Dem Dry Bones - quick update for a busy GP Professor David Kane 1 - PowerPoint PPT Presentation

Dem Dry Bones - quick update for a busy GP Professor David Kane 1

Who to Screen? All women age 65 or older • All men age 70 or older • Fracture after age 50 • Peri / postmenopausal woman < 65 with risk factors • Men age 50-69 with risk factors • Individualising treatment: those who will most benefit from treatment balanced with risk of adverse events

Osteoporosis Risk Factors Advancing age • Previous fracture • Glucocorticoid therapy …. Any dose for planned 3 months • Family history of hip fracture • Low body weight (BMI <19) • Neuromuscular disorders • Smoking • Alcohol >2 units/day • Medical - Rheumatoid arthritis, Inflammatory bowel disease, Coeliac • disease, Cystic fibrosis, Previous hyperthyroidism, Type 1 and 2 diabetes, Renal disease. Therapeutic - Androgen deprivation agents, aromatase inhibitors, proton • pump inhibitors, selective serotonin reuptake inhibitors (SSRIs) and anticonvulsants 4

FRAX for screening 10y probability of major Patient osteoporotic fracture Age(years)

AACE/ACE 2016 Guidelines for the Treatment of Postmenopausal Osteoporosis Osteopenia (T-score between -1.0 and -2.5) and a history of fragility fracture Osteopenia with a FRAX 10-year probability >3% for hip fracture or >20% for other major osteoporotic fracture T-score at any location <-2.5 Osteoporosis may also be diagnosed with a history of a low-trauma fracture, regardless of T-score

How to Treat - Lifestyle Measures Stop smoking Exercise Weight-bearing exercises. • Muscle-strengthening exercises • Balance exercises and Flexibility exercises • Physical Activity Associated with lower total and Hip fracture

How to Treat - Lifestyle Measures Calcium (1200mg) Calcium Intake 1200 mg/day Supermilk – 400mg Ca in 250mls, 200 IU Vit D • Orange Juice (with Calcium) 300mg in 250mls • Calcium Citrate (eg Solgar) if on PPI Cardiac Risk unproven Try to achieve by dietary means • Do not exceed 2000mg/day •

How to Treat - Lifestyle Measures Vitamin D (800IU or 20mcg) When to test? When osteoporosis diagnosed but also in winter • Annually in patient on treatment for osteoporosis • Effect of supplementation takes several months • Sources UV light – 20-25 minutes of sun exposure – 21 yo – 10,000IU • Diet – Oily fish best source – 100g salmon portion = 500IU • Insufficiency 1000 IU daily (normal diet plus supplement) • Toxicity Very rare – hypercalcaemia and hypercalciuria •

Antiresorptive treatment - Bisphosphonates First line treatment for postmenopausal women with osteoporosis Proven efficacy, low cost, availability of long-term safety data Alendronate or Risedronate – lack of hip efficacy in ibandronate Risedronate 150mg/month efficacious but not available as single tablet …………………. Delmas et al, Bone. 2008;42(1):36. Epub 2007 Sep 8. Optimal duration of treatment is not known At 5 years treatment check DEXA and assess risk Stop low risk patients and monitor DEXA 2 yearly • Continue high risk patients with denosumab for 5 years • If stopped, restart if femoral neck BMD reduces by 5%

HORIZON Study Rates of Fracture and Death in the Study Groups. Lyles KW et al. N Engl J Med 2007;357:1799-1809.

Anabolic Treatment Denosumab Parathormone 60mg sc 6 monthly • Teriparatide (EU) • Sustained 10 yr BMD gains • 20mcg sc daily (pen) • Need run off cover with • 2 year therapy • bisphosphonate (BP) GIOP - Superior to BP • GIOP - equivalent to BP • Abaloparatide not approved • Consider anabolic treatment in severe osteoporosis – post fragility fracture 13

Romosuzumab • MAb that neutralises Sclerostin • Anabolic AND Antiresorptive • S.C. Monthly for one year • Then bisphosphonate • Superior to Alendronate in BMD gain • Superior to Alendronate in all # • Increased serious CVS events in placebo trial • Avoid in patients with MI/CVA within 1 year

Incidence of New Vertebral, Clinical, and Nonvertebral Fracture. Saag KG et al. N Engl J Med 2017;377:1417-1427.

Secondary Fracture Prevention Risk of a subsequent fracture at least doubled after a first fragility • fracture Treatment can reduce the risk of second fracture by 50% to 70% • Decline in treatment initiation in patients with hip fracture from • approximately 10% in 2004 to just over 3% in 2015 …. JAMA Netw Open 2018;1:e180826

Management of Hip, Vertebral and Wrist Fracture Treat all over 65 hip and vertebral fractures • Diagnose at presentation with first fracture • Do not delay for DEXA or Fracture healing • Daily Vitamin D 800IU & Calcium 1200 mg • Initiate therapy immediately • Zoledronic acid reduces post hip fracture mortality •

• Review of steroid claims USA • Range of awards $25 000 to $8.1 million. • Complications sued for often multiple • Avascular necrosis (39%) • Mood changes (16%) • Visual complaints (14%) • Osteoporosis (12%) • Infectious complications (14%)