Explain WHAT osteoporosis is and its significance Describe WHY osteoporosis occurs Know WHO is at risk and WHOM to screen Outline HOW to investigate it Decide WHICH way to treat it Understand the RISKS and complexities of Rx Know WHEN it is working and WHEN to refer for a specialist opinion

1. Osteoporosis
Dr Dan Bailey
Consultant Geriatrician
September 2018

2. By the end of this session you
should be able to…
Explain WHAT osteoporosis is and its significance
Describe WHY osteoporosis occurs
Know WHO is at risk and WHOM to screen
Outline HOW to investigate it
Decide WHICH way to treat it
Understand the RISKS and complexities of Rx
Know WHEN it is working and WHEN to refer for
a specialist opinion

3. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

4. Where did the information for this presentation come from?
https://www.nice.org.uk/guidance/conditions-and-diseases/diabetes-and-other-endocrinal--nu
tritional-and-metabolic-conditions/osteoporosis
NICE (8 Guidance Products):
● Bisphosphonates for treating osteoporosis (TA 464) - August 2017
● Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility
fractures in postmenopausal women (TA 161) - August 2008
● Osteoporosis: assessing the risk of fragility fracture (CG 146) - August 2012
● Denosumab for the prevention of osteoporotic fractures in postmenopausal women (TA
204) - October 2010
● Osteoporosis (QS 149) - April 2017
Pending: Non-bisphosphonates for treating osteoporosis (in development)
Clinical Experience: 8+ years of running osteoporosis clinic

5. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

6. It is a disease of bone metabolism
Systemic skeletal disease:
• Low Bone Mass
• Disease of bone
microarchitecture
Imbalance in osteoblastic and osteoclastic activity
Loss of trabecular bone
20% die within 1 year after hip fracture
Survivors have a high risk of chronic pain
and further fractures
Patients can think of a stick of rock

7. Osteoporosis is an expensive,
worldwide epidemic, mostly
affecting elderly people
Worldwide:
• 2bn people affected
• 9m fractures/year
Effect of age:
• 2% of women aged 50
• 25% of women aged 80
UK:
• 300k fractures/year
• 91.5k hip fractures/year
• £2bn cost to NHS

8. It silently takes away your
independence
Post-menopausal bone loss 1% per year
Hip fracture is a common first presentation
of osteoporosis
50% of people have impaired mobility after
hip fracture
20% die within 1 year after hip fracture
Survivors have a high risk of chronic pain
and further fractures

9. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

10. There are two main reasons why
osteoporosis occurs
Peak bone mass attained at :
• 30 in women
• 21 in men
Failure to attain peak bone mass
Imbalance in bone formation and
resorption:
• Menopause

11. It’s your family’s fault
60-80% of cases are genetic
FHx gives a 3.7x increased fracture risk in
women over 50
Greater effect than decrease in BMD >1sd
below mean

12. Your lifestyle could be better too
Smoking more than 10 cigarettes/day
Drinking more than 3 units/day
Low BMI
Poor calcium and vitamin D intake
Rheumatoid arthritis
Glucocorticoid therapy
No exercise

13. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

14. It silently takes away your
independence
Post menopausal bone loss 1% per year
Hip fracture is a common first presentation
of osteoporosis
50% of people have impaired mobility after
hip fracture
20% die within 1 year after hip fracture
Survivors have a high risk of chronic pain
and further fractures
Who is at risk?
Fragility Fracture:
• Fall from standing or less
• Vertebral
• Hip
• Colles’
• Neck of Humerus/Shoulder
DXA Scan
Family History
Risk Assessment

15. Anyone over 75 years of age
Risk Factors:
• Fragility fracture
• Falls
• Low BMI
• Glucorticoids
• Alcohol > 14u/21u
• Smoking
• Secondary
osteoporosis
Any woman over 65
Man over 65 with Risk
Factors

16. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

17. I assess osteoporosis risk
with FRAX
Gives 10 year risk of major
osteoporotic fracture/hip fracture as a
percentage
Simple online tool – can be found with
Google!
Tells you what questions to ask!
Assume treatment at:
• 20% for major osteoporotic #
• 3% for hip fracture

18. FRAX has some limitations
Tool is bad if:
• Multiple fractures
• Vertebral fractures
• High alcohol intake
• >7.5mg of steroid/day for >3/12
• Secondary osteoporosis
Doesn’t consider:
• SSRI use
• Anticonvulsants
• Thiazoldinediones
• PPI
• ARV

19. Know the beast your are
dealing with…
Endocrine causes – e.g. hyper PTH,
hyperthyroid, hypogonadism
Malignancy – e.g. myeloma/mets
Vitamin/Electrolyte deficiencies – e.g.
Vit D/Ca2+
Lifestyle – e.g. smoking/EtOH

20. Do the right tests
Do the following:
• FBC
• ESR
• LFT
• TSH
• CA2+
• VIT D
• PTH
And consider:
• Urine electrophoresis
• PSA
• Sex hormones
• Coeliac Screen
• Urinary Cortisol
• Myeloma Screen

21. A word about DEXA...
Can be used to monitor Rx
response
Useful for diagnostic purposes
Always try to do before Rx
May be against NICE/NOGG
guidance
Think about:
● Mobility
● Tolerability
● Life expectancy

22. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

23. Vitamin D
Let the Sun shine in...
No consensus on refererence
range
? Osteomalacia if <25nmol/L
800IU/day if on Rx/insufficient
Supplements
UVB Light 290nm - 315nm
Oily Fish
Egg yolks
All ethnicities to supplement in UK
winter?

24. Calcium intake of 700-1200mg a day
J shaped curve of harm/benefit
(<700mg or >1500mg)
Treat if <700mg a day
Think about “Healthy
Living For Strong
Bones”!
It’s not all about dairy…
- 50g sardines
- 200ml Milk
- 280g red kidney
beans
All contain the same
amount of calcium
(200mg)

25. Oral Bisphosphonates
Choose Alendronate 70mg/week if:
● 10 year risk of major osteoporotic fracture
is at least 1%
● Patient can follow instructions
● eGFR >30ml/min
● No upper GI problems (No Ulcer in 6/12)
● Treat for 3-5 years
● Vertebral and hip fractures, or fractures in
men, may be better with Risedronate
35mg/week
Concordance is key:
● <80% increases fracture rate by ⅓
● At 1 year 50% of people are not taking
this correctly

26. Use if:
● 10 year risk of osteoporotic
fracture is 10% or higher
● Or at least 1% and problems with
oral medication
IV Bisphosphonates
Be aware:
● 3x annual infusions
(Zoledronate)
● Must have eGFR >35ml/min
● Calcium/Vit D must be normal
● Fracture prevention after 1 dose
● Do not give within 2 weeks of a
fracture

27. Denosumab:
● 60mg s/c every 6 months
● At least 5 years treatment
● Not renally cleared
● Can be used where unable to use
bisphosphonates
● Calcium must be checked 2 weeks after
dosing
Other treatments (Refer to clinic)
Raloxifene:
● SERM
● Contraindicated in breast cancer, endometrial
cancer, VTE history
Teriparatide:
● Used in treatment failure (# after 1 year of
compliant treatment + decline in BMD)
● Severe osteoporosis

28. Don’t forget that osteoporosis
can be a real pain
Affects patients and carers:
● Muscular
● Vertebral
● Regional
● Surgical
● Psychological
● Arthritis
Impacts on life story:
● Impairment
● Adjustment
● New roles
● Dependence
● Expense
● Body image
● Unemployment
● Longevity
● More
interventions

29. Let’s hear it for the boy(s)!
Men are affected by osteoporosis too:
● At 50 there is a ⅕ lifetime chance of
fracture
● Mortality from hip fracture is ⅓
higher
● Greater morbidity
● 25% of hip fracture cost is due to
men
● Hypogonadism and lifestyle factors
are common causes
FIRST LINE TREATMENT IS STILL
ALENDRONIC ACID

30. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

31. Pooled meta-analysis of 27 studies of
fracture data, and 35 studies of BMD
showed:
● Vertebral HR 0.45 (CrI 0.31-0.65)
● Hip HR 0.67 (CrI 0.48-0.96)
● Wrist HR 0.81 (CrI 0.46-1.44) - n/s
● Humerus HR 0.79 (CrI 0.58-1.11) -
n/s
Zoledronate now recommended as
cost per QALY has fallen since off
licence
What is the evidence for
bisphosphonates?

32. Warn about Bisphosphonate Related Osteo-Necrosis of the
Jaw (BRONJ)
A rare, but important, complication:
● More common with IV treatment of
over 1 year
● 1/10k - 1/100k
● 1/1000 per extraction
Risk Factors:
● Old Age
● Poor dental hygiene
● Smoker
● Dental work
● Prior BP
● Chemotherapy
Assess below gum line
Refer to dental for
assessment and
invasive treatment
BEFORE therapy
begins

33. Major Criteria:
● Minimal/No Trauma
● Originate at lateral cortex
● “Substantially transverse”
● Medial spike but cortex transverse
● Non-comminuted
● Localised periosteal thickening
Increasing risk with longer treatment
duration:
● Any BP 5.5/10k patient years
● 2 years Rx 8.4/10k patient years
● but #NOF 155/10k patient years
● and 1 AFF for every 400# prevented
A word on Atypical Femoral
Fracture

34. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

35. I think treatment has worked when...
● Patient has completed 3-5 years of
treatment
● No fall in BMD below baseline
● ? no fractures
Increase in BMD after 2 years is
<4% at hip and <5% at lumbar
spine
BMD margin of error is 5%

36. I think treatment is not working
when...
A fracture occurs:
● Note that fracture rate in trial
treatment arm was 3-18%
● If there are 2 or more incident
fractures after 1 year of treatment
● Do not include skull, hand, foot,
digit, or ankle
● 1 incident fracture + no change in
BMD

37. Treatment failure occurs
because of ...
● Poor adherence
● Co-morbidities
● Low calcium/Vit D
● Malabsorption
● Dose Error
● Interval Error
● Low efficacy
Risk factors for treatment failure:
● Prior fracture
● 2 or more falls/year
● Vit D< 20
● Dementia

38. Patients are eligible for a drug holiday if:
● They have completed 3-5 years of
oral treatment
● They have completed 3 years IV
● ? 5 years of denosumab (not clear)
Drug Holidays
Medication should be continued if:
● >75
● Hip or vertebral fracture
● 1 fracture on treatment
● On >7.5mg Pred for 3/12
● T score <-2.5
Drug Holidays monitored in clinic:
● Start with 18m holiday
● Up to 3 years hold
● BMD in 2 years
● If T score >-2.5
● Look at bone turnover

39. ● Are over 75 (but will see over 65s
too)
● Have a new fracture
● Cannot tolerate treatment
● Cannot comply with treatment
● Need/are on parenteral treatment
● Have a fracture on treatment
● Have falling BMD despite
treatment
● Need consideration of a drug
holiday
In clinic I like to see people
who...

40. WHAT WHY WHO HOW WHICH WHEN
THE JOURNEY
RISKS

41. My Headlines
● Use FRAX in anyone >75
● Or any woman >65 or man >65
with falls
● Baseline BMD assessment
where possible even if starting
treatment
● Check PTH/Vit D/Bone Profile
● Look at lifestyle and
secondary causes
● Start with Alendronate and
Calcium/D
● Assess for Falls Risk
● Any doubts refer to clinic or
ask me!

42. Louis reed
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Sam Xu
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Jaddy Liu
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Eunice Lituañas
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Ellen Carlson Hanse
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Dario Valenzuela
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Mathew Schwartz
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Alex Boyd
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Markus Spiske
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Raw Pixel
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Credit where credit’s
due…
Some photos
courtesy of Unsplash
(www.unsplash.com)

43. Anders Nord
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Mari Lezhava
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Jacky Lo
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Jeremy Wong
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Nikolai
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