Management of Osteoporosis in Primary Care

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Management of Osteoporosis in Primary Care

• Yuen Chong

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Overview

• Introduction
• Risk Factors
• Secondary Causes
• Diagnosis - DEXA
• Prevention
• Treatment / Management
• SIGN Guidelines

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Osteoporosis

• Causes over 200,000 fractures each year in the
  UK. ( est 1.7 billion annual NHS cost )
• 1 in 3 women and 1 in 12 men gt 50 years old will
  suffer osteoporotic fracture.
• 50 of hip fracture patients cease to be
  independent and 20 die within 6 months.
• A hip fracture cost about 20,000.

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Risk Factors 1

• Previous history of fractures.
• Female sex 15 male to female in Scotland
• Age gt 60
• Family History of Osteoporosis
• Ethnic origins Afro-Caribbean origin less
  susceptible than Caucasian or Asian group.
• Early Menopause Higher risk

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Risk Factors 2

• Low Body Mass Index ( BMI ) Low Bone Mineral
  Density (BMD )
• Smoking
• Sedentary lifestyle
• Long term ( gt3 months ) corticosteroid use

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Secondary Causes

• Coeliac disease
• Inflammatory bowel disease
• Chronic liver disease
• Primary hyperparathyroidism
• Functioning pituitary tumours
• Thyrotoxicosis

• Chronic renal failure
• Organ transplant
• Inflammatory arthritis
• Cystic fibrosis
• Primary hypogonadism
• Osteogenesis imperfecta
• Multiple sclerosis

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Diagnosis

• Usually diagnosed after fracture occurs.
• Osteoporotic vertebral collapse causes pain, loss
  in height and kyphosis.
• Calcium, Phosphate and Alk Phos are normal.
• Osteopenia cannot be reliably diagnosed on plain
  x-ray.
• DEXA is gold standard for diagnosis.

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DEXA

• DEXA ( Dual energy X-ray Absorptiometry) measures
  bone mineral density (BMD)
• Gold standard ( Cost 20 45 on NHS )
• Measured at 2 sites usually hip and spine.
• Osteoporosis is defined as BMD gt 2.5 standard
  deviation below the young normal mean (T score lt
  -2.5)
• Osteopenia BMD T score btw 1 and 2.5
• T score above -1 is normal.

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DEXA scanning Guidelines Tayside (January
2004)Consider DEXA where assessment would
influence management in the following groups

• Previous fragility fracture (especially of wrist,
  hip or spine)- sustained from a fall from
  standing height or less .
• Use of glucocorticoids (prednisolone gt5mg) for gt
  3/12 - if gt65yrs, on gt15mg prednisolone or if
  previous fragility fracture, may want to consider
  treatment anyway .
• Low BMI (lt 19 kg/m2)
• Secondary osteoporosis suspected

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DEXA scanning Guidelines Tayside (January 2004)

• Secondary amenorrhoea of 1 year in women lt 45yr -
  excluding breast-feeding women (including early
  natural menopause)
• Radiological osteopoenia (especially if
  associated with family history or other risk
  factor)
• FH of osteoporosis in mother, sibling or father
• Perimenopausal or postmenopausal if considering
  whether to start or continue HRT
  (Controversial!!?)

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Other investigations

• UE
• LFT
• Calcium
• TSH
• FBC
• PV / ESR If raised, check myeloma screen
• Testosterone in Male
• Consider PTH
• Coeliac antibodies if clinically relevant

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Prevention Lifestyle advice

• Stopping smoking before menopause reduces later
  fracture rate by 25.
• Exercise will increase bone density, even in
  women over 70. Exercise should be weight bearing
  for 30 minutes per day. If practised gt 3 times a
  week, fracture rates are halved.
• Alcohol keep to recommended limits.
• Diet include calcium 700mg ( 1 pint of milk )
  and vitamin d 400iu
• Falls risk assessment Physio(walking aids, hip
  protectors) and O.T referral.

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Pharmacological Management

• Bisphosphonates
• HRT
• Selective oestrogen-receptor modulator (
  SERM )
• Calcium and Vitamin D
• Calcitonin
• Parathyroid hormone ( not licensed in UK yet )

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Bisphosphonates

• Blocks osteoclast action
• Eg. Cyclical etidronate (Didronel), Alendronate
  (Fosamax), and Risedronate (Actonel)
• Licensed for prevention and treatment of
  postmenopausal osteoporosis and corticosteroid
  induced osteoporosis.
• Other uses include Pagets and hypercalcaemia.
• Counselling Taken on empty stomach at least 30
  minutes before meal also remain upright for 1
  hour after. Avoid antacid, milk and iron. Nausea
  is common SE, so better with once-weekly
  formulation.

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HRT

• It postpones postmenopausal bone loss and reduce
  fracture rates.
• CSM advice NOT first line for long term
  prophylaxis.
• An option where other therapies are
  contra-indicated,cannot be tolerated, or if lack
  of response.
• Most benefit if started early in menopause and
  continued for 5 years, but bone loss resumes
  (possibly at accelerated rate) after stopping.
• Counselling Discuss risk of breast ca and DVT.

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Selective osetrogen-receptor modulator (SERM) -
Raloxifene

• Mimics beneficial effects of oestrogen on then
  bone but blocks the oestrogen effect on the
  uterus and breast tissue.
• Reduces vertebral fracture by 30 in 3 years but
  no benefit to non-vertebral fractures.( licence
  is for prophylaxis and treatment of vertebral
  fractures in postmenopausal osteoporosis)
• May worsen certain menopausal symptoms like hot
  flushes and increases DVT risk.

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Calcium and Vitamin D

• May slow down rate of bone loss in elderly women
  who have low BMD.
• Complement other treatments.
• Elderly patients, esp those in residential and
  nursing homes may routinely benefit from taking
  supplements.

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Calcitonin

• Endogenous suppresion of bone resorption.
• Available as nasal spray and s/c injection.
• Salmon calcitonin (10 times more potent than
  human calcitonin )
• Reduces vertebral fracture by 33.
• Also useful for pain relief for up to 3 months
  after a vertebral fracture if other analgesics
  are ineffective.

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SIGN Guideline

• No 71

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Steroid-induced osteoporosisThe following should
receive prophylaxis

• Those on prednisolone 15mg daily or more.
• Those on prednisolone 7.5mg 15mg daily one or
  more risk factors.
• Those on 7.5mg 15mg daily but no risk factor
  --- Refer DEXA and treat if T below 1.5.
• Greatest bone loss occurs in first 6 months of
  treatment.

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Summary

• Osteoporosis is underdiagnosed and suboptimally
  managed.
• Poor compliance with treatment is a problem.
• Make use of DEXA Dr. G.Leese in Dundee and Dr.
  M.Garton in Perth.

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Thank You.

• Any Questions??

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Useful websites

• www.nos.org.uk - National Osteoporosis Society
• www.sign.ac.uk - SIGN Guidelines
• www.arc.org.uk - Arthritis Research Campaign (ARC
  )