pdp

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MANAGEMENT OF OSTEOPOROSIS Professor Opinder SahotaConsultant Physician QMC, Nottingham

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Financial Turmoil £15 billion cost saving over the next 3 yrs £1.5 billion for the SHA £300 million for each health community 1 ward closure = £1 MILLION

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> 15,000 will fall each year, >6000 twice or more Most will not call for help >70/week will attend A&E or the MIU A similar number will call the ambulance service 350 hip fractures/year ~1000 other fragility fractures Average PCT & council costs on falls are £50m per annum Ageing demography means this will increase 50% by 2020 For a typical 300K PCT :

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OSTEOPOROSIS Definition ‘Systemic skeletal disease characterised by low bone mass and microarchitectural deterioration in bone tissue, with consequent increase in bone fragility and susceptibility to fracture’

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VERTEBRAL FRACTURES WHAT IS A VERTEBRAL FRACTURE ?

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RISK FACTORS FOR OSTEOPOROSIS SECONDARY CAUSES METABOLIC CONDITIONS PRIMARY HYPERPARATHYROIDISM OSTEOMALACIA THYROTOXICOSIS OSTEOGENESIS IMPERFECTA OTHER DISEASES HYPOGONADISM (MALE / FEMALE) MALABSORPTION MALNUTRITION ANOREXIA NERVOSA MALIGNANCY

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RISK FACTORS FOR OSTEOPOROSIS PREVIOUS LOW TRAUMA FRACTURE CORTICOSTEROIDS (ANTICIPATED / ACCUMULATIVE  3 months)

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CORTICOSTERIODS AGE > 65 YRS TREAT -LOW TRAUMA FRACTURE 1mg or more for 3 mths or more / 2 bolus int dose -NO FRACTURE >5mg daily / 3 int doses per year AGE < 65 YRS DXA

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CONSIDER IF NOT DONE WITHIN THE LAST 6 MTHS AP/LAT SPINAL X-RAYS FBC, ESR BIOCHEMISTRY PROFILE (CALCIUM) TFT / PTH PROTEIN ELECTROPHORESIS URINE BENCE JONES PROTEIN TESTOSTERONE OESTRADIOL (PREMENOPAUSAL AMENORRHOEIC WOMEN) DIAGNOSTIC WORK UP

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THERAPEUTIC OPTIONS

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THERAPEUTIC OPTIONS ANALGESIA PARACETAMOL TRAMADOL NSAIDS / COXIB

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SURGICAL OPTIONS VERTEBROPLASTY / KYPHOPLASTY

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STOP SMOKING ALCOHOL WITHIN LIMITATION OPTIMAL ANALGESIA CALCIUM & VITAMIN D [CALCICHEW D3 FORTE 1 TAB BD]

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NICE Health Technology Appraisal 160,161 Oct 08 REDUCING VERTEBRAL & HIP FRACTURE RISK

Which Bisphosphonate ? : 

Which Bisphosphonate ? HTA NICE Osteoporosis Ibandronate Risedronate

DIN-LINK data: continuous adherence to medication for patients receiving daily or weekly alendronate : 

DIN-LINK data: continuous adherence to medication for patients receiving daily or weekly alendronate Months of treatment Percentage DIN-LINK data CompuFile Ltd., May ’05 "adherence was measured over one year as the length of continuous therapy, with cessation being defined as an interval in excess of 1.5 times the expected prescription duration".

Which Bisphosphonate ? : 

Which Bisphosphonate ? HTA NICE Osteoporosis Zoledronate iv

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HTA NICE Osteoporosis Osteonecrosis of the Jaw

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HTA NICE Osteoporosis Osteonecrosis of the Jaw Many associated with dental procedures(tooth extraction) Many have signs of local infection including osteomyelitis Advice MHRA Dental exam with approp dentistry in patients with risk factors(cancer, chemo, corticosteroids, poor oral hygiene) While on treatment, avoid invasive dental procedures

PTH (Teriparatide) : 

PTH (Teriparatide)

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RANK ligand member of the TNF superfamily Denosumab is a fully human monoclonal antibody to RANK ligand High affinity and specificity for human RANK ligand No detectable binding to other members of the TNF family: TNF-α, TNF-β, TRAIL, or CD40 ligand No neutralizing antibodies detected in trials Denosumab (Prolia)

RANK Ligand Is an Essential Mediator of Osteoclast Formation, Function, and Survival : 

RANK Ligand Is an Essential Mediator of Osteoclast Formation, Function, and Survival Osteoblasts Activated Osteoclast CFU-GM PrefusionOsteoclast MultinucleatedOsteoclast HormonesGrowth Factors Cytokines Bone Formation Bone Resorption RANKL RANK

OPG Is a Decoy Receptor That Prevents RANK Ligand Binding to RANK and Inhibits Osteoclast Formation, Function, and Survival : 

OPG Is a Decoy Receptor That Prevents RANK Ligand Binding to RANK and Inhibits Osteoclast Formation, Function, and Survival Bone Formation Bone Resorption Inhibited Osteoclast Formation, Function, and Survival Inhibited CFU-GM PrefusionOsteoclast Osteoblasts RANKL RANK OPG HormonesGrowth Factors Cytokines

Excess RANK Ligand Can Increase Bone Resorption Leading to Osteoporosis : 

Excess RANK Ligand Can Increase Bone Resorption Leading to Osteoporosis Bone Formation Bone Resorption Activated Osteoclast CFU-GM PrefusionOsteoclast MultinucleatedOsteoclast Osteoblasts RANKL RANK OPG Decreased Estrogen Leads to Increased RANK Ligand

Denosumab Binds RANK Ligand and Inhibits Osteoclast Formation, Function, and Survival : 

Denosumab Binds RANK Ligand and Inhibits Osteoclast Formation, Function, and Survival RANKL RANK OPGDenosumab Bone Formation Bone Resorption Inhibited Osteoclast Formation, Function, and Survival Inhibited CFU-GM PrefusionOsteoclast Osteoblasts HormonesGrowth Factors Cytokines

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FRACTURE PATHOGENESIS FORCE FRAGILITY FALL

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Falls : Medication