Update on Osteoporosis

Dr Terence O’Neill

Consultant Rheumatologist

• 3 million people have osteoporosis in the UK.

• 80 000 hip / 50 000 wrist / 120 000 vertebra

• £1.7 billion per annum.

Clinical / Public Health Impact

Risk of Future Fracture

Relative RiskPrior fracture Wrist Vertebra Hip

Wrist 3.3 1.7 1.9

Vertebra 1.4 4.4 2.3

Hip - 2.5 2.3Klotzbuecher, 2000

2001 Census

Projected Rise in Hip FracturesUK

0

20

40

60

80

100

120

140

2000 2010 2020 2030 2040 2050

Year

1000s

Men

Women

European Commission, 1998

Reduction in vertebral fractures

Clodronate

0

0.2

0.3

0.4

0.5

0.6

0.7 Alendronate

Ibandronate Risedronate Strontium

Relative risk

ALN CLOD IBAN RIS SR

0.5

Risk Factor

Case Finding Strategy

+

Risk Factors Indications for BMD

• Low trauma #

• Steroids (oral) > 7.5mg /day – 3 mths Hypogonadism menopause < 45 yrs

2nd amenorrhoea

• Radiologic osteopenia

• Comorbid diseases hyper PTH

coeliac disease

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

InvestigationsMeasure BMD

[DXA, hip +/- spine]

NORMAL

T score above -1

OSTEOPENIA

T score –1 to –2.5

OSTEOPOROSIS

T score below –2.5

Reassure

Lifestyle advice

Lifestyle advice

Treat if previous

fracture

Lifestyle advice

Offer treatment*Calcium + Vitamin D

Falls risk:

Assessment/advice and

Consider hip protectors RCP, 1999

Limitations

• Bone Mineral Density• Focus on T Score • Out of Date

Risk Assessment• Age

• Gender

• Prior Fracture (after age 50 years)

• Parental history of fracture

• Current Smoking

• Alcohol intake > 2 units / day

• Ever Corticosteroid use

• Secondary causes (e.g. RA)

T Score

http://www.shef.ac.uk/NOGG/

NOGG – November 2008

New Risk Assessment Tool ‘FRAX’ - Web BasedNo More T Scores !– 10 year fracture riskThresholds for Treatment (web / tables)Advice on which treatment

http://www.shef.ac.uk/FRAX/

http://www.shef.ac.uk/NOGGOR

BMD

60yr 70yr 80yr

No.

Risk

Factors

Women with No Prior #

NOGG - Treatment

• Alendronate

• If unable to take / intolerant

Risedronate / Ibandronate / Strontium

Raloxifene / Etidronate

What about NICE?

• After gestation of 6 years new technology appraisals published late 2008

• TA160 : Primary prevention

• TA 161 : Secondary prevention

NICE 161– Secondary Prevention

• Alendronate (ALN) treatment of choice in post-menopausal women if T-score < – 2.5

• Unable to take ALN – Risedronate (RIS) or etidronate (ETD)

• Unable to take RIS /ETD – Strontium / Raloxifene

* Age < 65 years + independent clinical risk factor for fracture + clinical risk of low BMD + T-score of < – 2.5

NICE 160– Primary Prevention

* Age 65-69 yrs + independent clinical risk factor for fracture + T-score of < – 2.5

* Age 75 +yrs + 2 or more risk factors – no need for BMD

NICE 160– Primary Prevention

* Age 70+ yrs + independent clinical risk factor for fracture OR clinical risk of low BMD + T-score of < – 2.5

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

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