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 ordinarily 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 Stepwise Objective 1: Improve outcomes and improve implementation - Hip efficiency of care after hip fractures – by fracture based on size following the 6 “Blue Book” standards patients of impact Objective 2: Respond to the first fracture, prevent the second – through Fracture Non-hip fragility Liaison Services in acute and primary care fracture patients Objective 3: Early intervention to restore Individuals at high risk of 1 st independence – through falls care pathway fragility fracture or other linking acute and urgent care services to secondary falls prevention injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through Older people preserving physical activity, healthy lifestyles and reducing environmental hazards Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care
Fragility fracture through the life span 1 Additional morbidity due to fragility fracture event Morbidity attributable to ageing alone “Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk” 2 1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
FRAX : combines risks +/_ BMD and offers recommendations • Benefits • Drawbacks • Web-based • 10 year risk • Easy to use • Under estimates treatment elderly • 10 year projection • Over estimates in • Recommendation younger women allied with N.O.G.G
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 • Problems • Different degrees of • Long term suppression potency. beyond therapeutic effect. Accrurel of • Suppresses both microdamage within osteoblast and osteoclast bone function • Atypical fractures • Evidence of contiuned use • Osteonecrosis of the jaw on cessation of treatment. • Can cause severe • Common as muck, cheap problems with gullet as chips!!
Strontium Ranelate • Pain to take!! • Unknown true • Increased risk of cardio mechanism of action- vascular events some weak osteoblast • Nausea, stimulation • Diarrhoea in 30% of • Adds Strontium into patients. skeleton, big increase in BMD
Teriparitide • Pulsed PTH dose • 2 year treatment plan. • Increases bone • ( bone cancer)- need to formation over bone follow up with resorption alternative agent • Excellent increases in • s/c Injection every day BMD at spine and • Usually well tolerated significantly reduces • Relatively expensive so vertebral fracture rates restrictions are quite in patients at very high stringent risk.
Denosumab • Monoclonal antibody to osteoclast activity, • 6 monthly s/c • Very specific mode of • Swift Offset time action. • Follow on therapy after • Can be used with completing course patients with • Can drop serum calcium compromised renal and cause severe function but... hypocalcaemia • Shared care agreement with GP’s
New Treatments • Cathepsin K : promotes osteoclast activity. • Enzyme Cathepsin K involved in breakdown of 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 • Reduce alcohol use • Stop smoking • Cigarettes causes early • 3+ alcoholic drinks per death and imperfect day functioning of bone cells • Damages / reduces liver • Additional benefits health • Good for exercise • Increases Falls risk capacity • Risk in Elderly across • Good for general cardio health generally. vascular health
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