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Osteoporosis

Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of the bone tissue , leading to enhanced bone fragility and a consequent increased fracture risk ( WHO 1994 ) 

According to WHO criteria OP is defined as a BMD that lies 2.5 standard deviations or more below the average value for young healthy women ( a T score of < 2.5 )

How common

Osteoporosis is a global health problem and the its incidence and importance is increasing with an ageing population worldwide A review of OP related fractures in 27 European countries in 2010 showed that
- 2/3rd of all incident occurred in women
- fracture incidence increased with age
- majority of hip fractures reported in patients >= 80 yrs
- Most common fractures were hip 18 % , forearm 16 % , vertebral 15 % and others 51 % It is estimated that 1 in2 women and 1 in 5 men over 50 will experience a fragility fracture in their lifetime ( European data ) Osteoporosis affects 21 % of women and 6 % of men aged 50-84 in the EU It is estimated that approximately 0.3 million hip fractures per annum in the US and 1.7 million hip fractures in Europe and virtually all of these events can be attributed to osteoporosis 3 million people in the UK have OP resulting in more than 500,000 sustaining a fragility fracture each year ( NOP 2015 ) The estimated cost of treatment is 
- 4.3 billion pounds / year in the UK ( RCP )
- on average fragility fractures account for 3 % of European countries healthcare spending -estimated 37.4 billion Euros in 2010 , rising to 98 billion Euros when taking into account the impact on health related QoL Rates of hip fracture varies markedly between populations – they are more common in Scandinavian and N American regions than those in S Europe , Asian and L American countries

Primary –Juvenile Post-menopausal ( most common ) Male and senile osteoporosis

Secondary- The following conditions are associated with increased
 risk of secondary osteoporosis ( OP ) low body weight ( from any cause ) chronic inflammatory diseases as inflammatory bowel disease , rheumatoid arthritis , COPD , coeliac disease , inflammatory CTD iatrogenic glucocorticoid excess or Cushing’s disease Hypogonadism or premature menopause Excess alcohol use and smoking Some other conditions associated with low BMD include type 1 DM ,untreated long standing hyperthyroidism , hyperparathyroidism , chronic malnutrition or malabsorption , bariatric surgery , chronic liver disease , MGUS , myeloma Medication related – aromatase inhibitors , androgen deprivation therapy in men with Ca Prostate , chronic PPI use

Risk factors – Age > 65 yrs for women 
and > 75 yrs in men BMI < 18 and 22 for PM women Family h/o osteoporosis Smoking ( current ) Glucocorticoid use ( current ) Early menopause > 2 alcoholic drinks daily Rheumatoid arthritis H/O eating disorders ,Previous fragility fracture Height loss > 2 cm within 3 yrs Low calcium intake Inadequate sun exposure Long term immobilisation H/O falls H/O eating disorders Inactive lifestyle

Assessment –Enquire why has the patient raised the topic Check awareness Assess for risk factors ( see box risk factors ) Falls history Full medication history Physical examination should include BMI , checking for kyphosis and deformities and looking for features of secondary osteporosis

disease burden –Risk of loosing independence , reduction in QoL Friends / relative turn to carers National programmes often difficult to access or insufficient Increased risk of institutionalization OP fractures of hip and spine increases the relative risk of mortality

Bone mineral density –The most widely validated test for measuring bone mineral density ( BMD ) is dual energy X-Ray absoptiometry ( DXA ) DXA may not be widely available and is expensive BMD reduction is a significant risk factor for fractures BMD measurement tests have high sensitivity but low specificity ie risk of fracture is high when OP is present but it is not negligible when BMD is normal Risk factors along with BMD enhance the information provided by BMD alone
 ( risk factors can be partially or wholly independent of BMD ) Normal BMD is a T score between 2.5 and – 1
- osteopenia is BMD between -1.0 and -2.5 As most critically relevant OP fractures occur at vertebral and femoral levels , the most frequently measures sites are L spine and proximal femur

Tests for secondary osteoporosis –Diagnosis is made following

- presence of a fragility fracture
- or a hip and or spine DXA BMD T score of – 2.5 or lower

The following tests can be done to assess the risk factors for secondary osteoporosis in primary care
 Us and Es FBC Bone profile and Vitamin D , PTH ( 1 hyperparathyroidism ) TSH , LFTs ESR , CRP ( inflammatory disorders ) Fasting Bl glucose , Hba1c Testosterone ( hypogonadism ) Serum protein electrophoresis ( for MGUS , Myeloma ) Anti-TTG antibodies ( celiac disease ) Anti-HIV antibodies ( HIV , AIDS ) Serum bone specific or total AP activity ( Paget’s dis ; osteomalacia ) Lateral X ray of Thoracic and Lumbar spine for vertebral fractures

Treatment gap –Reports mention that most patients are being failed by healthcare systems Even after fracture 60-85 % of women in the EU do not receive treatment Most people who are at increased risk do not get treated AND treatment uptake has been decreasing over time Treatment rates have declined in recent years despite a projected increase in prevalence This ‘ Treatment gap ‘ which is increasing indicates a need for
- better evaluation of patients
- consensus in recognition and treatment of high risk patients Public awareness of the condition is poor with only 25 % of adults familiar with the term ( NOS 2014 ) The disease remains silent until a fracture happens GPs tend to underestimate the importance and consider OP far less important than other chronic disease Difficulty with result interpretation and to know when to prescribe treatment , concerns about safety and efficacy of treatment Despite the very high economic burden there is currently minimal investment in pharmacological prevention ( in Europe 2010 ) which accounts for 5 % of the overall management cost , compared with cost of treating incident fracture ( 66 % ) and long -term fracture care ( 29 % ) Patient do not notice an immediate change in their condition , some may not understand the significance of prevention

Early detection-OP is a silent disease with no warning signs prior to the appearance of fracture – but it is identifiable and treatable at risk is the key to prevention A careful assessment of risk profile is an essential step in identifying those who need a BMD measurement Currently there is no universally accepted policy for population screening in the UK to identify individuals with OP or those at high risk of fracture

Risk calculators –NICE recommends estimating fracture risk 
( for e.g the predicted risk of major OP or hip fracture over 10 yrs ) expressed as percentage ).Tools as FRAX and Q Fracture are recommended by NICE
 FRAX tool computes the 10-year probability of hip or a major osteoporotic fracture ( clinical spine , hip , forearm or humerus ) using risk factors alone or the combination of clinical risk factors + BMD
The FRAX tool has been independently validated as the most accurate tool to measure fracture risk 
 Q Fracture – often integrated into the EMIS computer system. This was designed for primary care based on the UK population
 Others -several other tools are available as
-Simple Calculated OP Risk Estimation ( SCORE )
- OP Risk Assessment Instrument ( ORAI )
- OP Self Assessment Tool ( OST )


Fracture Liaison Service- Cost-effective , clinically proven way to identify , asses and treat- usually secondary care based service . Studies have shown that liasion nurses in primary care may be better placed than those in hospital to ensure the implementation of best practice

Lifestyle advice-Address modifiable lifestyle factors like
- alcohol
- smoking
- weight
- regular exercises- weight bearing physical activity Dietary modifications

Pharmacological management –Vitamin D supplementation is widely given as deficiency is common and may contribute to low bone mass and falls
 If the calcium intake is inadequate prescribe preparations containing 1000 mg of Ca daily

Inhibitors of bone resorption by osteoclasts-These include
 Bisphosphonates Selective oestrogen receptor modulators Monoclonal antibodies to the receptor activator of nuclear factor kappa-B ligand.

Bisphosphonates – Aaendronate and risedronate have been shown to reduce the risk of hip , vertebral and non-vertebral fractures ( first line treatment ) Gastrointestinal irritation is the most common SE affecting up to 20-30 % of users ( main reason of poor adherence )
Other rare SEs of bisphosphonate therapy include atypical femoral fractures and osteonecrosis of the jaw Zoledronate is an IV bisphosphonate which can be given once yearly Denosumab is a human monoclonal antibody that inhibits osteoclast formation Seek advice or used reduced dose in renal insufficiency ( bisphosphonates ) NICE in its guidance Bisphosphnates for OP comments that the duration of treatment in clinical practice is uncertain and based on persons risk treatment for up to 60 months ( 5 yrs ) may be recommended.

Anabolic agents that stimulate bone formation as terparatide
 ( parathyroid hormone PTH ) Strontium ranelate- unclear mechanism but possibly works by changes in bone quality and a weak effect on bone turnover.

Referral-GFR < 30 with OP Confirmed complex secondary causes Multiple fragility fractures and very low BMD Patients who sustain fragility fracture despite adherence to treatment some local protocols recommend referring male patients with OP to secondary care Pre-menopausal women with OP Oral bisphosphonates are not tolerated or contraindicated

PATIENT INFORMATION

Royal Osteoporosis Society – a valuable patient information resource on all aspects of OP https://theros.org.uk/information-and-support/understanding-osteoporosis

Factsheets https://theros.org.uk/fact-sheets-and-leaflets

National OP foundation https://www.nof.org/patients/

Oxford University Hospital PIL on alendronic acid https://www.ouh.nhs.uk/patient-guide/leaflets/files/11732Palendronic.pdf

Medicine compendium on alendronic acid https://www.medicines.org.uk/emc/files/pil.5697.pdf

Women’s Health Gov on OP https://www.womenshealth.gov/a-z-topics/osteoporosis

OSTEOPOROSIS RISK CALCULATORS

FRAX https://www.sheffield.ac.uk/FRAX/tool.aspx?country=1

Q Fracture https://qfracture.org/

American Bone Health https://americanbonehealth.org/calculator/

International Society of Bone Densitometry https://www.iscd.org/resources/calculators/othercalculators/

References

  1. Chan, Tom et al. “Improving Osteoporosis Management in Primary Care: An Audit of the Impact of a Community Based Fracture Liaison Nurse.” PloS one vol. 10,8 e0132146. 27 Aug. 2015, doi:10.1371/journal.pone.0132146
  2. Nuti, R., Brandi, M.L., Checchia, G. et al. Guidelines for the management of osteoporosis and fragility fractures. Intern Emerg Med 14, 85–102 (2019). https://doi.org/10.1007/s11739-018-1874-2
  3. Osteoporosis and fragility fractures A policy toolkit : Research, coordination and drafting of Osteoporosis and fragility fractures: a policy toolkit were led by Kirsten Budig, Ed Harding, Taylor Morris and Jody Tate of The Health Policy Partnership (HPP), with research assistance from Emily Kell. via https://www.healthpolicypartnership.com/wp-content/uploads/Osteoporosis_and_fragility_fractures_a_policy_toolkit.pdf
  4. Kanis, J A et al. “Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting.” Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA vol. 28,7 (2017): 2023-2034. doi:10.1007/s00198-017-4009-0 http://www.esceo.org/sites/esceo/files/publications/Identification-and-management-of-patients-at-increased-risk-of-osteoporotic-fracture.pdf
  5. Guidance on the Diagnosis and Management of Osteoporosis in New Zealand via https://osteoporosis.org.nz/wp-content/uploads/Osteoporosis-Guidance-NZ.pdf
  6. Parvin S, Barhey M, Abubacker T, et al
    FRI0496 OSTEOPOROSIS IN PRIMARY CARE – ARE WE MISSING A TRICK?
  7. International Osteoporosis Foundation: Epidemiology of osteoporosis via https://www.iofbonehealth.org/epidemiology
  8. Rosen CJ. The Epidemiology and Pathogenesis of Osteoporosis. [Updated 2017 Feb 21]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279134/
  9. Osteoporosis. Definition. Muñoz-Torres M, Varsavsky M, Avilés Pérez MD Epidemiology Rev Osteoporos Metab Miner. 2010; 2 (3) suplemento: 5-7 https://revistadeosteoporosisymetabolismomineral.com/2017/07/11/osteoporosis-definition-epidemiology/
  10. Merle, Blandine et al. “Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study.” PloS one vol. 14,7 e0219681. 16 Jul. 2019, doi:10.1371/journal.pone.0219681
  11. CKS Osteoporosis – prevention of fragility fractures https://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenarioRecommendation:4
  12. Osteoporosis Identification and management
    in primary care APPROPRIATE CARE GUIDE www.ace-hta.gov.sg
    Published: 7 Nov 2018 via http://www.ace-hta.gov.sg/our-guidance/osteoporosis-identification-and-management-in-primary-care.html
  13. Bisphosphonates for treating osteoporosis Technology appraisal guidance [TA464] Published date: Last updated:

  14. Ashcroft-Hands R (2019) Osteoporosis: risk assessment, management and prevention. Nursing Times [online]; 115: 2, 30-34. https://www.nursingtimes.net/clinical-archive/orthopaedics/osteoporosis-risk-assessment-management-and-prevention-01-02-2019/
  15. Approach to the patient with secondary osteoporosis in European Journal of Endocrinology Authors: Lorenz C Hofbauer 1 , 1 , Christine Hamann 1 and Peter R Ebeling DOI: https://doi.org/10.1530/EJE-10-0015 Page(s): 1009–1020 Volume/Issue: Volume 162: Issue 6
  16. Mumtaz, M. “An approach to the patient with osteoporosis.” The Malaysian journal of medical sciences : MJMS vol. 8,1 (2001): 11-9.
  17. WHO SCIENTIFIC GROUP ON THE ASSESSMENT OF OSTEOPOROSIS AT PRIMARY HEALTH CARE LEVEL Summary Meeting Repo https://www.who.int/chp/topics/Osteoporosis.pdf
  18. Osteoporosis Osteoporosis
    Quality standard Published: 28 April 2017 www.nice.org.uk/guidance/qs149
  19. MAKING THE DIAGNOSIS OF OSTEOPOROSIS via https://www.panoramaortho.com/wp-content/uploads/2017/05/Diagnosing-Osteoporosis.pdf

 

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