Osteoporosis 2024 2025 OSPAP Lecture Notes PDF

MPharm Programme Osteoporosis in Practice Louise Statham Senior Lecturer in Clinical Pharmacy [email protected] Slide 1 of 50 PHA332 Osteoporosis in Practice WEEK20 Le...

MPharm Programme Osteoporosis in Practice Louise Statham Senior Lecturer in Clinical Pharmacy [email protected] Slide 1 of 50 PHA332 Osteoporosis in Practice WEEK20 Lecture Overview This lecture has been broken down into the 5 sections. 1. Role of Pharmacist and background to practice 2. Assessing fracture risk 3. Pharmacological Therapies 4. Special Considerations 5. Treatment Review Summary Slide 2 of 58 OSPAP Osteoporosis in Practice WEEK20 Section 1: Role of Pharmacist and background to practice Slide 3 of 58 OSPAP Osteoporosis in Practice WEEK20 Osteoporosis: “Porous Bones” Osteoporosis has no symptoms per se but it is important to patients because it increases risk of fracture! Slide 4 of 58 OSPAP Osteoporosis in Practice WEEK20 What do the test results mean? Bone Density Results: Lumbar Spine: T-3.0 Z-1.8 Femoral Neck: T-2.5 Z-1.0 Total Hip: T-2.6 Z-1.1 Low bone density for age (Z-score Osteoporosis as T score is compares with healthy -2.5 or less (standard person of same age) deviations from young healthy norm) Slide 5 of 58 OSPAP Osteoporosis in Practice WEEK20 # = Fracture! Slide 6 of 58 OSPAP Osteoporosis in Practice WEEK20 Public Health Education of Primary # prevention Pharmacists at: younger people Identification of those Ward level at risk: NICE CG146 GP Practice Effective fracture (audit/clinic) reduction to reduce Community (med morbidity, mortality support) and cost Specialist (diagnosis/RV) Osteoporosis and Bone Secondary # prevention Health Fracture Liaison Services Medication Review Patient Review Adherence (NICE NG76, 197) Clinical Parameters Falls Reduction MDT: Pharmacists Initiation and Doctors (ward, elderly care, ortho- Prescribing geri, bone, endocrine..), Nurses Refer/interpret DXA (ward/specialist), Physiotherapy Secondary causes Occupational Therapists, Dentists Slide 7 of 58 OSPAP Osteoporosis in Practice WEEK20 Osteoporosis: a patient’s perspective The following videos are useful for context: a) Introduction video by Royal Osteoporosis Society- aimed at patients but a useful intro for students to build upon b) A patient describing her experience of osteoporosis – the patient should be at the centre of our decisions so always important to keep this in mind Slide 8 of 58 OSPAP Osteoporosis in Practice WEEK20 Fracture Increases Fracture Risk The most common types of osteoporotic fractures are hip, wrist and spine Slide 9 of 58 OSPAP Osteoporosis in Practice  Hip fractures in practice WEEK20 Hip fracture is the most serious consequence of falls among older people – Reduced function, loss of independence, loss of confidence, high mortality rate (10% at 1 month, 30% die within a year of hip fracture) Interventions include: Prevent further fracture “secondary prevention” (see later) If already on treatment check adherence and administration Lifestyle advice Falls assessment Including medication review Prevention of venous thromboembolism with LMWH Appropriate pain management Slide 10 of 58 OSPAP Osteoporosis in Practice WEEK20 Vertebral Fracture in Practice Interventions … Spine: Compression fractures Secondary fracture(#) – Acute and chronic back pain prevention Lifestyle advice – Height loss, kyphosis Pain control and analgesia review Physiotherapy Surgical management National Osteoporosis Society Slide 11 of 58 OSPAP Osteoporosis in Practice WEEK20 Section 2: Assessing Fracture Risk Slide 12 of 58 OSPAP Osteoporosis in Practice WEEK20 What are the risk factors for osteoporosis? Fragility # Parental hip fracture Excess alcohol Secondary causes e.g. Smoking – amenorrhoea – eating disorders Immobility – inflammatory bowel disease Drugs e.g. – Rheumatoid Arthritis – COPD – Corticosteroids – early menopause/hypogonadism – PPIs – low BMI – Anti-epileptics (Falls) – SSRIs – Aromatase inhibitors …. Slide 13 of 58 OSPAP Osteoporosis in Practice  How do we identify people WEEK20 who might need treatment? Primary Prevention: Secondary Prevention; People who have never People who have already had a fracture but are at had a fracture and need to increased risk of fracture reduce the risk of further fracture NICE G146 on fracture risk assessment outlines Fracture liaison services who should be assessed have an important role here- (updated 2017) pick up over 50s with fragility fracture and offer DXA scan Slide 14 of 58 OSPAP Osteoporosis in Practice WEEK20 Assessment of Fracture Risk: NICE guidelines: Outlines who to target for # risk assessment – All older patients (>65 female >75 male) – Other patients with specified risk factors Pharmacists can assess # risk as part of patient review # risk assessment tools available include FRAX® and QFracture® Following risk assessment: – lifestyle advice only – refer for DXA or – start treatment See CKS: Osteoporosis prevention of fragility fractures for an easy to follow guide https://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenario Slide 15 of 58 OSPAP Osteoporosis in Practice  Fracture risk assessment using FRAX WEEK20 www.shef.ac.uk/FRAX FRAX is an online tool that can be used to assess fracture risk (40-90 yrs) Gives a result as: 10 year risk of osteoporotic fracture and 10 yr risk of hip fracture (%) Links to NOGG (National Osteoporosis Guideline Group) guidance which classifies patients as red (start treatment) amber (DXA scan) or green (lifestyle advice) Slide 16 of 58 OSPAP Osteoporosis in Practice WEEK20 FRAX® Potential Pharmacist Intervention Slide 17 of 58 OSPAP Osteoporosis in Practice WEEK20 Action Following Assessment Depending on fracture risk one or more of the following options may be employed:- Lifestyle advice (smoking, alcohol, vit D, calcium, exercise) Referral for a DXA scan +/- specialist review Initiation of treatment (for “very high” fracture risk also consider refer to specialist) Relevant treatment guidelines include NICE*/NOGG. Many places also have local guidelines which may be employed *Postmenopausal women only Slide 18 of 58 OSPAP Osteoporosis in Practice WEEK20 Section 3. Pharmacological Therapies Slide 19 of 58 OSPAP Osteoporosis in Practice WEEK20 Pharmacological Treatment Options Antiresorptives: Bisphosphonates - Oral (alendronic acid, risedronate, ibandronic acid) - Parenteral (zoledronic acid, ibandronic acid) Denosumab (subcutaneous injection) Less commonly used: – HRT (early menopause) – Raloxifene (specialist only) – Strontium- discontinued by manufacturer in 2017- increased CV risk- brought by to the market 2019 Slide 20 of 58 OSPAP Osteoporosis in Practice WEEK20 Drugs with an anabolic action Can be used 1st line in some cases if very high fracture risk and meet NICE criteria – Refer to specialist who will review and prescribe – All SC injections – One-off course then followed with antiresorptive drug to maintain benefit (e.g. bisphosphonate or denosumab) Romosozumab (dual action, monthly injections) Teriparatide (daily injections -expensive) Abaloparatide – recently NICE approved Slide 21 of 58 OSPAP Osteoporosis in Practice WEEK20 Patient Information is ESSENTIAL Prophylactic treatment requires motivation Patients must be involved in treatment decision – SHARED DECISION MAKING PROCESS (NG 197) Explain – Why they have been prescribed their medication – How it works – Benefits – How to take correctly – Side effects & what to do if they occur – Length of treatment Patient Information Leaflets (e.g. Royal Osteoporosis Society, Local information leaflets) INFORMATION AT INITIATION AND ONGOING!!! Slide 22 of 58 OSPAP Osteoporosis in Practice  Adherence WEEK20 Adherence is a big problem – Increased # risk where poor Many studies show adherence to oral BPs is poor and happens soon after initiation. – E.g. Kothawala et al. Mayo Clinic Proceedings 2007; 82(12) 1493-1501 NICE CG76 Medicines adherence NICE G197 Shared Decision Making Involve patients in decisions about prescribed medicines and supporting adherence – Intentional versus non-intentional poor adherence – Tailor interventions to patient This Photo by Unknown Author Slide 23 of 58 OSPAP Osteoporosis in Practice is licensed under CC BY-NC-ND WEEK20 Oral BPs: often 1st line 1st line option for prevention and treatment NICE (2017) cost-effective if patient is eligible for risk assessment and has a 10-year probability of fracture of at least 1% (does not mean you should prescribe at 1% risk) Main drug interactions (absorption) – Avoid any other medicines for at least 30 mins – Avoid calcium supplements for at least 2 hours (preferably 4hrs) Main cautions & contraindications – eGFR