Fragile Bones and how to recognise them Rod Hughes Consultant physician and rheumatologist St Peter s hospital Chertsey
Osteoporosis Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing a person to an increased risk of fracture 1 Osteoporosis is present when the bone mineral density or bone mineral content is less than 2.5 standard deviations From the young adult mean ( 2.5 T-score) 2 1. Consensus Development Conference. JAMA 2001; 285:785 795. 2. WHO Study Group, WHO Technical Report Series, 843, 1994.
Normal Osteoporosis Osteoporosis is not just a problem of low BMD Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture
3D Microcomputed tomography images Normal Woman * Osteoporotic Woman (with vertebral fracture) * Loss of bone mass and horizontal trabeculae
Bone Remodelling Resting Bone Activation Resorption Osteoclasts Bone Bone Reversal Formation Osteoblasts Bone Osteoid Mineralisation Riggs BL, et al. N Engl J Med 1986; 314:1676 1684.
Age Related Changes in Bone Mass Attainment of Peak Bone Mass Consolidation Age-related Bone Loss Bone Mass Men Menopause Women Fracture Threshold 0 10 20 30 40 50 60 Age (years) Compston JE. Clin Endocrinol 1990; 33:653 682.
Incidence of Osteoporotic Fractures in Women The majority of hip fractures occur in women over 75 Incidence of osteoporotic fractures in women per 100,000 person-years 3500 Hip 3000 Vertebrae 2500 Colles 2000 1500 1000 500 0 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-85 >85 Age group (years) Adapted from Cooper C, et al. Trends Endocrinol Metab 1992; 3:224 229.
Clinical Impact of Osteoporosis Over Time Signs Kyphosis Loss of height Tummy bulges due to loss of space under the ribs Clinically diagnosed fracture Symptoms Neck becomes weak and head falls forward Pain in whole or part of back Breathing difficulties Indigestion & gastrooesophageal reflux Stress incontinence Difficulty with mobility following a fracture
Burden of risk and fracture occurrence 30% northern european postmenopausal women have OP 51% women with OP have had a low trauma fracture over their lifetime Issues of length of hospital stay, QoL and cost especially for hip fracture
Aims of identification and treatment Higher rates of OP in caucasian northern europeans The majority of fractures > 50yrs in women and men are the result of OP Reduce risk of fracture by altering remediable risk factors (eg calcium deficiency) Reduce fracture occurrence especially at hip by preventing progressive bone loss
Presence of Previous Vertebral Fracture Increases the Risk of Future Vertebral Fracture Relative Risk 8 7 6 5 4 3 2 1 0 5.4 4.5 7.4 Study of Osteoporotic MORE 2 Ross et al, 1993 3 Fractures 1 1. Black DM, et al. J Bone Miner Res 1999; 14(5):821 828. 2. McClung M, et al. JAMA 1999; 282(7):687 689. 3. Ross PD, et al. Osteoporos Int 1993; 3:120 126.
Risk of Another Vertebral Fracture Is Higher in the Year Following a New Fracture Risk of fracture increased with the number of baseline fractures Incidence of New Vertebral Fracture (%) 30 25 20 15 10 5 0 Overall 0 (n=69) 1 (n=61) * 2+ (n=251) Number of Baseline Vertebral Fractures *p<0.05, vs. patients with no prevalent vertebral fractures (12-fold increased risk) Lindsay R, et al. JAMA. 2001; 285:320 323.
Osteoporosis Can Progress Rapidly Following a Vertebral Fracture Percent (%) of patients 30 25 20 15 10 5 0 19.2% 1 in 5 postmenopausal women will have another vertebral fracture within a year 1 26.1% 1 in 4 postmenopausal women will have any osteoporotic fracture within a year 2 1. Lindsay R, et al. JAMA 2001; 285:320 23. 2.Lindsay R, et al. J Bone Miner Res 2001; 16(S1):SA294.
The Domino Fracture Effect
Summary: Understanding of Osteoporosis With every fracture, the risk of new vertebral fracture within 1 year increases Rapid protection from vertebral fractures is important Early intervention is important
HIP FRACTURE >20% fatality 50% permanent disability or loss of independence 1.7 m worldwide in 1990 and >6 m by 2050
Aim of Treating Patients is to Prevent Fracture The aim of therapeutic interventions is to decrease the incidence of osteoporotic fractures An indication for treatment of osteoporosis will be granted only if anti-fracture efficacy has been demonstrated at, at least one site [hip or spine] and no deleterious effect has been shown at the other site The European Agency for the Evaluation of Medicinal Products CPMP/EWP/552/95 rev 1, 2001.
Risk Factors For Osteoporosis For women a lack of oestrogen caused by: Early menopause (before the age of 45 years) Early surgical menopause (before the age of 45 years), especially if both ovaries are removed (oophorectomy) Missing periods for six months or more (excluding pregnancy) as a result of over-exercising or over-dieting For men Low levels of testosterone (hypogonadism) National Osteoporosis Society http://www.nos.org.uk/pdf/areyouatrisk.pdf
Risk Factors For Osteoporosis For men and women Low body weight Maternal history of a hip fracture Malabsorption, inflammatory bowel disease and gastric surgery Use of oral glucocorticoids Long-term immobility Heavy drinking Smoking National Osteoporosis Society http://www.nos.org.uk/pdf/areyouatrisk.pdf
Investigation and Diagnosis History and physical examination Blood cell count, erythrocyte sedimentation rate, serum calcium, albumin, phosphate, alkaline phosphatase and liver transaminases Radiograph of lumbar and thoracic spinal column Bone mass measurement Testosterone and gonadotrophins (in men) Osteoporosis: Clinical guidelines for prevention and treatment, RCP 1999.
BMD Scanning
1. National Osteoporosis Society http://www.nos.org.uk/osteo.asp. 2. Torgerson DJ, et al. UK KEY ADVANCE SERIES (2001): The effective management of osteoporosis. 3. IMS MAT data October 1999. 4. Cooper C et al. Osteoporosis Int 1992, 2:285-9. UK Facts and Figures An estimated 3 million people in the UK suffer from osteoporosis 1 Hip fractures alone cost the NHS an estimated 1.7 billion 2 The NHS spends an estimated total of only 52 million on osteoporosis treatments each year 3 Due to an increase in the elderly population, the number of hip fractures worldwide will increase five-fold in next 50 years 4
Current practice All PMP women with a T score < - 2.5 receive calcium and vitamin D supplements All PMP women with a T score < -2.5 and Z score < -1.0 receive anti-resorptive treatment regardless of previous fracture All PMP women receiving steroids at a dose of > 7.5mg for > 6 months receive an anti-resorptive
Current practice HRT Bisphosphonate Raloxifene PTH Prevents hip fracture - + - + Prevents vertebral fracture - + + + Preserves/ Increases bone density + + + +++ Cost per month treatment 10 Actonel 22 Fosamax 23 Didronel 13 22 272
Bisphosphonates and Osteoclasts Interfere with the action of osteoclasts Recruitment Differentiation Action PCP PCP PCP Intracellular uptake of bisphosphonate during resorption Loss of resorptive function Russell R, et al. Osteoporos Int 1999; 9(suppl 2):S68 S80. Apoptosis
Risedronate: Significant Reduction in Risk of Next Clinical Vertebral Fracture in 6 Months Postmenopausal women with a pre-existing vertebral fracture 2.0 Control Risedronate Cumulative % of Patients 1.0 0.0 * * * 0 3 6 9 12 Months *p<0.01 vs control; Combined analysis of VERT-NA and VERT-MN in 2442 postmenopausal women with a pre-existing vertebral fracture. All patients received 1000 mg/day calcium and, if baseline levels were low, 500 IU/day vitamin D. Clinical vertebral fractures were reported as adverse events and all were confirmed radiographically. Adapted from Watts NB, et al. J Bone Miner Res 2001; 16(suppl 1):S407; Adami S & Roux C, 2 nd International Congress for Osteoporosis, 2001 p27.
National Osteoporosis Guidelines UK National Guidelines Development Groups Royal College of Physicians Bone and Tooth Society of Great Britain National Osteoporosis Society Osteoporosis Clinical guidelines for prevention and treatment, 1999 Guidelines on the prevention and treatment of Glucocorticoid Induced Osteoporosis, 2002
RCP guidelines Osteoporosis 1999/2000 Glucocorticoid induced osteoporosis 2003
NICE and Osteoporosis 2003/2004 First draft of a technology appraisal entitled Prevention and treatment of osteoporosis and prevention of osteoporotic fractures in post menopausal women 19 th December posted on website Consultation ended 23 rd January Final guidance expected June 2004
Osteoporosis for the osteopath Important to have a basic understanding Osteoporosis often symptom free before fracture Post menopausal women most affected Recognise when not previously recognised Able to suggest when X ray needed Recognition can lead to effective treatment Avoid over enthusiastic manipulative techniques