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20 of August 2024 Learning Aim and Objectives Aim: • Dthe condition, learn about therapiesf Objectives • Understand role of primary care treatmentners in identification and Discuss referral pathways Case study and discussionhttps://wall.sli.do/event/wKz7VDorSJTqrbx2jWuWKi?section=8a007482-eb84-499c-84a5-2104daa3032e Definitions: What is Osteoporosis? • Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. • It is estimated that there are 3 million people in the UK suffering from osteoporosis • Over 500,000 patients with fragility fractures present to hospitals in the UK each year, representing an estimated cost to the NHS of £4.4 billion a year. Less than 1/3 receive Statistics from NICE impact: Falls and Fractures Definitions: What is Osteoporosis continued? • Osteoporosis is asymptomatic and often fracture occursosed until a fragility • sustained after a fall from standingracture height or less although vertebral fractures can occur spontaneously or as bending or liftinge activities such as • WHO definition: BMD of 2.5 standard deviations below the mean peak mass as measured by DEXA of femoral neck and reported as T-scoreBone mass vs age Men and Women •The age when osteoporosis becomes apparent depends on: • Peak bone mass, which depends also levels of nutrition (particularly calcium and vitamin D), sex hormone levels (androgens and oestrogens), and level of physical activity. • The rate of bone loss, which depends on a number of factors including oestrogen deficiency in women and decreased hyperparathyroidism.r men and Fragility Fractures in the context of Public Health Priorities disability (YLDs) due to prevalent cases of the disease or health condition in a population.ature mortality (YLLs) and the years lived with aSlido 2: Do you have a strategy to identify patients at risk of osteoporosis in your current practice? https://wall.sli.do/event/wKz7VDorSJTqrbx2jWuWKi?section=8a007482-eb84-499c-84a5-2104daa3032eWho should be assessed for fracture risk? •All women aged 65 years and over, and all men aged 75 years and over. •All women aged 50–64 years and all men aged 50–74 years who have any of the following risk factors:  •A previous osteoporotic fragility fracture. •Current use or frequent recent use of oral corticosteroids. •History of falls. •Low body mass index (less than 18.5 kg/m ). 2 •Smoker. •Alcohol intake of more than 14 units per week. •A secondary cause of osteoporosis, including: • Hypogonadism in either sex, including untreated premature menopause (menopause before 40 years of age), treatment with aromatase inhibitors (such as exemastane) or gonadotrophin- releasing hormone agonists (such as goserelin). • Endocrine conditions, including diabetes mellitus, Cushing's disease, hyperthyroidism, hyperparathyroidism, and hyperprolactinaemia. • Conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis. • Rheumatoid arthritis and other inflammatory arthropathies. • Haematological conditions such as multiple myeloma and haemoglobinopathies. • Chronic obstructive pulmonary disease. • Chronic liver failure. • Chronic kidney disease. • Immobility. https://www.nogg.org.uk Risk factors for osteoporosis • The risk of getting an osteoporotic fracture depends on the person's risk of falls, their bone strength (determined by bone mineral density [BMD]), and other risk factors. • Fracture risk increases progressively with decreasing BMD, but BMD is poorly sensitive at predicting fracture risk when used without considering other risk factors. • Calculators approximate risk • Clinician review of appropriateness of recommended action • Individually tailored management plan • If in doubt, speak to experts [Compston, 2010; NICE, 2017a; NOGG, 2021; BMJ Best Practice, 2020; SIGN, 2020]Using FRAX in real life frax.shef.ac.uk/FRAX/tool.aspx?country=1 Defining high risk patients: BMD T-Score ≤-3.5 (at the hip or spine) or BMD T-score ≤-2.5 (at the hip or spine) and one of: • a vertebral fracture within 24 months • history of ≥2 osteoporotic vertebral fractures • very high fracture risk (e.g., as quantified by FRAX)Risk factors currently not accounted for in FRAX • Thoracic kyphosis •Nutritional deficiencies: calcium, vitamin D, magnesium, protein • Height loss (> 4cm) [note that vitamin D deficiency may contribute to fracture risk through undermineralisation of bone (osteomalacia) rather than osteoporosis] • Falls and frailty • Inflammatory disease: ankylosing spondylitis, other • Medications: inflammatory arthritides, connective tissue diseases • Some immunosuppressants (calmodulin/calcineurin phosphatase • Endocrine disease: hyperthyroidism, hyperparathyroidism, inhibitors) Cushing’s disease, type 1+2 diabetes • (Excess) thyroid hormone treatment (levothyroxine and/or • Haematological disorders/ malignancy liothyronine). Patients with thyroid cancer with suppressed TSH • Muscle disease: myositis, myopathies and dystrophies are at particular risk • Asthma, chronic obstructive pulmonary disease • Drugs affecting gonadal hormone production (aromatase inhibitors, androgen deprivation therapy, medroxyprogesterone • HIV infection acetate, gonadotrophin hormone releasing agonists) • Neurological/ psychiatric disease e.g. Parkinson’s disease, multiple sclerosis, epilepsy, stroke, depression, • Some antidiabetic drugs dementia • Some anticonvulsants Bariatric surgery and other conditions associated with malabsorption • Some antiretrovirals Able to be accommodated in FRAX by proxy, by entering ‘yes’ in the rheumatoid arthritis inputApproximate adjustments and considerations to aid interpretation of FRAX https://www.nogg.org.ukSlido 3 If you identify patients at risk of osteoporosis, what actions do you complete? https://wall.sli.do/event/wKz7VDorSJTqrbx2jWuWKi?section=8a007482-eb84-499c-84a5-2104daa3032eInvestigations to consider in osteoporosis / fragility fracture https://www.nogg.org.uk Anti-fracture efficacy of approved drug treatments for postmenopausal women, and men, with osteoporosis when given with https://www.nogg.org.uk Oral bisphosphonates – clinical flowchart for long term treatment and monitoring https://www.nogg.org.ukSummary of osteoporosis treatmentsLifestyle and Dietary Measures • In postmenopausal women and older men (>50 years) at increased risk of fracture a daily dose of 800IU cholecalciferol should be advised. • In postmenopausal women and older men receiving bone protective therapy for osteoporosis, calcium below 700 mg/day, and vitamin D supplementationintake is considered in those at risk of or with evidence of vitamin D insufficiency. • Regular weight-bearing exercise should be advised, tailored according to the needs and abilities of the individual patient. • increased risk of fracture and further assessment and appropriate measures undertaken in those at risk. Case Study • Adcal D3 caplets 2 bd • 77 year old lady with PMH of PMR, OA, Wedge • Alendronic acid 70mg once a week fracture of thoracic vertebra, Hiatus hernia, • Butrans patch 15microgram once a week - troubled by rash caused by this • Candesartan 8mg od Diabetes, Depression, IBS, GORD, • Clobetasone cream – irritation caused by butrans Hypothyroidism and Hypertension admitted with • Codeine 30mg nocte, takes additional doses if going for an appointment new onset back pain after bending. Diagnosed • Double base • Ensure compact liquid one bd with new T9 fracture on imaging. • Esomeprazole 40mg od • CFS 5/6, maternal hip fracture x 2 • Levothyroxine 75microgram om • Metoclopramide 10mg tds • BMI 17.1, current smoker 10 per day, hysterectomy aged 38, • Mirtazapine 15mg nocte • Movicol one prn • Last DEXA result • Nizatidine 300mg nocte • Paracetamol 1gram qds • Lumbar spine T-score: -3.9, Z-score: -1.5, • Rosuvastatin 10mg od • • Salbutamol prn Left femoral neck: T-score: -2.5, Z-score: -0.4, • Total left hip: T-score: -3.0, Z-score: -1.2. • Temazepam 10mg nocte • Trimethoprim 100mg nocte • Osteoporotic Fracture: 38% Hip Fracture: 26%ros-op-standards-november-2017.pdf (theros.org.uk)T ake Home Messages • Fracture prevention is everyone’s business • established in all care settingsents at risk should be • should be established to ensure effective management of osteoporosis • Advice and guidance services are available to support primary care clinicians • Ensure falls risk is managed in patients who are at risk of fragility fractures • Only by working together can we improve outcomes as the problem of fragility fractures is likely to increase • Identification and treatment of osteoporosis is covered by QoFUseful resources: •Osteoporosis - Prevention of Fragility Fractures NICE CKS Guidelines (updated Apr 2023): https:// cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/ •FRAX Calculator UK (Link from National Osteoporosis Guideline Group UK: https://frax.shef.ac.uk/ FRAX/tool.aspx?country=1 •WHO Falls Management: https://www.who.int/news-room/fact-sheets/detail/falls •National Osteoporosis Guideline Group UK: https://www.nogg.org.uk/full-guideline/section-4- intervention-thresholds-and-strategy •https://www.nogg.org.uk/full-guideline/section-7-strategies-management-osteoporosis-and- fracture-risk •SIGN Scottish Osteoporosis Guidelines (discussion of evidence for links between PPIs and Osteoporosis on page 27): https://www.sign.ac.uk/media/1812/sign-142-osteoporosis-v3.pdf •Osteonecrosis of the Jaw relative risk discussed on page 37 of National Osteoporosis Guideline Group UK: https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2021-g.pdf •Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus, Journal of Bone and Mineral Research. Khan A et al 2015: https:// pubmed.ncbi.nlm.nih.gov/25414052/ •Flow Chart for Oral Bisphosphonates long term treatment and monitoring NOGG Guidelines: Page 35: https://www.nogg.org.uk/sites/nogg/download/NOGG-Guideline-2021-g.pdf •Royal Osteoporosis Society Resources for Primary care Osteoporosis resources for primary care | ROS (theros.org.uk) •RCGP Learning on osteoporosis Login | Royal College of General Practitioners (site.com)