W5 Clinical Assessment and Management of Osteoporosis (PD) Flashcards
Osteoporosis
definition?
features?
Skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture (Föger-Samwald et al. 2020)
- Low bone mass
- Abnormal bone architecture
- Structural deterioration in bone
- Reduced bone strength
- Increased bone fragility
- Increased fracture susceptibility
- Asymptomatic - not picked up until a fracture occurs
Osteoporosis Pathophysiology:
Imbalance in the process of bone remodelling by osteoclasts and osteoblasts
Osteoblasts form bone
Osteoclasts resorb/breakdown bone
Osteoporosis WHO definition:
Bone mineral density (BMD) 2.5 standard deviations below mean peak bone mass as measured by dual-energy X-ray absorptiometry (DEXA/DXA) applied to the femoral neck and reported as a T-score
i.e. T-score ≤ -2.5
Prevalence of Osteoporosis (for info)
- Increased risk in women – reduced oestrogen post menopause
- 2% prevalence at 50 years of age to circa. 50% at 80 years
- > 2 million women diagnosed in England and Wales
- Around 180k fractures annually due to osteoporosis
- 1 in 3 women and 1 in 5 men will get a fracture in life as a result of osteoporosis
- Higher risk of fractures in white men and women
Fractures
What is an osteoporosis fracture?
What is a fragility fracture?
Where do fractures usually occur?
Osteoporotic fracture – A fragility fracture that occurs as a result of osteoporosis
Fragility fracture – Fracture following a fall from standing height or less, or as a result of
routine activities
Characteristically, fractures occur in the wrist, spine, and hip, but they can also occur in the arm, pelvis, ribs, and other bones
Fracture Risk Factors
-Risk of fracture is dependent upon falls risk, bone strength (measured by BMD), plus other risk factors
-Factors that affect bone strength are split into those that reduce BMD and those that don’t reduce BMD
Fracture risk factors that
Reduce BMD:
Do not reduce BMD:
Falls risks:
- Endocrine disease – DM, hyperthyroid,
hyperparathyroidism - GI conditions – Crohn’s, UC, Coeliac, Chronic Pancreatitis
- Chronic diseases –CKD, Liver disease, COPD
- Menopause
- Immobility
- BMI under 18.5
Do not reduce BMD:
* Age
* Oral Corticosteroids
* Smoking
* Alcohol consumption
* Prev fragility fracture
* Rheumatoid Athritis
* Parental Hx of hip fracture
Falls risks:
* Impaired vision
* Neuromuscular weakness
* Cognitive impairment
* Alcohol and sedatives
* Polypharmacy
* Hypotension
* Frailty
Assessment of Fracture Risk – Who?
High risk groups?
Aim of Osteoporosis management is to assess fracture risk and prevent fragility fractures
Consider assessment of fracture risk in high-risk groups :
- Women over 65; Men over 75
- Woman aged 50-64/Men aged 50-74 with risk factors or secondary cause of osteoporosis
- Under 50s with: Current/frequent oral steroid use, untreated premature menopause, previous fragility fracture
- Under 40s with: Current/recent high dose oral steroid use (>7.5mg prednisolone daily for 3 months+), previous hx
spine, hip, forearm, proximal humerus fracture or multiple fractures - Consider in patients prescribed: SSRIs, carbamazepine, aromatase inhibitors, gonadotrophin-releasing hormone
agonists, PPIs, pioglitazone
National Osteoporosis Guideline Group UK
NICE guidelines 146
Assessment of Fracture Risk – How?
- Exclude non-osteoporotic causes for fragility fracture (e.g. metastatic bone disease) and secondary causes of
osteoporosis - For over 50 + Hx fragility fracture OR under 40 with major risk factor offer DEXA scan WITHOUT calculating
fracture risk - For others calculate 10-year fragility fracture risk – QFracture or FRAX – before arranging DEXA based on
identified risk - Assess for vitamin D deficiency and calcium intake
-Aged over 65 or not exposed to sunlight
-Calcium intake of at least 1000mg/day recommended for people at increased fracture risk
Identify any falls risk factors (e.g. age >65yrs with Hx of fall, cognitive impairment etc)
What is QFracture and FRAX?
- Web based calculators/risk tools – QFracture preferred by NICE
- Use to calculate risk of developing osteoporotic fracture through questionnaire
Amber zone: measure BMD through DEXA
Red zone: start treatment
Dark red zone: treat and consider referral to specialist
See tables on lecture slide
Management of Fracture Risk
High risk (Red) – Offer DEXA
* If T score is -2.5 or lower start bone sparing drug treatment
* If T-score > -2.5 modify risk factors, treat underlying conditions, repeat DEXA within 2 years
Intermediate risk (Amber)
* If risk is close to threshold with underestimated fracture risk factors, refer for DEXA then reassess
fracture risk
* Offer drug treatment if T score is -2.5 or lower
Low risk (Green) – Lifestyle advice, follow up within 5 years
Assessment of Fracture Risk
Secondary care specialist referral- who is eligible/considered?
Very high-risk patients
Patients <40 yrs of age
Consideration of parenteral treatment
Vertebral factor within the last 2 years
2 or more vertebral fractures
T-score < -3.5
Treated with high dose glucocorticoids
Clinical Management
Non-pharmacological/Lifestyle advice
- Healthy balanced diet
- Adequate calcium intake – minimum 700mg daily (diet or supplementation)
- Vitamin D – 800iu daily – From diet/supplement or prescribed if evidence of deficiency
- Regular weight-bearing and muscle strengthening exercise
- Smoking cessation
- Restrict alcohol to less than 2 units per day
- Maintain healthy normal weight – BMI 20-25
Pharmacological Management
Calcium & Vitamin D (Colecalciferol)
Bisphosphonates
Denosumab
Teriparatide
Romosozumab
Strontium Renelate
Raloxifene
Calcium and vitamin D exercise – using the BNF
Daily intake of at least 1g calcium and 400 units of vitamin D
Miss B. Summers (age 67) needs to be started on a calcium and vitamin D preparation
Use the BNF to identify a product that you could prescribe
Calcichew D3 chewable tablets
Adcal D3 chewable tablets
Accrete D3 film-coated tablets
