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

• 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

Osteoporosis Risk Factors

FRAX for screening

Patient Age(years) 10y probability of major

• steoporotic fracture

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

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

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%

Lyles KW et al. N Engl J Med 2007;357:1799-1809.

HORIZON Study Rates of Fracture and Death in the Study Groups.

Denosumab

• 60mg sc 6 monthly
• Sustained 10 yr BMD gains
• Need run off cover with

bisphosphonate (BP)

• GIOP - equivalent to BP

Parathormone

• Teriparatide (EU)
• 20mcg sc daily (pen)
• 2 year therapy
• GIOP - Superior to BP
• Abaloparatide not approved

13

Anabolic Treatment

Consider anabolic treatment in severe osteoporosis – post fragility fracture

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

Saag KG et al. N Engl J Med 2017;377:1417-1427.

Incidence of New Vertebral, Clinical, and Nonvertebral Fracture.

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%)