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Hello, everyone. Uh, good evening and welcome to our primary care event. I think I was saying to Julie earlier, you can tell that she's somewhere nice and hot and I'm somewhere nice and cold. Um, tonight Julia is gonna talk to you about um, what you need to know about bone health, you know, and if you have any questions, pop them in the chat and we'll get round to them at the end, we will have a couple of polls going. So please answer those as and when they pop up on the screen, um, feedback form will be in your inbox at the end of the event. Please do fill it out, fill out future learning that you would like, fill out things er, about, er, the event that you liked or disliked or whatever. We'll be passing all of these on to Jua. Um, and then once you fill out a feedback form, your attendance certificate will be on your medal account. So without any further ado I'm going to hand you over. Thank you, Jua. Thanks very much. So, hi, everybody. It's a pleasure to be invited to speak to you today about bone health uh the theme of my talk is uh what primary care practitioners need to know. I'm hopefully going to get some interaction from yourselves because the idea is obviously that we, we're going to get feedback. And as sue has said, we'll do a couple of polls during my talk. So really, really happy to be here. My job is a consultant pharmacist in frailty and one of my subspecialties is looking after the bone health clinic. So what we're aiming to do tonight is define osteoporosis, discuss the impact of the condition and also learn about therapies and obviously, we are taking the primary care lens. Uh with regards to this aim, the objectives are, you know, understanding your role in identification and treatment. Um Having a little bit of a discussion around referral pathways and a quick case study and as we've said, um hopefully having a good Q and a session at the end uh where, where you can ask whatever you wish to ask about, but health um so we'll start off with a poll uh and it will appear on your screen just as I talk, I would just like to ask you what your current level of confidence is in managing bone health. Uh The options are obviously on your screen. Do you feel very confident, confident, neutral, not confident or not confident at all? So will I be able to see the results of the poll? Yeah, so we have got, I didn't think of that without the second screen, we have got 3% are confident, 9% 3% are very confident, 11% are confident, 60% are neutral and 22% not confident. So mainly neutral, neutral, Okie Dokie. So hopefully some of this talk will be helpful to you. Um You know, no matter where on the spectrum you are. And obviously, I'm really looking forward to some good interaction and and questions at the very end. So just starting off at a very beginning, um you know, the, the simple definition of what, what is osteoporosis and to be honest, as, as health care professionals, we we've not really had a definition for quite a while. So when we think about osteoporosis and we're explaining it to our patients again, uh outpatient perception of what this disease is is somewhat, not really always well informed. So it's just worthwhile starting at the very beginning. So, osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue with consequent in bone fragility and susceptibility to fracture. Uh So the way I tend to explain this to my patients is uh describing bones as a honeycomb uh structure. And obviously, some of those honeycomb walls uh not being there within uh the actual bone structure. So you may not feel any different if you have osteoporosis. Uh But unfortunately, we often find uh osteoporosis after a fragility fracture has occurred. Uh It's estimated that there are 3 million people in the UK suffering from osteoporosis. So we do know that there is a gap between a number of people who have actually got the condition and the number of people that are diagnosed and and therefore treated with it. And in terms of numbers of fragility fractures, well, um these are significant uh around more than half a million of fragility fractures present hospitals in the UK. And the cost obviously is significant around 4.5 billion when this paper was written again, just wanting to um highlight to yourselves that less than a third of those patients receive bone protection treatments. So we do have a significant treatment gap between uh people that suffer fragility fractures and those that receive treatment. So just a couple of pictures really underlining what the difference between a healthy bone and osteoporotic bone. And and obviously, this is image of a vertebrae. Uh So you can see what that actually looks like in real life. Um Common sites for uh fragility fractures are wrists, spine and hip. So if we continue the definition, so as we've all already mentioned that the problem with osteoporosis is of it's often asymptomatic and we only find it when that actual fragility fracture occurs. Um We define a fragility fracture as one that's sustained from a fall from standing height. Although you will have patients who have suffered vertebral fractures which can occur spontaneously or as a result of routine activities such as bending or lifting something that I find in clinic often is that patients have a vertebral fracture, which we might see when we order imaging for other reasons. And uh they're not always communicated that uh you know, they have had a vertebral fracture and therefore sometimes this comes as news to them in the specialist clinic. So again, from your perspective, um you know, that detailed being uh in the communication from hospital, if you are ordering imaging and finding the vertebral fractures, it's just important to note these as you know, alarm bells ringing with regards to the risk of osteoporosis in sorry, could I ask you just to move your mic slightly away from, you know, when sometimes it it it catches a little bit? Mhm. That's perfect. Perfect. Perfect. Thank you. Yes, that's perfect. Thank you. Sorry. No problem at all. Um So in terms of the World Health Organization definition, uh osteoporosis is defined as 2.5 standard deviations below the mean peak mass. And obviously, we obtain these values by obtaining a dexa of the femoral neck and a reported T score. So just to uh have a pictorial representation of this, uh when we uh order a dexa scan, osteoporosis is defined as at score, that's minus 2.5 or less at the femoral neck. Um anybody that has at score between minus one and minus 2.5 will be diagnosed as osteopenia and values which are greater than minus one are defined as normal bone. It's just again important to note that BMD measurement does not assess the structural deterioration in bone. And consequently, you will see quite a significant number of osteoporotic fractures in women who do not have osteoporosis as defined by who. So it is worth noting that people who have had osteopenia on their dexa scan but have had fractures would also be suitable for treatment in terms of the actual natural course of developing osteoporosis. So this is just a pictorial representation with regards to reaching peak bone mass. So really when we're thinking about interventions for improving bone strength, we should be targeting people at that peak uh bone mass age. So for people who are, you know, around 30 to 45 when we reach our peak bone mass, and we know that the loss in terms of uh uh bone mass is more significant in females uh rather than males. Um But the age when osteoporosis actually becomes apparent depends on both the peak mass that you reach. And this is dependent predominantly on genetic factors, but also your sex hormone levels, your nutrition and how much physical activity you have. And the other aspect which obviously defines uh when osteoporosis becomes apparent is the rate of bone loss. And this is dependent on an estrogen deficiency in women and decreased test testosterone in older men as well as hyperparathyroidism. In terms of the impact of fragility fractures. So again, this is something that is often underestimated both by our general population, but also perhaps by um government and people who formulate investment in the healthcare service. So the fragility fractures, when we consider disability adjusted life years, this is basically some of the years are lost due to premature mortality and the years left with disability due to prevalent cases of the diseases. We see that fragility fractures are four in terms of disease burden. So that's ahead of uh conditions such as stroke, co PD Parkinson's disease and rheumatoid arthritis. So just to underline that fragility fractures are really burdensome with regards to um changing the life course of our patients and the estimated lifetime risk of hip fractures, which again, we know have got really significant risk of mortality and disability is 70.2% for women aged 50 years and over and 8.3% for men aged 50 years and over. So it's really something that's probably under recognize as a risk. And I'm really grateful that, you know, we're talking about this tonight as, as I'm hoping that we, you know, continue raising the actual profile of the disease, identification and early treatment. So we'll just move on to another quick Paul and I'm grateful to sue for just reporting back. Do you have a strategy where you work to identify patients who are at risk of osteoporosis as part of your current practice? So, the options are. Yes, it's practice nurse. L. Yes, responsive to new fracture diagnosis. Yes. As part of frailty assessment. Yes. As part of the LS referrals back to primary care. Yes, via other route or no. There is no strategy to identify patients at this current time. Oh, we have 26 responses so far. So we have um 3% saying yes, practice nurse. L we have 21% saying yes, responsive, responsive to new fracture diagnosis. 15%. Yes. As part oh gone up to 23% as part of frailty assessment. Zero. Yes. As part of F LS referrals 10 via other routes and 42 no systems currently in place. So your majority is no systems and then the frailty and then the fracture diagnosis. Thank you very much. So, so again, this is just to illustrate really um you know what aspects we might think about with regard to identification of relevant patients. I completely agree with colleagues who do this as part of frailty assessment. This is part of what we do as a comprehensive geriatric assessment for all of our patients that present to secondary care. And it's good to see that's also the case in our primary care environment. And I think we still have work to do on the fracture liaison side. And again, I'm not surprised that there's not many colleagues who are receiving referrals via this route. We do need to have better identification of patients at risk um as as evidenced by colleagues who do not have a strategy to identify patients at risk. So if we start off at the uh who should actually be assessed for fracture risk, there's a number of publications which you might find useful. Um The nice and obviously the more recent nog guidelines from 2021 will define who should be assessed for fracture risk. And it does say all women age 65 years and over and all men age 75 years and over. So our kind of frailty assessment definitely fits within the national guidelines and then apologies. This is now a very busy slide but all women who are 50 years and over and all men who are 50 years and over with, you know, specific risk factors. And there's many of these really your your previous osteoporotic fragility fracture, as you have told me is a real, you know, strong alarm bell for identification of patients that's at risk. But we've got lots of other things. So steroids, uh low BMI S falls, smoking alcohol, and the whole plethora of secondary causes of osteoporosis. So there's there's a lot on there. I apologize for the busines, but this is really to underline that there are many patients really who should have a fracture risk assessment. And I suppose it's thinking about our systems and how we inbuilt these fracture risk assessments as part of our routine practice to make sure that there are no patients who miss out when we think about risk factors for osteoporosis. Again, these are varied and some of these we've we've mentioned in terms of the assessing the patients, I've segregated them on this slide in the group which are independent of your bone mineral density measure. So again, the age as we've noted from no guidelines is important. Uh your previous history of a fragility fracture, really strong indicator of risk. And, and, and again, we've got more and more evidence about early treatment and managing patients where we identify fragility fracture much much sooner because of what we now understand uh something called imminent risk of fracture. So we know that the risk of refracture is really most significant in the 6 to 12 months post index fracture. So, identifying patients and getting them on the treatment early is now recognized as a priority. We've got other risk factors independent of BMD such as maternal history of hip fractures, steroids. As you've said, lifestyle risk factors, low BM I falls, um the actual ethnic origin of the patient and, and where they live. So latitudes further from the equator at all the risk factors for osteoporosis. And then on the right hand side, we've got those which are dependent on your BMD. So things like premature menopause, untreated hypergonadism, all the malabsorption syndromes that we've seen on the previous slide and lots of other uh conditions uh which again would, would kind of give us uh risk factors. So just to kind of summarize the risk of a person suffering an osteoporotic fracture depends on their personal risk of falls. The bone strength as measured by the bone mineral density, as well as other risk factors. So we do know that fracture risk increases progressively with a decrease in their bone mineral density. But as we've already said BMD is poorly sensitive at predicting fracture risk when used without considering other factors. Uh So this is just again to highlight just, you know, having a Dexa, which gives us a reassurance from the BMD perspective is not quite the end of the story. We do need to consider patient as a whole when we're thinking about osteoporosis. So we've got calculators you can use to approximate an individual's risk. But I think the most important part is that clinician review. So once your calculator suggests what should happen next with your patient, it then obviously, you know, having a conversation and review of your patient and making sure that you as a clinician agree that the recommended action is the best course to follow. I always, you know, do lots of shared decision making and individually tailoring management plans to the patient needs. And I always, you know, just very much advise if there are any questions or if you're in doubt, speak to experts again, from from what we have in our locality, we've got open advice and guidance to primary care clinicians. So if you do have any bone health management queries, you can send an ag request to us in the geriatric department and we will obviously advise appropriately. So, you know, if there's any question marks from your perspective, I'd always say, do not be afraid to ask that question. So the calculator obviously that we used at the nog uh advises us to use is Frax and, and the link again to the Frax calculator is just on this slide. I'm sure quite a number of colleagues would be familiar with this, but just in case you've not seen it, obviously, the flag of the nation is on the in the right hand corner. And you know, you need to select the right uh country for when you are using the calculator. And it's a relatively simple tool to use in that you, you you are entering a person's age, height, weight, sex, you know, other other information as per the screenshot. And very quickly it calculates the risk of that person having a major osteoporotic fracture and having a hip fracture. So these numbers are obviously interesting, but the best bit of the Frax is that you can click into the view, no guidance uh screen. So where this takes you on to an actual graph, which is where you can visually see where the person plot with regards to their 10 year probability of major osteoporotic fracture. And with the latest NOG update from 2022 uh when obviously you can have um lifestyle advice, recommendation, measure your BMD recommendation treat. And now this is the, the the newly added section where you are basically advised to consider specialist referral and treat. So these are your highest risk patients with regards to their risk of suffering an osteoporotic fracture. And the definition of that high risk somebody with at score of three minus 3.5 or less. And that's at the hip or the spine or at score, that's minus less than that's equal to a less than minus 2.5. And having suffered a vertebral fracture in the last two years, history of two or more osteoporotic vertebral fracture or very high fracture risk as calculated by a frax. Um So obviously, we use Frax as part of our bone health assessment routinely in frail patients. We again know that the actual risk of fractures is significant and I would again encourage colleagues who have not perhaps used this tool to just have a look at it because it is quite easy to use. It take very long. And it does give you advice at the uh you know, at the at the other side, which is useful for busy clinicians. You can see, you know, visually as to where your patient plots and it's quite powerful again to show it to your patients because you can say, well, you know, this is what your fracture risk is. This is what I'm going to do next. With regards to trying to mitigate it. So, whilst Frax is a really good tool, it's just important to note that there are some risk factors which are not currently accounted for in Frax. And again, there's a, there's a new version of Frax plus which is currently in development, but just to kind of give you a little bit of an overview. And again, I apologize, this is a very busy slide, things that you might think about risk as a as risk factors for osteoporotic fractures such as thoracic kyphosis loss of height, you know, really quite significantly falls and frailties. So I've put those in bold and lots of other things. Uh So they're not outwardly on the frax calculator. Now again, just noting that some medication will influence a person's uh fragility fracture risk and all of those are really up to us as clinicians to think about somebody with Parkinson's disease. Again, for example, will have approximately 2.4 times higher risk of suffering a fracture than somebody without Parkinson's disease. So if you do find that your patient fits into any of those categories, you can actually accommodate the current Frax calculator by entering yes, in the rheumatoid arthritis input. And what that will do is that will adjust the calculation for all these other things which you might have in your patients. So again, this is in the log guidelines as a recommendation to cover all the other possible conditions which can influence an individual's risk of fracture. And again, just thinking about approximate adjustments and consideration to, to aid interpretation of Frax calculations. So we'll just draw your attention to the falls history because this is again, really quite important. So if you are looking after patients who have had two or more falls in the last year, the major risk of osteoporotic fracture and hip fracture probability increases by 30%. So, whilst the Frax calculation may not be really, you know, very, very high. If they've got significant false history, we need to account for the fact that the fracture risk is higher. So again, all of this is in the no guidelines which uh which I've put on the bottom of this slide if you want to have a further read of that. So we're just going to move on to our final poll of the evening. Um So I would just like to ask if you for patients that you identify as being at risk of fragility fractures, fractures, what actions would you take? And you can obviously be selecting more than one from the following. So treat with bisphosphonate if appropriate, optimize calcium and Vitamin D ensure that falls risk is minimized. Refer to specialist if needed, continue specialist treatment under a shared care protocol such as denosumab or anything else. If you have a an other option, please pop it in the chat and I can read that out to you. Ok. So for this we have. 00. Is everyone done? So it, oh, it's actually nearly in the right order. Uh, at the top of the list, we have treat with the oral biops. Yep. And then next we have, uh, that's at 46 that's nearly half. Um, uh, 45. Now, er, 28% optimized calcium, 9% insurer falls risk is minimized. Uh, 5% refer to specialist, 7% continue, specialist treatment and 3% is other. Ok. Fabulous. So, obviously, oral bisphosphonates are still our first line treatment in terms of managing patients who are at risk of fragility fractures. So, um you know, treating appropriate cohort of patients is absolutely, you know, paramount um in terms of your investigations for these patients that you've identified as being at risk of osteoporosis, again, these are the things that we would routinely consider. So, you know, your routine part of investigations will be history, physical examination, you know, really thinking about height and thoracic kyphosis as the aspects that you want to uh dig out. Um and in terms of the, the bloods, which we would be ordering, they're all on your screen. Um Further kind of more specialist things are on the right hand side of this slide. And obviously, these would usually be under the direction of, of the specialist rather than something that you might do in a primary care setting. And now I'm just going to show you a summary of efficacy in terms of approved drug treatments and this is for post menopausal women and men. So again, just referring back to our poll with regards to calcium and Vitamin D optimization, just important to note that obviously evidence with regards to treatment options for osteoporosis was all implied and carried out with people who were supplemented with calcium and Vitamin D So you will often see, you know, calcium and Vitamin D co prescribed with treatments for osteoporosis as I'm sure you are familiar. So what we now just want to kind of tease out is that we've got treatments are superior to oral bisphosphonates with regards to vertebral fracture prevention. And this is what the again, no guidelines suggests really for those patients who have got that high risk and people who have had vertebral fractures in the past, we should be thinking of offering them treatments such as teriparatide and obviously the newest kid on the block Ramosu because we have evidence of them being superior to risedronate and alendronate respectively. So it's just really for your benefit. If you are, if you do have patients who are on oral treatments who have had a number of fractures or who fall in that high risk category, they may benefit from being referred for a specialist review with regards to these, you know, more, more effective treatments for fracture prevention. We have moved to using a lot more in a way of alendronate as well. In terms of hospital practice, you know, we've got really good data, not only on fracture prevention, but this, you know, emerging data around mortality for IVS Alendronate. And again, if you work in Scotland, IVS Alendronate is the first line treatment for people who are admitted to hospital with hip fracture, providing that their renal capacity allows. So there's obviously increasing use of injectable therapies. I think overall as a trend in osteoporosis practice, and I certainly have, you know, a significant percentage of patients who are on the nos. Again, we've got good evidence of, of of benefit. It's a useful agent if you've got patients in, in the kind of frail cohort who have got renal issues as you can use it in, in, in, in people who've got calculated clearance, which is less than 30 mil per minute. And again, it's a subcutaneous injection. So from the perspective of patient acceptance, it's, it's relatively, you know, easy to adopt. It's not treatment burdensome, it's only given once every six months. So, you know, I do have quite a significant number of people also on the nos therapy. So just important to note for any of those colleagues who weren't doing the via the shared care. It's, it's a treatment that needs to be given regularly. And you know, we need to make sure that we're giving it around about the six month mark, you can give it as a prolonged course of treatment. But if for whatever reason, the nos is stopped then it does need to be followed up with um usually a bisphosphonate as an antiresorptive treatment. Uh And that's because uh if you leave a person who was on denosumab without anything on the other side of it, the gains achieved with denosumab are lost. And there is a risk of something called a rebound fracture because you are, you get a quite a kind of significant decrease in your bone mineral density. So it's just important if you do have any patients who are on denosumab, um to make sure that there are no significant treatment gaps and if the treatment is stopped to think about uh consolidation therapy. So in terms of the um nog guidance, again, there is a useful flow chart for, as we've said, the most commonly prescribed initiated treatment in primary care, which is oral bisphosphonate. So this underlines what we would expect in terms of long term treatment and monitoring and um surmise is really what, what the best evidence is. Um So again, the thing that's changed with the latest edition of NOG is that a person that's aged 70 or over and has been identified obviously as being at risk of fragility fractures, you can start a bisphosphonate and counsel the patient for 10 year of treatment. Obviously, traditionally, we start and counsel the patient for five years. But um if the patient fits um the the you know, age of 70 with a previous hip fracture or two or more vertebral fractures or they're taking the steroids, you can actually start off intending to offer prolonged course. I mean, I still always tell patients that if I'm discharging them to the care of the GP that their treatment will be reviewed at the five years. And that's obviously quite a lot of my patients are frail and, and their needs might change in the five year course. And again, it's just a helpful point for them to understand that they should have a review of treatment at that point to just to really look at all the, all the different things which can change their risk of fracture to, to look at, you know, their frailty at that point and to make sure that it is still appropriate in line with their needs. So, uh you know, the kind of no guideline does allow continuation for 10 years. And then at the end of that, a decision with regards to ongoing management on individual basis and obviously appropriate treatment holidays, if you are reviewing that at five year point and five, finding that uh the patient then becomes uh you know, scores under the no intervention threshold and their T score is greater than minus 2.5. And I think importantly, the falls risk is minimal because I always think about falls when, when I'm thinking about bone protection. So I will just summ your treatment options with what I believe is a really nice slide from the British Journal of Pharmacology and it does just summ all the treatment options are available. Obviously, not all of these will be used in primary care environment, but it's just really to give you an idea as to how these different agents which we now have at our disposal work. So, as I've said, there's a huge kind of move towards using um using things like the PTH analogs. We've just had the newest one approved a few weeks ago. Um So the teriparatide, obviously, we know has got superiority for the vertebral fracture cohort. And we've got these uh you know, as anti sclerostin antibodies, which which is the ramosum and, and this drug obviously has duality of action. So it lays down new bone as well as being anti resorptive. And this is where we see like really the most significant bone mineral density gains in our populations. And obviously, both of these drugs have got their own individual cautions. So, for example, for Ramo Suum, um there is a small risk of cardiac events. So we undertake a cardiovascular assessment for patients that are being started on this treatment. In terms of the PTH analogs. Obviously, we would make sure that all their bloods including the PTH are suitable for treatment initiation. It is not appropriate for anybody who's had previous radiation therapy for cancer treatment. So again, taking a good history is important and both of these treatments are both the teriparatide and the rosum needs to be followed by anti resorptive because you lose the benefit a little bit like you do for denosumab if you leave your patient without anything at all. So this is just again, just to kind of show you what the treatment options are very much moving more and more uh to using the injectable therapies. And I think towards using therapies much sooner than perhaps we historically used to. Um But yeah, this, this gives you the summary of the treatment options. It's also always important to think about lifestyle and dietary measures. So as we've already noted, we do supplement routinely cholecalciferol in a dose of 800 units in those patients who are at increased risk of fracture. Again, when I speak to patients with regards to dietary intake, I often find they don't have really sufficient amount of calcium in their diet. So we would do the supplementation use usually both calcium and Vitamin D together particularly if treating them with anti resorptions, which can obviously affect their calcium levels. We do advise regular weight bearing exercises and obviously tailored to the individual patients needs. So the combination of resistance based exercises with um with exercises which challenge their balance. So I usually talk about things like gardening or yoga or tai chi. And both of these strategies are found to be helpful with regards to improving their bone health. And again, as I've already noted, a number of times really falls history should always be obtained. And always think about, you know, what other interventions would be needed to reduce the risk of falling because we can be on, you know, the best treatment that you can offer from the osteoporosis perspective. But if that person's falls risk is not addressed at the same time, unfortunately, we would not be doing them, you know, the best of service. So absolutely, always check the falls history and think about further measures to reduce the falls risk. So that's all my slide. With regards to theory, I do have a quick case study really just to illustrate some of the points that I have mentioned. And then uh we will get stuck into Q and A which I hope will be uh of interest to you. So this is again a real life uh presentation, 77 year old lady, uh previous medical history of PMR, but not on steroids. Currently osteoarthritis, uh thoracic vertebral fracture, hiatus, hernia, diabetes, depression, ibs go hypothyroidism and hypertension. And she actually presented with new onset back pain after bending and we diagnosed a new T nine fracture on imaging on her frailty assessment. Her clinical frailty score was between five and six. So she was between mild and moderate in terms of frailty. She required some help with regards to her daily activity and she had a family history of hip fractures. Her BMI was 17, she smoked at the time of presentation and had a hysterectomy age 38 with no follow up HRT on her Dexa scan. She had a really quite significantly um low uh T score in the lumbar spine and the total left hip hip T score of minus three. So this gave the osteoporotic fracture risk of 38% and a hip fracture risk of 26%. Both of which are high figures. Um I've just listed all of her medication on the right hand side and really to kind of illustrate um what treatment options would be at this point. So she had already had alendronic acid. And despite the alendronic acid, again, it's always worthwhile checking the compliance. So the first question was, you know, have you been taking it? We often find that people are not too keen on alendronic acid. They don't like the fact that they have to, you know, stay upright and do it first thing in the morning, quite often. Compliance is not very good really with oral bisphosphonate. But um this lady obviously has also got hiatus, hernia and gastros vagal reflux disease. So it's lots of reasons for us to to perhaps review the oral bisphosphonate. And again, to me, the most importantly, you know, she, she has had new fracture despite the oral bisphosphonate. So we definitely look to escalate her treatment with regards to her osteoporosis. And obviously, the Dexa does tell us that she's really got significant high fracture risk going forward. So in terms of our treatment options obviously, because she's had a number of vertebral fractures. In the past, we would uh consider raum. So look at her cure risk for cure risk score. Again, she has got um uh obviously history of hypertension. Uh So when we talk about patients and and the kind of cardiac risk and raum, often we get the reluctance of patients to kind of consider this as a treatment option. And really the next best thing we could offer her is teriparatide because she said uh multiple fractures. So the conversation around uh appropriateness of teriparatide took place with this patient, but she wasn't really keen on daily injections, which is what you would need to do with the teriparatide. So in terms of our kind of shared decision making within agreed to um you know, move her over to uh intravenous bisphosphonates. Again, this uh allows us to stop the alendronic acid. And we know that obviously fracture risk will be significantly reduced even after that first dose of IV is alendronic acid and her renal capacity was sufficient for us to do that. Um The other things that we did with this lady is obviously look at her falls risk. She's on a number of medication which can increase her falls risk. So it obviously chronic opioid use is one to think about. Um and temazepam as, as a benzodiazepine is one where we could have a conversation around potentially uh looking at the high risk falls drugs. The other thing to, to think about in a moderately frail person is just checking her lying and standing BP. She's obviously on Candesartan to manage her BP. Uh She also takes Mirtazapine and, and as we know in a frail older person, antidepressants themselves can increase the risk of postural hypotension. So we definitely should be checking the L and standing BP and review the prescribed medication. Um So hope would be that obviously, by taking away the alendronic acid, we can try and mitigate some of the gastric complaints. She's on quite intensive treatment for her uh gi reflux symptoms. She's on high dose PPI as well as being on histamine two receptor antagonist. So, nizatidine, so, you know, at the same time as doing her bone health, we we, we take the opportunity to look at her polypharmacy and also um you know, do counseling around smoking cessation as a really important factor with regards to future fracture risk. And again, something that's actually within uh a patient's gift to change. So, so you can positively change uh your, your kind of lifestyle habits. Um And, and hopefully, you know, kind of reduce your fracture risk going forward. And again, in a patient like this, it's just important to keep an eye on the BMI because obviously she's uh kind of uh uh heading towards a low side of things. So, looking at her nutrition, her intake, uh and we've got the compact liquid on her prescription. So how is she getting on with the supplementation? Is there anything else that we need to do really to, to boost her from the nutritional perspective? So, just to finish off again, we've talked about identifying patients who are at risk of fractures and this is from the role of osteoporosis society standards with regards to identifying patients. So, as I've already noted, and I think you've told me in terms of your poor results, we do need to be better at identifying patients at risk. We need to have fracture liaison services who pick up those low risk patients, obviously complete a bone health assessment. From your perspective. As primary care colleagues, you know, you, you need to be given that information if if we are identifying um fractures as incidental findings, you know, we need to have a kind of reaction that follows on from that. So patients who have had fragility fractures need to be identified more effectively. We as clinicians obviously need to think about our own systems for identification. And once we've identified, identified those patients at risk, we need to understand what our local referral pathways are with regard to treatment initiation. So obviously, if you are referring patients within your locality, who do you refer to, if you want to seek advice from a specialist, how would you go about that is worthwhile? Just thinking about your own local, set up, understanding what the processes are and perhaps then thinking about any gaps in the service and what can be done really with regard to addressing those obviously role osteoporosis societies, campaigning alongside many of us who work in the field for universal fracture, liaison prevention. Um And, and I know in Wales, um they have universal LS starting from September of this year. So this is very much a model that we want to replicate in England with regards to identification of patients. And as, as I've already said, we do know that initiating that treatment early really makes a difference. So we need to be identifying and treating patients uh much earlier on that we have been doing historically. So just finishing off with the take home messages and giving us 15 minutes for AQ and A I would just like to say that fracture prevention is everyone's business and it's not just my job, it's not just your job. Absolutely, everybody is on this page. I think the method of identification of patients at risk should be established in all care settings. So again, it's a little bit of reflection in your own environment about how that happens. Referral pathways from primary to secondary care should be established to ensure we effectively manage osteoporosis. And as I've said, advice and guidance services should be available to support colleagues who work in primary care. Please don't forget falls risk. If you're identifying patients who are at risk of fragility fracture, I think only by working together can we improve outcomes as we know that we're going to see more and more fragility fractures as our population ages. As we see, obviously more in a way of frailty identification of treatment of osteoporosis is actually covered by. And there is specific ROS guidance ROS tools colleagues who work in primary care can utilize. And I've summed some of these on my final page with regards to the useful resources, I think I use ROS a lot. There's a specific part of their website which is dedicated as resources for primary care. But I know I use their patient information leaflets in my clinical practice. There's the Royal College of GP learning on osteoporosis. And again, I would highly recommend that because that is a really useful starting point for colleagues who want to develop a further skill set within this field. So I will end there. Um Obviously, and we're gonna hand over to sue with regards to Q and A and I'm going to stop sharing um with a bit of luck. Very good, well done. Um So we've just got a couple of questions in the chat, but I'm sure more will come. Um But one of them refers back to your uh there was a slide that you did. Um It was the approximate adjustments and considerations to aid interpretation of FRAXs at F Rx. And uh Rachel asks what, what does N AE mean on the slide? OK. Let me go back to it. So it's A these are the no, that's absolutely fine. So these are the adjustments which are in the no guide lines. So basically, it tells us um what we should be thinking about alongside the Frax calculation. The most important thing we need to take away from the primary care point is the falls from that slide. So the reason I put that up there is, you know, the fact that if you have fallen two or more times, then you should be increasing your calculation by 30%. But N ae did we say? Yeah, I was there quite a few times. I did actually try and Google it but it didn't come up with anything. I can't see it on this slide. Was it? Um I'm gonna have to get back to that. If, if the person that's asking the question can send me just the, the actual slide that I'm going back to and I can, I can get back to you on and thinks it might be no, no available evidence. Let me see if I can find. 00 So this is this is then the treatment slide, the actual treatment efficacy slide rather than the adjustment to that. That makes more sense. This one here. Can you see my note? No available evidence? Yeah, that's, that's what it means. So, so sorry II, you sent me back to the Frax Frax adjustment slide and I could not see N AE but yeah, so, so basically ibandronate and hip fracture. We don't have available evidence and that's what the N AE stands for. And the same is the case for calcitriol for nonvertebral and hip fractures. Uh We do have some evidence for Calci trial for the vertebral fractures. Perfect. There we go. We've got another question. Sorry, Rachel. Yes. So I've got Andrea uh all high risk patients on frax score go straight to treatment not require. I think this is very individualized. Andrew. I think the way you would approach this is think about your Frax score. As the first thing that you would do, there will be scenarios where you will, it's not appropriate to do a Dexa scan. So your patient might have difficulty maintaining the sufficient position for the scanner to complete the scan. They may have cognitive impairment, they have learning difficulties. So there may be reasons why you do not wish to do a Dexa scan. So you can obviously utilize your Frax score to give you an indication as to what you should do next. And obviously, that will all be around your kind of clinic. Um clinical decision making. You know, what you feel is the next most appropriate course. I would say just in terms of offering Dexa, you know, would never draw uh you know, do not offer a Dexa scan based upon, I don't know, upper limit of age. I know obviously the Frax calculator stops at age 90. However, the Dexa scan is useful, not just from giving you your bone mineral density scores. We do a couple of other things with Dexa scans because the um the colleagues that will be completing the Dexa scan will do a questionnaire and can do thoracolumbar, uh xray x-ray scanogram at the time that they do a Dexa if there is any suspicion around vertebral fractures. The other thing that a Dexa scan is useful for is if, if you've got patients who are on prolonged treatments of antiresorptive, the actual scan can take place of bilateral femoral shaft. And we would be looking for any signs of remodeling of any changes which may indicate the risk of atypical fracture is there. So I would always think about Dexa scan. Um You know, if, if a patient is completing a course of treatment and I've got a Dexa scan from baseline, then I would be thinking of offering them a repeat Dexa scan because again, we go back to the point of osteoporosis being a silent condition. It's sometimes quite powerful to uh do that repeat at the end of the course of treatment and tell your patient. Well, actually your bone mineral density gain uh is such uh giving them some numbers and then obviously counsel and, and, and, and, and make the plan for follow on therapy. So I would say Dexa scan is useful for many reasons. Uh but obviously you can treat just using the frax based upon your clinical. Um opinion of the patient. Any other questions? Yep, we've got another one from Rachel. Yeah. So with patients who have regular short course of steroids for COPD exacerbation also need protection. Is there a criteria for this? I think that's a great question, Rachel. So I always kind of tease out my patients who have got rescue treatments and try and cumulate as to how many courses of treatment they've had in 12 months because again, it's something possibly that can sail under the radar. So if we go, if we go to the slide where we talk about Frax adjustments, there is a specific advice regarding the actual steroid use. So it it, it basically if you are taking the steroid use on your Frax calculator, it it assumes a medium dose uh between 2.5 and 7.5 mg daily. But people who have frequent exposure to oral glucocorticoids, uh I would still consider to have potential risk with regards to their fracture. So, you know, think about the cumulative exposure to steroids. Uh if they are uh if they are having, you know, I say two or more courses in a 12 month period, you may wish to consider those steroids. I think often I find patients who are in that cohort where they're getting quite a lot of steroid courses will also score on frailty um and other things which are kind of they need adjusting on Frax. So pretty routinely, I will be ticking, you know, the kind of rheumatoid arthritis box as well as other boxes to account for their actual fragility fracture risk. But yeah, it's a great, it's a great point. I think cumulative exposure, a number of courses is important. And again, the other cohort that, that I often get referrals for is patients who have got inflammatory bowel disease. So they obviously usually have longer courses of steroids. And again, it's important to account for that because we do, we do know obviously that that will impact on the fragility fracture risk. Ok. I've got a question from Walid. Are there alternative diagnostic methods to dexa available, especially in countries where Dexa scan is not accessible. So again, in terms of your kind of golden uh diagnostic tool, uh the way we would practice in the UK is by using a Dexa scan. I do know that there are other modalities available, but really the Dexa is the kind of if you look at a golden stuff with regards to identifying osteoporosis. So I would I would probably be inquiring in your local environment as to if there are any alternative methods. I think even radiological osteopenia in the context of limited resources can be utilized in terms of your kind of osteoporosis risk assessment. Because um you know, we would be thinking about radiological osteopenia alongside these other factors. So you could still utilize a Frax calculator in somebody who's got radiological osteopenia without necessarily having the BMD values, which is why I think it's a really useful tool and the Frax calculator will then give you what that person's individual risk would be. But yeah, there are other modalities for assessing bone mineral density. The gold standard would be Hologic Dexa scan. Peter says, thank you. When referring for Dexa and patient has a past medical history of cancer. Should I mention this? Can Dexa help with differential from fragility to pathological fracture in the lumbar spine? So it again, it's a really great question. Uh Peter. So we would obviously try and make the differential in terms of the nature of the fracture. Uh If the patient presents to us in secondary care environment, um obviously, people who have got pathological fracture may also have osteoporosis, but the pathways for treatment are often different. So what I would do for any referrals with patients who have got history of cancer is look at, you know, the nature of their cancer always check for any ongoing bone modifying therapy. So we've got a number of cancers where it's pretty routine now to use bone modification. So, you know, myeloma patients, a lot of our breast cancer patients will have uh adjuvant bisphosphonate. So they will be on denosumab for the oncology indication. And you obviously, in that case, then they, they will just remain on the oncology pathway rather than come across the bone health pathway. And the Dexa itself is not actually useful in terms of differentiating, I think the differentiation is obviously done via different imaging modalities. Um The the the kind of point would be that, you know, do we need to do that if a patient is on appropriate modifying therapy from the oncology perspective? And to be honest, my experience of this is there's lots of liaison with different teams. Again, kind of speaking to uh uh uh urology colleagues for patients who are on prostate cancer pathway. Highlighting to them, I know asking them whether it is something that they want to be uh looking after in terms of kind of fracture prevention going forward or if they are not for any uh uh bisphosphonate therapy under the oncology pathway, then obviously ask patient to come across to the kind of bone health pathway and looking after them from that and it's complex because different services will be different, will be providing um you know, different parts and aspects of the treatment. So I would say anybody with cancer is probably, you know, high, high kind of alert patient and it's worthwhile finding out um you know what they're on uh if they're on any adjuvant therapies uh from the oncology perspective, does, does the oncology team or does their treating team know about the fact that they've had a fracture just to make sure that everybody's looped in uh in that finding. So, uh quite a lot of that uh conversation should take place if the, if the fracture is discovered uh either in a kind of primary care setting or in the secondary care setting. Ok. Next question. Uh Jay says after a five year treatment with a bisphosphonate, how long can a patient have a drug holiday for? Again? Great question comes up all the time, doesn't it? And again, I think this is very individual. Um I would, I would use in my, in my patient cohort the frailty, the falls risk. Um the overall um you know, other things which are going on with the patient when we decide where we're deciding on a drug holiday. Uh You know, I would usually, if I'm quite satisfied, satisfied that the falls risk is low and there's not much in a way of other risk factors, then I would kind of suggest that we do a three year drug holiday, obviously, with the potential to review the situation, should anything change? So if they develop a new neurological condition, if, if there's, you know, if there are things which are going to impact on their falls risk, then I think the bone health conversation should also be reviewed at the same time. But we do again, we have really good evidence um from the bisphosphonate perspective, you know, that, that we do, we do get that sustained benefit even after the treatment is stopped. And this is one of the things that I obviously reassure patients with, if we are moving on to a treatment holiday. And I think that's our last question in the, I have never heard drug holiday in that term before. I see. This is why osteoporosis is exciting. Oh, J has just asked another one. Yeah. Do they need a Dexa to restart the, the bisphosphonate after a drug holiday? I don't think that you absolutely have had to have a Dexa. Obviously, you as a clinician will know what their risks are if you're thinking about restarting it. And as I've said, you know, there will be scenarios where Dexa is not appropriate if you are concerned, obviously, it's helpful to have a Dexa because you will have an up to date information with regards to your BMD and your fracture calculation. So if you can get one, it is helpful, but I wouldn't, you know, it's like everything else, isn't it? It's not an absolute you as a clinician uh with your patient coming up with a plan is the most important aspect really in terms of clinical practice. Perfect. That's wonderful. I think that's us. Does anyone else have any other questions at all? As always, your feedback form will be in your inbox. It should be there right about now. Actually, um Please fill it out. Um I think jua might come back again as well. It might be great. Thank you so much. I've done a 13 hour day, but it's been really, really great. I really enjoyed the conversation. It doesn't look like you've done a 13 hour day at all. But if, if everyone's happy, we will say goodnight. Um and we will see you at our next middle education event. Like I said, please fill out the feedback form. It's really important. We'll be passing that onto Jua. Um And maybe we can have her back for another talk. If there's something more you want her to go into, then we can maybe get her back and we can do some more talks. You've got lots of thank yous in the chat. That's great. Thank you so much for inviting us. We really appreciate it. Lovely. Take care everyone. Bye bye bye.