Update on Osteoporosis Dr Terence O Neill Consultant

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Update on Osteoporosis

• Dr Terence ONeill
• Consultant Rheumatologist

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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
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2001 Census
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Projected Rise in Hip FracturesUK
European Commission, 1998
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Reduction in vertebral fractures
Clodronate
0.5
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Case Finding Strategy
Risk Factor

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Risk Factors Indications for BMD

• Low trauma
• Steroids (oral) gt 7.5mg /day 3
  mths Hypogonadism menopause lt 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

• Bone Mineral Density
• Focus on T Score
• Out of Date

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Risk Assessment

• Age
• Gender
• Prior Fracture (after age 50 years)
• Parental history of fracture
• Current Smoking
• Alcohol intake gt 2 units / day
• Ever Corticosteroid use
• Secondary causes (e.g. RA)

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T Score
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http//www.shef.ac.uk/NOGG/
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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

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http//www.shef.ac.uk/FRAX/
OR
http//www.shef.ac.uk/NOGG
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Women with No Prior
60yr
70yr
80yr
No. Risk Factors
BMD
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NOGG - Treatment

• Alendronate
• If unable to take / intolerant
• Risedronate / Ibandronate / Strontium
• Raloxifene / Etidronate

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What about NICE?

• 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

• Alendronate (ALN) treatment of choice in
  post-menopausal women if T-score lt 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
Age lt 65 years independent clinical risk
factor for fracture clinical risk of low BMD
T-score of lt 2.5
Age 65-69 yrs independent clinical risk
factor for fracture T-score of lt 2.5
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NICE 160 Primary Prevention
Age 70 yrs independent clinical risk
factor for fracture OR clinical risk of low BMD
T-score of lt 2.5
Age 75 yrs 2 or more risk factors no need
for BMD
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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

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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