) rare but discuss with dentistDenosumabWatch calcium (drops) and kidney function on blood tests
HRT
Small risk blood clots, breast cancer, stroke
Treatment Harms
Slide10Osteoporosis
Theoretical risk cardiovascular disease if too much calcium in diet (>1400mg/day)More pronounced risk if taking calcium alone, without vitamin DIncreasing calcium in diet or with supplements did not show fracture preventionSo, only supplement if a good indicationCalcium
Supplements
Slide11Any questions?
Dr Guy Cunliffe –GP Partner from the Swan Medical Group