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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 l.jpg

Update on Osteoporosis

Dr Terence O’Neill

Consultant Rheumatologist


Clinical public health impact l.jpg
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.


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Risk of Future Fracture

Klotzbuecher, 2000



Projected rise in hip fractures uk l.jpg
Projected Rise in Hip FracturesUK

European Commission, 1998


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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


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Case Finding Strategy

Risk Factor

+


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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


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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


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Limitations or are at risk of osteoporosis

  • Bone Mineral Density

  • Focus on T Score

  • Out of Date


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Age or are at risk of osteoporosis

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


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T Score or are at risk of osteoporosis


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http://www.shef.ac.uk/NOGG/ or are at risk of osteoporosis


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NOGG – November 2008 or are at risk of osteoporosis

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 l.jpg

http://www.shef.ac.uk/FRAX/ or are at risk of osteoporosis

OR

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


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Women with No Prior # or are at risk of osteoporosis

60yr

70yr

80yr

No.

Risk

Factors

BMD


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NOGG - Treatment or are at risk of osteoporosis

  • Alendronate

  • If unable to take / intolerant

    Risedronate / Ibandronate / Strontium

    Raloxifene / Etidronate


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What about NICE? or are at risk of osteoporosis

  • After gestation of 6 years new technology appraisals published late 2008

  • TA160 : Primary prevention

  • TA 161 : Secondary prevention


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NICE 161– Secondary Prevention or are at risk of osteoporosis

  • 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


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NICE 160– Primary Prevention or are at risk of osteoporosis

* 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


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NICE 160– Primary Prevention or are at risk of osteoporosis

* 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


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NICE 160/161 or are at risk of osteoporosis

  • 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


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Summary or are at risk of osteoporosis

  • 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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