Osteoporosis Update Monica Clark Osteoporosis Nurse Description A - - PowerPoint PPT Presentation

Osteoporosis Update

Monica Clark Osteoporosis Nurse

Description

• A reduction in bone mass
• with micro architectural deterioration in bone

tissue leading to increase in fracture risk

• Fragility by loss of structure and reduced

mechanical strength.

• Fragility fractures are fractures that result

from mechanical forces that would not

• rdinarily result in fracture : a fall from

standing height.

Causes

• Ageing
• Genes/ family history / frame / inherited conditions
• Hormone status ( male + females) early menopause
• Medications: steriod use, breast / prostate cancer

treatments, Epilepsy medications

• Medical conditions. Thyroid excess, PTH excess, renal

disease

• Absorption problems; Coeliac, small bowel disease.

Anorexia, gastric surgery.

• Lifestyle, smoking, alcohol excess, reduced exercise,

longstanding poor nutrition

• Immobility, pregnancy, vitamin D deficiency

Falls and fracture care and prevention A road map for a systematic approach

Hip fracture patients

Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards

Non-hip fragility fracture patients

Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care

Individuals at high risk of 1st fragility fracture or other injurious falls

Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention

Older people

Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards

Stepwise implementation - based on size

• f impact

Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care

Fragility fracture through the life span1

• 1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O
• 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

“Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk”2

Morbidity attributable to ageing alone Additional morbidity due to fragility fracture event

FRAX : combines risks +/_ BMD and

• ffers recommendations
• Benefits
• Web-based
• Easy to use
• 10 year projection
• Recommendation

allied with N.O.G.G

• Drawbacks
• 10 year risk
• Under estimates

treatment elderly

• Over estimates in

younger women

Current Treatments

• Anti resorption therapy: Bisphosphonates, (oral .

I.V), Denosumab (s/c)

• DABA: (Dual action bone agent) -Strontium

Ranelate , ( oral)

• Bone building therapy. Teriperatide ( s/c)
• HRT: Bone maintanence.
• Supplements, : calcium/ vitamin D, & vitamin D

Bisphosphonates

• Different degrees of

potency.

• Suppresses both
• steoblast and osteoclast

function

• Evidence of contiuned use
• n cessation of

treatment.

• Common as muck, cheap

as chips!!

• Problems
• Long term suppression

beyond therapeutic

• effect. Accrurel of

microdamage within bone

• Atypical fractures
• Osteonecrosis of the jaw
• Can cause severe

problems with gullet

Strontium Ranelate

• Unknown true

mechanism of action- some weak osteoblast stimulation

• Adds Strontium into

skeleton, big increase in BMD

• Pain to take!!
• Increased risk of cardio

vascular events

• Nausea,
• Diarrhoea in 30% of

patients.

Teriparitide

• Pulsed PTH dose
• Increases bone

formation over bone resorption

• Excellent increases in

BMD at spine and significantly reduces vertebral fracture rates in patients at very high risk.

• 2 year treatment plan.
• ( bone cancer)- need to

follow up with alternative agent

• s/c Injection every day
• Usually well tolerated
• Relatively expensive so

restrictions are quite stringent

Denosumab

• Monoclonal antibody to
• steoclast activity,
• Very specific mode of

action.

• Can be used with

patients with compromised renal function but...

• Shared care agreement

with GP’s

• 6 monthly s/c
• Swift Offset time
• Follow on therapy after

completing course

• Can drop serum calcium

and cause severe hypocalcaemia

New Treatments

• Cathepsin K: promotes osteoclast activity.
• Enzyme Cathepsin K involved in breakdown
• f collegen and allows breakdown of cartiledge and

bone

• Ondancatib is an antagonist to Cathepsin K and inhibits

bone resorption

• Reduces bone resorption and results in increases in

trabecular and corticol BMD.

• Significant reduction fractures at 3 years vertebral 54%,

non- vertebral 23% , hip 47%.

Sclerostin

• Targets osteoclasts- 90% of all bone cells..

Sclerostin has anti anabolic effect on bone formation and is bone specific.

• Target Sclerostin with antibody Romosozumab

/ Blosozumab – to have powerful effect on bone formation.

• Short lived effect and fast off set time.
• Use powerful effect, then switch to other

therapies to see continuation of improvement.

Current Issues

• Atypical femoral fractures (A.F.F.)
• Rate: 11 per 10,000 with 4-5 years use
• Rate: Hip fracture 155 per 10,000.
• Long term use of anti resorptives , Alendronic

acid , Denosumab.

• Pain pro dromal
• Spontaneous fracture
• Beaking of corticol surface. Often noted on lateral

cortex first. Localised thickening of cortex

• Often bilateral

Vertebral fracture

• Generally underestimated but significant
• fractures. 30% come to light.
• Powerful predictors of future fracture. Also allow

treatment at lower BMD.

• Often clinically silent : back pain
• Description issues at reporting ( when a fracture

is not called a fracture)

• Can be identified opportunistically. X-ray, MRI,

C.T, Barium studies.

Nutritional requirements of supplements

• National Recommendations for calcium intake

700mg per day ( equiv 1pint milk)

• Osteoporosis. Up to 1200mg. Reflected in

supplements dose

• Vitamin D: 10ug/ 400IU / day
• Safe access to sun exposure
• Foods provide up to 15% vitamin D intake, oily

fish, fortified margarines & cereals, egg yolk.

• Best advice is Healthy Plate.

Eat well plate: its all about a healthy balanced diet.

Dietary Sources of Vitamin D

Healthy advice

• Stop smoking
• Cigarettes causes early

death and imperfect functioning of bone cells

• Additional benefits
• Good for exercise

capacity

• Good for general cardio

vascular health

• Reduce alcohol use
• 3+ alcoholic drinks per

day

• Damages / reduces liver

health

• Increases Falls risk
• Risk in Elderly across

health generally.