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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
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)
slide7

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
slide9

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:
slide11

Other possible causes of #:

  • Malignancy,
  • Osteomalacia,
  • Hyperparathyroidism 4
slide12

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

slide13

Management

Non-pharmacological Pharmacological

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
slide15

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

slide19

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
slide21

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.
slide22

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)
slide27

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
slide31

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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