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Update on Osteoporosis. Dr Terence O’Neill Consultant Rheumatologist. Clinical / Public Health Impact. 3 million people have osteoporosis in the UK. 80 000 hip / 50 000 wrist / 120 000 vertebra £1.7 billion per annum. Risk of Future Fracture. Klotzbuecher, 2000. 2001 Census.

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update on osteoporosis

Update on Osteoporosis

Dr Terence O’Neill

Consultant Rheumatologist

clinical public health impact
Clinical / Public Health Impact
  • 3 million people have osteoporosis in the UK.
  • 80 000 hip / 50 000 wrist /120 000 vertebra
  • £1.7 billion per annum.
risk of future fracture
Risk of Future Fracture

Klotzbuecher, 2000

projected rise in hip fractures uk
Projected Rise in Hip FracturesUK

European Commission, 1998

reduction in vertebral fractures

Relativerisk

0.7

Alendronate

0.6

0.5

Ibandronate

0.4

Risedronate

Strontium

0.3

0.2

0

ALN

CLOD

IBAN

RIS

SR

Reduction in vertebral fractures

0.5

Clodronate

risk factors indications for bmd
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

medical management of men and women aged 45 years who have or are at risk of osteoporosis
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

Investigations

Measure BMD

[DXA, hip +/- spine]

OSTEOPENIA

T score –1 to –2.5

OSTEOPOROSIS

T score below –2.5

NORMAL

T score above -1

Lifestyle advice

Offer treatment*

Lifestyle advice

Treat if previous

fracture

Reassure

Lifestyle advice

Calcium + Vitamin D

Falls risk:

Assessment/advice and

Consider hip protectors

RCP, 1999

limitations
Limitations
  • Bone Mineral Density
  • Focus on T Score
  • Out of Date
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)

Risk Assessment
nogg november 2008
NOGG – November 2008

New Risk Assessment Tool

‘FRAX’- Web Based

No More T Scores !– 10 year fracture risk

Thresholds for Treatment (web / tables)

Advice on which treatment

http www shef ac uk frax

http://www.shef.ac.uk/FRAX/

OR

http://www.shef.ac.uk/NOGG

women with no prior
Women with No Prior #

60yr

70yr

80yr

No.

Risk

Factors

BMD

nogg treatment
NOGG - Treatment
  • Alendronate
  • If unable to take / intolerant

Risedronate / Ibandronate / Strontium

Raloxifene / Etidronate

what about nice
What about NICE?
  • After gestation of 6 years new technology appraisals published late 2008
  • TA160 : Primary prevention
  • TA 161 : Secondary prevention
nice 161 secondary prevention
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
slide32

NICE 160– Primary Prevention

* Age < 65 years + independent clinical risk factor for fracture + clinical risk of low BMD + T-score of < – 2.5

* Age 65-69 yrs + independent clinical risk factor for fracture + T-score of < – 2.5

slide34

NICE 160– Primary Prevention

* Age 70+ yrs + independent clinical risk factor for fracture OR clinical risk of low BMD + T-score of < – 2.5

* Age 75 +yrs + 2 or more risk factors – no need for BMD

nice 160 161
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
summary
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
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