The Inter-disciplinary Team. The CUHK Fall Prevention Clinic. Medical Care of Fragility Fracture in the Community: GP perspective 脆性骨折的社區醫療護理

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1 Medical Care of Fragility Fracture in the Community: GP perspective 脆性骨折的社區醫療護理 Consultation with the Family Physician 家庭醫生骨骼健康會診 Dr Peter T K Lau 劉天驥醫生 DFM, MFM (CUHK), MBBS (HK) Honorary Clinical Assistant Professor School of Public Health and Primary Care, CUHK Presented at the Seminar on Promoting Decentralized Rehabilitation for Fragility Fractures January 24, 2014, PWH The CUHK Fall Prevention Clinic The Inter-disciplinary Team An innovative approach to fracture prevention in the community. Successfully involves and integrates the participation of: University (with its team of specialist doctors, nurse specialists, physiotherapists and occupational therapists), NGOs (with their social workers and volunteer helpers) and Private sector (with family physicians firmly rooted in the community) in providing a comprehensive service to promote bone health and prevent fracture. Orthopedic Specialist Geriatrician Anesthetist Primary care physician / Family physician Orthopedic nurse Dietitian Physiotherapist Occupational therapist Social worker Clinic assistant, volunteer helper and other concerned parties The family physician, espousing the family medicine concept of holistic, comprehensive and continuous care, is uniquely positioned to act as coordinator of the team. Support from and close liaison with the orthopedic specialist is essential 1

2 Fracture Care in the Community Comprehensive Fragility Fracture Management Program: Web based Software Care / Rehabilitation of the index fracture Prevention of another fracture Detect any new onset fracture Index Injury Fall History 2

3 Action for osteoporosis/ balance/ fall prevention Management for MSK problems Serial BMD Measurements Medical Summary 3

4 Referral to SOPD Initiate and Maintain Specific Treatment for Osteoporosis Assess the indications for treatment Convince the patient of the benefits of treatment Choosing and prescribing the right medication Monitoring adherence to treatment Monitoring response Monitoring adverse effects Available pharmacological agents : Estrogen 雌激素 (HRT 激素補充劑 ) 1. Bisphosphonate 雙磷酸鹽 2. Selective Estrogen Receptor Modulator, SERM 選擇性雌激素受體調節劑 3. HRT 激素補充療法 4. Calcitonin 降血鈣素 5. Parathyroid Hormone 副甲狀腺激素 6. Strontium 鍶 長期使用雌激素補充療法, 可能增加乳癌的危險性, 而心臟病 中風 靜脈血栓的發生率也增加 激素治療僅適用於併有嚴重更年期症狀的婦女, 醫生一般不會單純因為治療骨質疏鬆而使用激素補充療法 4

5 Calcitonin 降血鈣素 抑制鈣質從骨骼轉移至血液 另有鎮痛療效 例如 Miacalcic 噴鼻或注射劑 Selective Estrogen Receptor Modulator, SERM 選擇性雌激素受體調節劑 raloxifene 與激素療法不同的是不會影響乳房或子宮 這些藥物能夠加強骨質, 但不會增加服藥者罹患乳癌或子宮癌的風險 Bisphosphonates 雙磷酸鹽 Parathyroid Hormone 副甲狀腺激素 In the elderly population, bisphosphonates are by far the most commonly prescribed anti-osteoporotic medications. Examples: alendronate (Fosamax ), risedronate (Actonel ), ibandronate (Boniva ) 口服劑 Teriparatide 用來治療絕經期後婦女的骨質疏鬆症和有出現骨折的高風險的男士 能夠幫助新的骨頭生長 方法是每日注射 5

6 Strontium 鍶 Choice of Agents 鍶能刺激造骨細胞的增生, 同時抑制蝕骨細胞的活動, 既能降低骨吸收, 又能促進骨形成, 具有獨特的雙重作用 研究顯示鍶可以提升骨質密度, 降低脊椎及髖部骨折發生率 鍶制劑為口服顆粒劑, 每日一次以開水配服 Choice of Agents Monitor response to medical treatment Unsatisfactory response: when the patient has another fragility fracture despite adhering fully to treatment for 1 year, and evidence of a decline in BMD below the pre-treatment baseline Serial BMD measurement every 1-2 years may be useful Intolerance of bisphosphonates: oesophageal ulceration, erosion or stricture, or severe lower gastrointestinal symptoms NOGG Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK (2008) Osteonecrosis of the jaw 6

7 BMD Testing Useful in confirming the presence of osteoporosis / osteopenia Monitor treatment response Establish a baseline value Serial measurement Esophagitis Associated with the Use of Alendronate NEJM Volume 335: October 3, 1996 Number 14 Recommendations to reduce the risk of esophagitis include: swallowing alendronate with 180 to 240 ml (6 to 8 oz) of water on arising in the morning, remaining upright for at least 30 minutes after swallowing the tablet and until the first food of the day has been ingested, and discontinuing the drug promptly if esophageal symptoms develop. IV bisphosphonates IV injection may offer a new option for patients who experience gastrointestinal side effects with oral bisphosphonates, or are unable to comply with oral bisphosphonate dosing guidelines. Bisphosphonate-Associated Osteonecrosis of the Jaw NEJM Vol 355 Nov 30, 2006 No. 22 A 54-year-old man with a 3-year history of IgG myeloma, who was being treated with pamidronate for 3 years (infusion of 90 mg monthly), presented with a 1- month history of severe bilateral jaw pain. A. Clinical examination revealed areas of exposed bone 1 to 1.5 cm in length with surrounding erythema on the posterior lingual mandible bilaterally. Pamidronate was discontinued. B. At 2 months of follow-up, the bony lesions were larger, raised, slightly mobile, and asymptomatic. C. At 4 months, both bony lesions were completely healed and the mucosa was reepithelialized. At 1 year of follow-up, the patient remains free of lesions and symptoms, and his myeloma is stable without the use of pamidronate. 7

8 Atypical subtrochanteric femur fracture Atypical subtrochanteric femur fracture FDA Drug Safety Communication: Ongoing safety review of oral bisphosphonates and atypical subtrochanteric femur fractures. Safety Announcement [March 10, 2010] A typical osteoporosis fracture (left), is contrasted with an atypical fracture in a patient after many years of bisphosphonate therapy. At this point, the data that FDA has reviewed have not shown a clear connection between bisphosphonate use and a risk of atypical subtrochanteric femur fractures. FDA's review of data did not show an increase in this risk in women using these medications. Atypical subtrochanteric femur fracture American College of Rheumatology Hotline, March 22, 2010 There are case reports of atypical subtrochanteric stress fractures in patients taking bisphosphonates long-term (i.e., greater than 5 years). At present, there is no conclusive data supporting a significantly increased risk for these types of fracture. Bisphosphonates have proven beneficial in preventing osteoporotic fractures in patients with osteoporosis, but this benefit may be attenuated after very long term therapy (e.g., after 10 years). Doctors should discuss these atypical fractures as well as the more common insufficiency fractures with their osteoporosis patients who are on long term bisphosphonate therapy, to help them decide whether to continue therapy after 5-10 years. At present, it would appear to be premature to discontinue therapy because of these concerns. Consider clinical assessment (e.g., FRAX) to identify patients with low risk of insufficiency fractures and do not initiate or continue bisphosphonate therapy in those individuals. Atypical subtrochanteric femur fracture Clin Cases Miner Bone Metab Jan-Apr; 10(1): Bisphosphonates have a proven efficacy in the reduction of osteoporotic fractures as well as in the treatment of other bone diseases which benefit from a decrease in osteoclast activity. BPs have an excellent benefit-to-risk ratio; however, minor adverse events, such as atypical femoral fractures (AFFs), occur in a variable percentage of patients who have undergone long-term treatment. The European Medicines Agency stated that AFFs are a class effect of BPs, but that the benefits arising from their use continue to outweigh its risks. There is no rationale for withholding BPs therapy from patients with osteoporosis, although continued use of BPs beyond a treatment period of 3 to 5 years should be revaluated annually. Consideration should be given to stopping (at least temporarily) BPs therapy in patients who are reassessed to be at low or low-moderate risk (no incident fractures, T-score of -2.0 or higher, and no other major risk factors) after a 3 to 5 year therapeutic period. 8

9 Calculation of Fracture Risk Drug Holiday for long term users of bisphosphonates The option of a "drug holiday" of 1~2 years should be considered after about 3~5 years of bisphosphonate usage. If the fracture risk is excessive (e.g. extremely low DEXA scores combined with tendency to fall) it may be advisable to keep the drug slightly beyond 5 years if a positive response to treatment can be demonstrated. Drug Holiday for long term users of bisphosphonates It is essential to have a reliable documentation of when bisphosphonate therapy has commenced. some patients have been attending different facilities (PWH, TPH, JOCOC, private clinics etc) and may even have switched agents (e.g. from SERM to bisphosphonate or from one bisphosphonate to another). It certainly helps if patients have a regular primary care physician to keep track of their medication. It is also useful to record this piece of vital information in the web-based consultation notes. Non-pharmacological intervention Supportive measures may be less dramatic than medications, but they are nevertheless the foundations of osteoporotic care, and are suitable to all types of patients. The physician s role is to promote advise coordinate the provision of nonpharmacological interventions in fracture care. 9

10 Non-pharmacological intervention Calcium and Vitamin D supplementation 補充鈣質及維生素丁. Recommended daily intake of calcium is 1000 to 1500 mg, and Vit D is 400 to 800 iu. Dietary advice to augment calcium intake 富含鈣質的日常飲食 Weight bearing and balance training exercise 負重及平衡運動 such as jogging or Tai Chi Smoking cessation 戒煙 Avoid excessive drinking 節制飲酒 Vibration therapy 震盪治療 Use of hip protector 髖關節保護器 Fracture Care in the Community: Non-pharmacological intervention National Osteoporosis Guideline Group (NOGG) Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK (2008) Calcium and Vitamin D 健康飲食習慣 成人每天攝取 鈣質 1000 至 1500 mg 維生素丁 400 至 800 iu 奶類食物 豆類製品 十字花科的蔬菜 沙丁魚等, 都富含鈣質 Lifestyle Modifications 適量的負重運動 例如緩步跑 耍太極 戒煙 節制飲酒 10

11 Vibration Therapy Hip Protector 髖關節保護器 Information provided by Occupational Therapy Department, Shatin Hospital Detecting New Onset Fracture Height loss predicts osteoporotic fracture Osteoporosis Update OSTEOPOROSIS SOCIETY OF CANADA Winter 2005 vol.9 no.1 Continuous, regular surveillance Sometimes simple measurements can be a great help 11

12 Height loss predicts osteoporotic fracture J Clin Densitom Spring;7(1):65-70 Height loss of 2 in. or more is a highly significant predictor of osteoporosis at the hip. Women with at least 3 in. of height loss had odds of osteoporosis of the hip that were 9.6 times greater than women with less than an inch of height loss. Loss of height may be an important clue in detecting osteoporosis of the hip, implying that evaluation of height loss should be routine in the outpatient setting. Working with the community Health Education on Osteoporosis and Fragility Fracture Mobilize community resources in fracture prevention and rehabilitation Pilot Scheme on Community Care Service Voucher for the Elderly 長者社區照顧服務券試驗計劃 The Social Welfare Department (SWD) will launch the First Phase (two years) of the Pilot Scheme in September Adopting a new funding mode, namely the moneyfollows-the-user approach, eligible elderly may choose community care services (CCS) that suit their individual needs with the use of service vouchers. A maximum of 1,200 vouchers may be issued under the Pilot Scheme for the use of elderly in need. 長者醫療券 政府為 70 歲或以上長者每人每年提供每張面值 50 元的醫療券, 以資助他們使用私營基層醫療服務的部分費用 由 2013 年 1 月 1 日起, 政府把醫療券金額增至每年 1,000 元 換言之, 每名合資格長者每年可獲發 20 張每張面值 50 元的醫療券 12

13 長者醫療券 Add Quality to Life, and Life to Years The community physician is uniquely poised to provide an attentive and effective fracture prevention service on account of the good rapport with patients and the holistic approach valued by the discipline of family medicine. Compression of morbidity 本港 70 歲或以上長者約有 65 萬人, 政府調查顯示, 逾 50%(36 萬 ) 合資格長者有醫療券戶口, 當中逾 40%, 即 14.4 萬長者曾用過戶口 13