Notes for CMP fracture by benbenzhou

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									                   Fracture Prevention in Postmenopausal Women (summary of NICE guidance)
                                                                                                                                                                            Middlesbrough
                       Please refer to separate guidance for management of Glucocorticoid-induced Osteoporosis                                                        Redcar and Cleveland


                   Previous fragility fracture                                                                         No previous fracture
 Assess risk with FRAx and refer to relevant NOGG, NICE and RCP guidelines
                                                                                    FRAX (www.shef.ac.uk/FRAX) may be a useful tool for opportunistic assessment of fracture risk
                                                                                                     and refer to relevant NOGG, NICE and RCP guiedlines

         Age ≥ 75                                       Any Age                           Age < 65              Age 65 to 69               Age ≥ 70                        Age ≥ 75
                                                                                           PLUS                      PLUS                    PLUS                           PLUS
                                                                                     1+ independent            1+ independent          1+ independent                  2+ independent
                                                                                    clinical risk factors        clinical risk       clinical risk factors           clinical risk factors
                                                                                            AND                     factors           OR indicators of               OR indicator of low
                                                                                       1+ additional                                       low BMD                           BMD
                                                                                      indicator of low
                                                                                            BMD
   DEXA not required if                                                                                                                                          DEXA not required if
clinically inappropriate or                                                                                                                                     clinically inappropriate
         unfeasible                            T-score -2.5 or below                                        T-score -2.5 or below                                     or unfeasible



                                                                      Give LIFESTYLE ADVICE to all women
                                                             A good calcium intake (aim 1g calcium daily)
                                                             Exercise (e.g. walking)                                                  Independent Clinical risk factors:
                                                             Stopping smoking                                                          Parental history of hip fracture
                                                             Avoid excessive alcohol                                                   Alcohol intake of 4 or more units per day
 PRIMARY CARE MONITORING                                     Consider falls risk assessment                                            Rheumatoid arthritis

 Baseline Investigations                                                                                                               Indicators of low BMD:
  U&Es, LFTs, Bone biochemistry                                       FIRST LINE TREATMENT OPTION                                      Low BMI (<22kg/m2)
  Thyroid function, FBC and ESR                                                                                                        Medical conditions such as Crohn’s
                                                            ALENDRONATE 70mg (ONCE weekly)
    (myeloma screen if raised)                                                                                                            disease, ankylosing spondylitis, untreated
                                                            Calcium & Vitamin D3 supplement (1000mg and 800iu per
                                                                                                                                          premature menopause, hyperthyroidism,
                                                             day) where intake inadequate
 Monitoring Response                                                                                                                      coeliac disease, prolonged immobility
  Assess compliance 2 to 3 months
                                                                                                                                       Heavy smokers may also be at increased risk;
   after initiation of drug therapy                             ALTERNATIVE treatment may be considered if:                            however, NICE did not consider ‘currently smoking’
  Repeat DEXA scanning after 2 to 3                 Unable to comply with special instructions for administration                    alone to be a statistically significant risk factor.
   years.                                            Contra-indicated or intolerant (persistent severe upper GI disturbance)
  Monitor renal function and bone                  Order of preference: risedronate then strontium (where criteria met as             Reassess fracture risk after 2 to 3 years
   chemistry annually.                              described overleaf)                                                                where treatment is not indicated
                                                         ALTERNATIVE treatment options
   NICE considers alternatives only to be cost-effective at higher fracture risk as indicated by T-score, age and number of clinical risk factors (see below).
   However, clinicians may consider these treatments at lower thresholds according to their clinical judgement based on individual patient circumstances.


                  Previous fragility fracture                                                               No previous fracture
              AND unable to take ALENDRONATE                                                          AND unable to take ALENDRONATE


                     Use RISEDRONATE where:
                                                                                                             Use RISEDRONATE where:
                 Number of independent clinical risk factors
                                                                                                        Number of independent clinical risk factors
                 (required T-score)
                                                                                                        (required T-score)
 Age (years)             0                 1             2
                                                                                        Age (years)             0                 1            2
    50 - 54                               -3.0         -2.5
                                                                                          65 - 69                                -3.5         -3.0
    55 - 64            -3.0               -3.0         -2.5
                                                                                           70-74              -3.5               -3.0         -2.5
    65 - 69            -3.0               -2.5         -2.5
                                                                                         75 or older          -3.0               -3.0         -2.5
  70 or older          -2.5               -2.5         -2.5
                                                                                       Otherwise treatment with risedronate not recommended
Otherwise treatment with risedronate not recommended
                                                                                       Reassess fracture risk after 2 to 3 years
Reassess fracture risk after 2 to 3 years


                                                            Unable to take a BISPHOSPHONATE
                     May also consider referral to secondary care for other treatment which may include zoledronic acid (annual infusion)



                Use STRONTIUM RANELATE where:

                  Number of independent clinical risk factors                                           Use STRONTIUM RANELATE where:
                  (required T-score)
                                                                                                        Number of independent clinical risk factors
  Age (years)             0                 1                2
                                                                                                        (required T-score)
     50 - 54                              -3.5             -3.5
                                                                                        Age (years)             0                  1            2
     55 - 64             -4.0             -3.5             -3.5
                                                                                           65 - 69                               -4.5          -4.0
     65 - 69             -3.0             -3.0             -2.5
                                                                                           70-74              -4.5               -4.0          -3.5
     70 - 74             -3.0             -3.0             -2.5
                                                                                         75 or older          -4.0               -4.0          -3.0
  75 or older            -3.0             -2.5             -2.5
                                                                                       Otherwise treatment with strontium ranelate not recommended
Raloxifene may be an option for those at high risk of breast cancer
                                                                                       Reassess fracture risk after 2 to 3 years or refer
(off-license in UK) but no evidence against hip fracture.
Where treatment with strontium or raloxifene not recommended -
reassess fracture risk after 2 to 3 years or refer


                                      REFERRAL TO SECONDARY CARE for those unable to take ORAL THERAPY

								
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