Osteoporosis

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Osteoporosis
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Definition of osteoporosis NIH Consensus
Development Panel on Osteoporosis. JAMA
200128578595 NICE TA 160 161, October 2008
Osteoporosis is defined as a skeletal disorder
characterised by compromised bone strength
predisposing a person to an increased risk of
fracture. Bone strength primarily reflects the
integration of bone density and bone
quality NICE define osteoporosis as a
T-score 2.5SD at the hip or spine
Normal bone Osteoporotic bone
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Who should we treat?
Think RISK

• Osteoporosis is a risk factor
• The outcome of importance is fractures
• Fracture incidence significantly influenced by
  falls
• Also important to reduce these as well as improve
  bone strength
• Treatment aimed at those at high risk of
  fracture
• Particularly clinical (as opposed to
  radiological) fractures of the hip and spine

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Risk factors for fracture and patient
assessmentNICE TA 160 161, October 2008

• Independent clinical risk factors (RF)
• Parental history of hip fracture
• Alcohol intake of gt4 units per day
• Rheumatoid arthritis

• Indicators of low BMD (ILB)
• Low body mass index (lt22 kg/m2)
• Medical conditions e.g. ankylosing spondylitis,
  Crohns disease, RA
• Prolonged immobility
• Untreated premature menopause

• Other factors of potential importance
• Age and gender (female gt male), prior fracture
  
• Long-term use of corticosteroids
• Calcium and vitamin D consumption
• Smoking history
• Factors affecting the risk of falls
• NICE TAs include primary and secondary prevention
  in post-menopausal women
• The future clinical guideline to advise on men
  and steroid-induced

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Primary preventionNICE TA 160, October 2008

• Alendronate is recommended for women in the
  following groups
• Age gt70 years with 1 RF or ILB, and confirmed
  osteoporosis
• In women gt75 years with 2 RF or ILB a DEXA
  scan may not be required if the responsible
  clinician considers it to be clinically
  inappropriate or unfeasible
• Age 6569 years, with 1 RF, and confirmed
  osteoporosis
• Age lt65 years with 1 RF, and 1 ILB, and
  confirmed osteoporosis
• Other therapies are recommended subject to
  patients meeting additional BMD and/or risk
  factor criteria
• Details of these requirements are given in tables
  in the guidance
• Other therapies include risedronate, etidronate
  and strontium ranelate?
• Raloxifene is not recommended

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Secondary preventionNICE TA 161, October 2008

• Alendronate is recommended for women
• Who have sustained a clinically apparent
  osteoporotic fragility fracture and have
  confirmed osteoporosis
• Aged 75 years a DEXA scan may not be required
  if the responsible clinician considers it to be
  clinically inappropriate or unfeasible
• Other therapies are recommended subject to
  patients meeting additional BMD and/or risk
  factor criteria
• Details of these requirements are given in tables
  in the guidance
• Other therapies include risedronate, etidronate,
  strontium ranelate?, raloxifene and teriparatide?

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Selecting treatmentsNICE TA 160 161, October
2008

• When the decision has been made to initiate
• treatment with alendronate, the preparation
• prescribed should be chosen on the basis of the
• lowest acquisition cost available
• Which is the generic 70mg once weekly formulation
• Women who are currently receiving treatment with
  one of the drugs covered by this guidance, but
  for whom treatment would not have been
  recommended, should have the option to continue
  treatment until they and their clinicians
  consider it appropriate to stop
• In deciding between risedronate and etidronate,
  and between strontium ranelate? and raloxifene,
  clinicians and patients need to balance the
  overall proven effectiveness profile of the drugs
  against their tolerability and adverse effects in
  individual patients
• Osteoporosis treatments often have complex
  administration requirements and compliance with
  therapies is known to be poor

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The place of calcium and vitamin DNICE TA 160
161, October 2008 Bischoff-Ferrari, HA et al.
JAMA 2005293225764Avenell A, et al. Cochrane
2005

• Recommended intake of calcium is 7001200mg
  daily
• Foods rich in calcium include dairy products and
  green vegetables
• Evidence-based doses of Vitamin D 700800IU
  daily
• Daily exposure to natural sunlight April
  October will provide required vitamin D
• Foods rich in vitamin D include oily fish, meat,
  eggs and fortified breakfast cereals
• Routine supplementation of calcium and vitamin D
• Only appears to be beneficial in reducing
  fracture rates in high risk populations, eg the
  institutionalised elderly
• Community-dwelling, mobile populations do not
  appear to benefit
• NICE recommend
• Calcium and/or vitamin D supplementation be
  considered alongside osteoporosis treatments
  unless clinicians are confident that women have
  an adequate calcium intake and are vitamin D
  replete

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What does all that translate to?

• Active policy for those who fall (to prevent
  further falls)
• High-strength daily calcium (1g) and vitamin D
  (800IU) for the institutionalised frail elderly
• BMD measurement in the young, worried well is
  rarely worthwhile
• The benefit of osteoporosis treatment is related
  to the population baseline risk
• Primary prevention in high risk individuals (see
  NICE definitions) may be worthwhile
• Bisphosphonates are cost effective in this group
• Secondary prevention people with an existing
  fragility fracture are high risk, and need
  consideration of drug therapy ( DEXA according
  to age)
• The bisphosphonates alendronate and risedronate
  have the most evidence of effectiveness
• Alendronate is first choice based on safety,
  effectiveness, cost and patient factors
• Other treatments have roles in some circumstances

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3 (careful) steps to osteoporosis heaven

• Focus on falls as well as fractures
• Review medicines as part of an integrated
• approach
• Treat risk
• Treat RISK not BMD (cf CV disease)
• Assess individual risks using NICE guidance
• Use alendronate first line, if appropriate (do
  the 4 boxes above)
• Newer drugs provide choice (but little else)
• Address patient compliance issues
• Bone protection for high-dose/long-term steroid
  users (oral and inhaled)
• High strength calcium and vitamin D for
• Those on osteoporosis treatment where optimal
  calcium and vitamin D intake cannot be assured
• Mobile elderly in nursing/residential homes