update on osteoporosis dr terence o’neill consultant rheumatologist
TRANSCRIPT
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Update on Osteoporosis
Dr Terence O’Neill
Consultant Rheumatologist
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• 3 million people have osteoporosis in the UK.
• 80 000 hip / 50 000 wrist / 120 000 vertebra
• £1.7 billion per annum.
Clinical / Public Health Impact
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Risk of Future Fracture
Relative RiskPrior fracture Wrist Vertebra Hip
Wrist 3.3 1.7 1.9
Vertebra 1.4 4.4 2.3
Hip - 2.5 2.3Klotzbuecher, 2000
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2001 Census
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Projected Rise in Hip FracturesUK
0
20
40
60
80
100
120
140
2000 2010 2020 2030 2040 2050
Year
1000s
Men
Women
European Commission, 1998
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Reduction in vertebral fractures
Clodronate
0
0.2
0.3
0.4
0.5
0.6
0.7 Alendronate
Ibandronate Risedronate Strontium
Relative risk
ALN CLOD IBAN RIS SR
0.5
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Risk Factor
Case Finding Strategy
+
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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
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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
InvestigationsMeasure BMD
[DXA, hip +/- spine]
NORMAL
T score above -1
OSTEOPENIA
T score –1 to –2.5
OSTEOPOROSIS
T score below –2.5
Reassure
Lifestyle advice
Lifestyle advice
Treat if previous
fracture
Lifestyle advice
Offer treatment*Calcium + Vitamin D
Falls risk:
Assessment/advice and
Consider hip protectors RCP, 1999
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Limitations
• Bone Mineral Density• Focus on T Score • Out of Date
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Risk Assessment• 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)
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T Score
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http://www.shef.ac.uk/NOGG/
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NOGG – November 2008
New Risk Assessment Tool ‘FRAX’ - Web BasedNo More T Scores !– 10 year fracture riskThresholds for Treatment (web / tables)Advice on which treatment
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http://www.shef.ac.uk/FRAX/
http://www.shef.ac.uk/NOGGOR
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BMD
60yr 70yr 80yr
No.
Risk
Factors
Women with No Prior #
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NOGG - Treatment
• Alendronate
• If unable to take / intolerant
Risedronate / Ibandronate / Strontium
Raloxifene / Etidronate
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What about NICE?
• After gestation of 6 years new technology appraisals published late 2008
• TA160 : Primary prevention
• TA 161 : Secondary prevention
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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
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* Age < 65 years + independent clinical risk factor for fracture + clinical risk of low BMD + T-score of < – 2.5
NICE 160– Primary Prevention
* Age 65-69 yrs + independent clinical risk factor for fracture + T-score of < – 2.5
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* Age 75 +yrs + 2 or more risk factors – no need for BMD
NICE 160– Primary Prevention
* Age 70+ yrs + independent clinical risk factor for fracture OR clinical risk of low BMD + T-score of < – 2.5
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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
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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