Osteoporosis an update
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OSTEOPOROSIS An update. May 2012. Osteoporosis. Df : A progressive systemic skeletal disorder characterised by a low bone mass and micro-architectural deterioration of bone. T score of < -2.5 when measuring bone mineral density on DEXA scan (Dual –energy x-ray absorptiometry)

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Osteoporosis an update

OSTEOPOROSISAn update

May 2012


Osteoporosis

Osteoporosis

  • Df: A progressive systemic skeletal disorder characterised by a low bone mass and micro-architectural deterioration of bone.

  • T score of < -2.5 when measuring bone mineral density on DEXA scan (Dual –energy x-ray absorptiometry)

  • Osteopenia: T score -1 to -2.5.


Dexa scans

DEXA Scans

  • Z score- bone strength compared to other people in your own age

  • T score- compares bone density to that of a 25 year old.

  • Measures bone mineral density using central hip and/or spine DEXA scanning and is expressed in the number of standard deviations below peak bone mineral density.


Why is it important

Why is it important?

  • 70,000 hip and 120,000 spine and 50,000 wrist # a yr due to osteoporosis . 1

  • > 1/3rd of women sustain a # relating to osteoporosis. 2

  • Costing NHS > 940 M a yr. 2


Quick revision

Quick revision

  • Bone remodelling predominates 15-17 yrs (once longitudinal growth ceases)

  • Consists of:

  • bone dissolution/resorption by osteoclasts +

  • bone formation by osteoblasts

  • Adults, remodelling cycle is balanced so resorption = bone formation (90-130 days)


Osteoporosis an update

  • However remodelling can become imbalanced so result in significant bone loss

  • Age-related bone loss starts in 40’s/50’s as a result of:

  • ↑ed bone breakdown by osteoclasts

  • ↓ed bone formation by osteblasts


Risk factors

Risk Factors

  • Hormonal.

  • Late menarche, early menopause, long hx of oligomenorrhoea.

  • During menopause oestrogen deprivation ↑ed bone resorption, so→ bone loss.

  • Smoking

  • Excessive alcohol intake


Osteoporosis an update

  • Lack of weight bearing exercise

  • Vitamin D deficiency

  • Glucocorticoid exposure.

  • ↓ Ca absorption, ↑ bone resorption, ↓ bone formation, thus → bone loss.


Investigations

Investigations

  • < 75 yrs DEXA scan 3

  • Bloods:

  • FBC, ESR, TSH, U+E’s, bone and LFTs.

  • Consider checking serum paraproteins /urinary Bence Jones proteins to exclude other causes for # such as:


Osteoporosis an update

  • Other possible causes of #:

  • Malignancy,

  • Osteomalacia,

  • Hyperparathyroidism 4


Osteoporosis an update

  • If ≥ 75 yrs + DEXA clinically inappropriate clincial assessment is sufficient for diagnosis. 3


Osteoporosis an update

Management

Non-pharmacologicalPharmacological


Non pharmacological

Non-pharmacological

  • Diet.

  • 1000 mg Calcium daily intake for postmenopausal women →24 % reduction in hip #.5

  • 1000 mg equivalent to 1 pint milk/50 g cheese/50 g sardines/1 pot of yogurt.

  • Avoid caffeinated products. Evidence inconclusive.

  • Regular exercise. Weight bearing exercise > 30 mins/day ↓# rate. 4


Osteoporosis an update

  • Stop smoking. Pre-menopause leads to 25 % ↓# rate postmenopausal 4

  • ↓alcohol consumption to < 21 units/wk male, <14 units/wk women 4


Pharmaocological nice guidance 3

Pharmaocological(NICE guidance)3

1. osteoporosis, no # 2. osteoporosis, already sustained #


1 o prevention of osteoporotic in pm women

1o prevention of osteoporotic # in PM women

1st line Alendronate

2nd line Risedronate and Etidronate

3rd line Strontium Ranelate

4th line Denosumab


2 o prevention of in pm women who have sustained osteoporotic

2o Prevention of # in PM women who have sustained osteoporotic #

1st line alendronate

2nd line risedronate/etidronate

3rd line strontium ranelate/raloxifene

4th line teriparatide


Osteoporosis an update

  • If there are contraindications, intolerances or side effects then the next line of treatment should be tried.

  • As an adjunct to treatment calcium and vitamin D supplementation should be considered in patients with a diagnosis of osteoporosis.


Bisphosphonates

Bisphosphonates

  • Alendronic acid/risedronate/etidronate

  • MOA: adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth + dissolution so ↓ the rate of bone turn over. 6

  • Poorly absorbed.1-5 % of oral dose actually absorbed. 5


Osteoporosis an update

  • Special instructions:

  • To be swallowed whole, with water while sitting or standing on an empty stomach 30 mins before breakfast.

  • Pt should then stand or sit upraight for at least 30 mins after taking the tablet.

  • Side effects:

  • oesophageal reactions- oesophagitis/ulcers/stricture/erosions.


Osteoporosis an update

  • Alendronic Acid Dose:6

  • Men 10 mg daily

  • Women

  • 70 mg OW if postmenopausal,

  • 10 mg daily if corticosteroid induced osteoporosis not on HRT.


St rontium ranelate

Strontium Ranelate

  • MOA: stimulates bone formation + reduces bone resorption. 6

  • Special instructions:

  • Avoid food 2 hrs before and after taking in particular calcium- containing products

  • Side effects: severe allergic reactions such as drug rash with eosinophilia and systemic symptoms (DRESS). Signs: rash/fever/swollen glands/ ↑ WCC

  • Dose: 2 g OD.


Raloxifene

Raloxifene

  • MOA: SERM, beneficial effects on bone, but no effect on breast or endometrium.

  • CI: past VTE, endometrial carcinoma

  • Dose: 60 mg OD


Teriparatide

Teriparatide

  • MOA: recombinant fragment of parathyroid hormone. Increasing availability of Calcium.

  • Special instructions- only initiated by specialists experienced in the treatment of osteoporosis.

  • Dose: 20 mcg OD s/c


Denosumab 7 new nice guidance

Denosumab7 New NICE guidance

  • Tx option for the 10 prevention of osteoporotic # if the following apply:

  • Postmenopausal women at ↑ ed risk of #

  • Unable to comply with special instructions for administering alendronate/risedronate/etidronate

  • Intolerances or CI to the above

  • Can be used in pts who have a combination of T-score + age and no. of independent clinical risk factors for # (see nxt box)


Osteoporosis an update

Independent risk factors:

1. Parental history of hip #

2. Alcohol intake ≥ 4 units per day

3. RA


Akt question

AKT Question

  • Which of the following is considered a second line option for the primary prevention of # in postmenopausal women? Select ONE option only.

  • Raloxifene

  • Adcal D3 + Risedronate

  • Teriparatide

  • Alendronic acid


Answer

Answer

  • B is the correct answer.

  • A+C are used in secondary prevention

  • D is first line for primary prevention


References

References

  •  Osteoporosis. An Information booklet. www.arc.org.uk Updated May 2007.

  • Royal College of Physicians. Clinical Guidelines for the prevention and treatment of osteoporosis. www.rcplondon.ac.uk/

  • NICE guidance Oct 2008 http://www.nice.org.uk/nicemedia/live/11746/42486/42486.pdf

  • Oxford Handbook of General Practice. P568-569


Osteoporosis an update

  • SIGN (Scottish intercollegiate guidelines network) guidelines for osteoporosis.

    http://www.sign.ac.uk/guidelines updated 2004.

  • BNF Chapter 6.6.2 p463. Bisphospahtes and other drugs affecting bone metabolism.

  • Denosumab for the prevention of osteoporotic fractures in fractures in postmenopausal women Nice Guidance, Oct 2010.

    http://www.nice.org.uk/nicemedia/live/13251/51329/51329.pdf


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