West Hertfordshire

1

• West Hertfordshire
• Management of Osteoporosis
• Bone densitometry service
• (DEXA)
• Consultants Adam Young
• David Collins
• Bone Health nurses Sue Woods
• Evelyn Jones
• Admin/Secretarial Kaye Gillard
• Terry McCourt

2
Prevention and treatment of osteoporotic
fracture. Issues in 1994.

• Primary or secondary prevention?
• Prevention or treatment for established disease?
• How best to select patients for treatment.
• How effective are currently available drugs?
• How good is the evidence?
• In whom and when should DXA be done?
• How big is the problem?

3

• Osteoporosis
• 1994 DoH RCP Advisory Group on Osteoporosis
• NOS
• 1996 EL(96) 110 HA should purchase BMD with DXA
• 1999 RCP Guidelines Evidence based
• Health care purchasers
• Health care providers
• Users of osteoporosis services
• 2001 NSF (older people) Fall prevention
• 2002 RCP Guidelines Steroid induced osteoporosis
• 2004 NICE appraisal secondary prevention ww
  w.nice.org.uk/article.asp?a97559
• 2005 NICE primary prevention

4
Clinical Risk factors for bone lossHigh risk
Low Risk

• Steroids
• Fracture
• Early menopause
• Amenorrhoea
• Hypogonadism
• Endocrine

• Family Hx (maternal hip )
• Osteopaenia (plain x-ray)
• Smoking
• Alcohol
• Malabsorption
• Low BMI
• Chronic disease/immobility
• Height loss/spinal deformity

5
Effect of prevalent vertebral fracture on
subsequent fracture risk (Ross et al. Ann Intern
Med, 1991114919-923)
6
Diagnostic workup in presence of osteoporotic
fracture

• FBC and ESR
• Calcium and Alkaline Phosphate
• Serum electrophoresis
• Urine electrophoresis
• Thyroid function
• Testosterone in men
• Oestradiol in amenorrhoeic premenopausal women
• Serum prolactin where appropriate

7

• West Hertfordshire. Osteoporosis
• 1994 Advisory Group on OP - Multidisciplinary
  response
• Local guidelines
• PGC lectures, working groups
• 1996 Osteoporosis Steering group
• Clinical audits - community/GP
• - rheumatology
• Seminars with HHA (DXA)
• Local Support Groups
• Revised guidelines
• Option appraisal business case for DEXA
• 1997 DXA at St Albans
• 1999 Appropriateness of referrals
• 2000 RCP/NOS Guidelines
• 2001 Pilot forearm DXA, business case for Lunar
  prodigy
• 2002 Elderly care NSF - PCTs
• 2003/4 3rd edition local guidelines

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Clinical audit of management of osteoporosis.
Proportion of treated and untreated patients
in major risk groups in 11 GP practices
9
Clinical audit of osteoporosis managementProporti
on of rheumatology outpatients at risk of
osteoporosis and those treated
10
Indications for use of DEXA

• Patients at very high risk
• early menopause
• steroids
• prolonged amenorrhoea
• previous fragility fracture
• Several lesser risk factors
• No risk
• concern/anxiety
• relative contraindications or concerns about HRT
  when considered for prevention
• monitoring response/compliance to some
  therapeutic agents

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West Herts DEXA Referrals 1997-2004. n5273
12
West Herts DEXA Referrals 1997-2004. n5273
Wait in months
13
Referral pattern for bone density (DXA)
1997-2004West Herts GPs and Hospital
Specialties. 5273 scans
14
West Herts. Referral pattern for DXA.Main
reasons for referral (n4688). Repeats (11)
excluded
15
Referral pattern for bone density (DXA) Low risk
factors only (38)
16
Referral pattern for bone density (DXA) No risk
factors ( 9)
17
Main reason for referral DEXA results with
T-Score (Hip, spine, or both) lt -2.5
18
Bone density (DXA) at distal radius, femoral neck
and lumbar spine. with osteoporosis (T score)
according to steroid dose
Percentage with T Score lt -2.5
19
Ability of clinical risk factors to predict
osteoporosis (T score) at spine and hip
L Spine Hip
OR (95 CI) OR (95
CI)

• Fracture
• Steroids
• Endocrine
• Osteopaenia
• Kyphosis

• 2.24 (1.8-2.9) 1.41 (1.1-1.9)
• 1.07 (0.8-1.4) 1.38 (1.1-1.9)
• 1.35 (0.8-2.2) 1.62 (0.9-2.7)
• 2.31 (1.6-3.6) 2.62 (1.5-4.4)
• 1.79 (1.1-2.9) 2.41 (1.3-4.2)

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ROC curvesCan distal radius BMD predict
osteoporosis (T Score) at lumbar spine?
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SACH DXA service General measures for all
patients

• Review of risk factors
• Dietary history. Calcium intake
• Life style measures (Grade C)
• Calcium and Vit D supplements in high risk or
  diet deficient patients (Grade B)
• If on HRT, encourage to continue therapy (Grade
  B)
• Advice about potential risk of steroids on bone
• Review indications, current dose, delivery method
  and type of steroid used (Grade C)
• Booklets, advice leaflets etc (NoS)

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Use of clinical/DXA data

• Local audits/referral patterns
• T4, osteopaenia, low dose steroids
• AE, orthopaedics
• Dialogue with purchasers of health care
• data
• lifestyle and reversible factors
• Hypothesis testing
• forearm bmd

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Evidence based health careStrengths of evidence.
Grades A-C

• A. Meta analysis of, or at least 1 RCT (1a/b)
• B. At least 1 non randomised well designed
  study (IIa/b, III)
• C. Consensus /anecdotal studies (IV)

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Prevention of osteoporosisIntervention
BMD Spine Hip

• Exercise A B B
• Ca/Vit D A B B
• Dietary Ca B B B
• Stop smoking B B B
• Less alcohol C C B
• HRT A B B
• SERMs A A -
• Residronate A - -
• Alendronate A - -

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Treatment of osteoporosisIntervention
BMD Spine Hip

• Ca/Vit D A A B
• HRT A A B
• Residronate A A B
• Alendronate A A A
• Calcitonin A A B
• Fluoride A A -
• Anabolic steroids A - B
• Calcitriol A A C
• not licensed in UK inconsistent data

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Management of osteoporosis DXA servicesIssues
for 2004

• US Womens Health Initiative. JAMA 20032893243
• UK Million Women Study. Lancet 2003362419
• NICE appraisal. webnice.org.uk/article.asp?a9755
  9
• PTH Teriparatide (Forsteo)
• DEXA new generation fan beam machines
• Health economy. Local database on use of drugs
  costs
• Equality of service across West Herts

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NICE appraisal for secondary preventionPost
menopausal women
lt65yrs DXA t-score lt-3.2 lt-2.5
mat hip steroids Rx
bisphosphonate gt65yrs gt70yrs
(multiple) DXA t-score no response lt-4.0
Rx to Rx lt-3.2 mat hip PTH
steroids (teriparatide)
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N Thames Regional Audit (RAG). Steroid treated
patients. Those on either HRT and/or resorptive
agents, or not for osteoporosis. Comparison of
Rheumatologists . No Rx Rx
85
30
47
56
7
23
37
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Effect of current steroid dose on fracture risk
(Osteoporosis International 200213777)
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Glucocorticoid induced osteoporosisRCP/NOS/BTS
Guidelines 2002

• Steroid use1 in UK (2.4 70-79yrs)
  B
• Increased risk of hip spinal
  A
• - dose and time dependent B
• BMD - bone loss greatest in early months
  B
• - risk over above effect of
  low BMD A
• - recommended to assess risk
• Interventions - minimum steroid dose C
• - Rx primary condition C
• - lifestyle measures C
• - specific drug therapies

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Glucocorticoid induced osteoporosisRCP/NOS/BTS
Guidelines 2002

• High risk group start Bisphosphs early
  A
• BMD - steroids needed gt3 months
  C
• - T-score lt -1.5 may need
  bisphosphs C
• - monitoring ? necessary but not lt2yrs
  C
• BMD
• Drugs LS FN V
• Alendronate A A A
• Risedronate A A A
• Etidronate A A A
• HRT A A nae
• CaVit D A A nae

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Notes on management of glucocorticoid-induced
osteoporosisCommitment or exposure to
glucocorticoids, (gt Prednisolone 5mg/day) for gt 3
months

• Bone Mineral Density (BMD) as measured by DXA
  scanning is only part of the risk assessment of a
  patient.
• Oral glucocorticoids treatment presents an
  additional risk factor hence the lower threshold
  of T score -1.5 or lower for active treatment in
  this group of patients.
• The increase in fracture risk starts at the
  commencement of oral glucocorticoid treatment,
  therefore prevention management should be
  considered then.
• The relative risk of fracture returns to baseline
  6 months after stopping the glucocorticoid
  treatment.
• The fracture risk reduces even if no change in
  BMD is observed, due to an improvement in bone
  quality.
• Only DXA scan individuals lt 65 years who have had
  no convincing fragility fracture.
• Significant improvement in the DXA scan may take
  2-3 years to be observed. There is no need to
  repeat the scan if the initial BMD is high.
• All patients should be started on Vitamin D and
  Calcium tablets, as it is often difficult to
  achieve an adequately Calcium and Vitamin D rich
  diet. n.b. AdCal-D3 2 tabs daily is the most
  cost effective.
• Patients in whom investigations indicate a
  secondary cause for bone disease should be
  referred to a specialist. (e.g. malabsorption,
  liver disease, chronic renal failure,
  myelomatosis)

West Herts Osteoporosis Steering Group, 04/2003