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					           West Hertfordshire
       Management of Osteoporosis
        Bone densitometry service
                (DEXA)


Consultants:       Adam Young
                   David Collins

Bone Health nurses: Sue Woods
                    Evelyn Jones

Admin/Secretarial: Kaye Gillard
                   Terry McCourt
    Prevention and treatment of osteoporotic
           fracture. Issues in 1994.

•    Primary or secondary prevention?
•    Prevention or treatment for established disease?
•    How best to select patients for treatment.
•    How effective are currently available drugs?
•    How good is the evidence?
•    In whom and when should DXA be done?
• How big is the problem?
                        Osteoporosis

1994   DoH              RCP Advisory Group on Osteoporosis
                        NOS
1996   EL(96) 110       HA should purchase BMD with DXA

1999   RCP Guidelines          Evidence based
                               Health care purchasers
                               Health care providers
                               Users of osteoporosis services
2001   NSF (older people)      Fall prevention
2002   RCP Guidelines          Steroid induced osteoporosis

2004   NICE appraisal          secondary prevention
                               www.nice.org.uk/article.asp?a=97559

2005   NICE                    primary prevention
       Clinical Risk factors for bone loss
      High risk                     Low Risk

•   Steroids             •   Family Hx (maternal hip #)
•   Fracture             •   Osteopaenia (plain x-ray)
                         •   Smoking
•   Early menopause
                         •   Alcohol
•   Amenorrhoea          •   Malabsorption
•   Hypogonadism         •   Low BMI
•   Endocrine            •   Chronic disease/immobility
                         •   Height loss/spinal deformity
Effect of prevalent vertebral fracture on
        subsequent fracture risk
      (Ross et al. Ann Intern Med, 1991;114:919-923)


     30
                                     Bone mass
     25
                                         Low
     20                                  Medium
RR
                                         High
     15

     10

      5

      0
               One #                  No #
Diagnostic workup in presence of
     osteoporotic fracture

• FBC and ESR
• Calcium and Alkaline Phosphate
• Serum electrophoresis
• Urine electrophoresis
• Thyroid function
• Testosterone in men
• Oestradiol in amenorrhoeic premenopausal
  women
• Serum prolactin where appropriate
                West Hertfordshire. Osteoporosis
1994   Advisory Group on OP - Multidisciplinary response
                 Local guidelines
                 PGC lectures, working groups
1996   Osteoporosis Steering group
                 Clinical audits - community/GP
                                  - rheumatology
                 Seminars with HHA (DXA)
                 Local Support Groups
                 Revised guidelines
                 Option appraisal & business case for DEXA
1997   DXA at St Albans
1999   Appropriateness of referrals
2000   RCP/NOS Guidelines
2001   Pilot forearm DXA, business case for Lunar prodigy
2002   Elderly care NSF - PCTs
2003/4 3rd edition local guidelines
Clinical audit of management of osteoporosis.
  Proportion of treated and untreated patients
    in major risk groups in 11 GP practices



      Steroids                       32%    No Rx
                 .                          Rx
   Amenorrhoea                27%
                 .
   Osteoporosis
                                      78%

   Hysterectomy                                     61%

     Hys+BSO                        80%
                     0   50   100 150 200 250 300 350
Clinical audit of osteoporosis management
  Proportion of rheumatology outpatients at risk of
           osteoporosis and those treated

         259 of 1008 consecutive OPD patients at risk
                           (25%)


         143 (55%) at risk because on steroid therapy


                  Preventive Rx = 64 (46%)
                     No Rx = 79 (54%)


                       Ca/VitD = 48%
                       HRT     = 24%
                       BPP     = 28%
           Indications for use of DEXA
• Patients at very high risk
   –   early menopause
   –   steroids
   –   prolonged amenorrhoea
   –   previous fragility fracture
• Several lesser risk factors
• No risk
   – concern/anxiety
   – relative contraindications or concerns about HRT
     when considered for prevention
   – monitoring response/compliance to some therapeutic
     agents
  West Herts DEXA Referrals 1997-2004. n=5273
                                                                      Wait in
             SACH/HHGH     St A GPs     HH GPs      Harp GPs          months
350

300

250

200
150

100

50

 0
      1997   1998   1999   2000       2001   2002     2003     2004
Referral pattern for bone density (DXA) 1997-2004
   West Herts GPs and Hospital Specialties. 5273 scans

       Others
       Gynae
         CoE
      Orthop
          GI
    Endocrine
 Rheumatology
         GPs

                0   10   20   30   40    50     60       70
        West Herts. Referral pattern for DXA.
Main reasons for referral (n=4688). Repeats (11%) excluded


      No risks

   Low risk(s)

   Endocrine

     Fracture

    Early MP

      Steroids

                 0   10      20       30       40
      Referral pattern for bone density (DXA)
                    Low risk factors only (38%)


       Misc

Past steroids

          GI

   Kyphosis

  Family Hx

 Osteopenia

                0       10      20       30       40
      Referral pattern for bone density (DXA)
                        No risk factors ( 9%)



Inapproriate



    HRT Rx



    Concern


               0   10     20   30   40   50     60   70
         Main reason for referral & DEXA results
            % with T-Score (Hip, spine, or both) = < -2.5

   Fracture
   Early MP
    Steroids
   Hysterect
       HRT
Past steroids
          GI
   Kyphosis
  Family Hx
 Osteopenia

                0     10        20        30        40
 Ability of clinical risk factors to predict
 osteoporosis (T score) at spine and hip
                L Spine            Hip
              OR (95% CI)       OR (95% CI)


Fracture      2.24* (1.8-2.9)   1.41*   (1.1-1.9)
Steroids      1.07 (0.8-1.4)    1.38*   (1.1-1.9)
Endocrine     1.35 (0.8-2.2)    1.62    (0.9-2.7)
Osteopaenia   2.31* (1.6-3.6)   2.62*   (1.5-4.4)
Kyphosis      1.79* (1.1-2.9)   2.41*   (1.3-4.2)
             SACH DXA service
        General measures for all patients

•   Review of risk factors
•   Dietary history. Calcium intake
•   Life style measures (Grade C)
•   Calcium and Vit D supplements in high risk or diet
    deficient patients (Grade B)
•   If on HRT, encourage to continue therapy (Grade B)
•   Advice about potential risk of steroids on bone
•   Review indications, current dose, delivery method and
    type of steroid used (Grade C)
•   Booklets, advice leaflets etc (NoS)
            Use of clinical/DXA data

• Local audits/referral patterns
   – T4, osteopaenia, low dose steroids
   – A&E, orthopaedics


• Dialogue with purchasers of health care
   – data
   – lifestyle and reversible factors


• Hypothesis testing
   – forearm bmd
           Prevention of osteoporosis

    Intervention         BMD Spine# Hip#
•   Exercise                A    B      B
•   Ca/Vit D                A    B      B
•   Dietary Ca              B    B      B
•   Stop smoking            B    B      B
•   Less alcohol            C    C      B
•   HRT                     A    B      B
•   SERMs                   A    A      -
•   Residronate             A    -      -
•   Alendronate             A    -      -
            Treatment of osteoporosis

     Intervention          BMD Spine# Hip#
•   Ca/Vit D                   A      A       B
•   HRT                        A      A       B
•   Residronate                A      A       B
•   Alendronate                A      A       A
•   Calcitonin                 A      A       B
•   Fluoride*                  A      A^      -
•   Anabolic steroids          A      -       B
•   Calcitriol                 A      A^      C

* not licensed in UK    ^ inconsistent data
Management of osteoporosis & DXA services
            Issues for 2004


•   US Womens Health Initiative. JAMA 2003;289:3243
•   UK Million Women Study. Lancet 2003;362;419
•   NICE appraisal. web:nice.org.uk/article.asp?a=97559
•   PTH – Teriparatide (Forsteo)
•   DEXA – new generation fan beam machines
•   Health economy. Local database on use of drugs & costs
•   Equality of service across West Herts
         NICE appraisal for secondary prevention
                Post menopausal women

<65yrs       #              DXA t-score
                            <-3.2
                            <-2.5 + mat hip#
                                  + steroids           Rx
                                                bisphosphonate

>65yrs       #


>70yrs       # (multiple)   DXA t-score
             no response     <-4.0                       Rx
               to Rx         <-3.2 + mat hip#           PTH
                                   + steroids      (teriparatide)

				
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