SYMPOSIUM 1. Osteoporosis, Nutrition and Fragility Fractures (TW, KM).ppt

BSMS Student Symposium - April 2023 The “Fragility fracture” Epidemic - What should we be doing? 9.00 – 9.30 Recognize the problem & find the cases Dr. Trevor Wheatley, Consultant Endocrinologist Princess Royal Hospital, University Hospitals Sussex Honorary Senior Lecturer, BSMS 9.30 – 10.00 Nut...

BSMS Student Symposium - April 2023 The “Fragility fracture” Epidemic - What should we be doing? 9.00 – 9.30 Recognize the problem & find the cases Dr. Trevor Wheatley, Consultant Endocrinologist Princess Royal Hospital, University Hospitals Sussex Honorary Senior Lecturer, BSMS 9.30 – 10.00 Nutrition & Bone Health Dr Kathy Martyn Principal Lecturer, School of Sport and Health Sciences University of Brighton BSMS Student Symposium - April 2023 The “Fragility fracture” Epidemic - What should we be doing? 10.30 – 11.00 Preventing & managing fragility fractures The role of the physiotherapist Bex Morant, Senior physiotherapist 11.00 – 11.30 The pharmacology of Fracture prevention Dr. Trevor Wheatley, Consultant Endocrinologist 11.30 – 11. 50 Discussion & questions “What I tell you today may not be true tomorrow” Fuller Albright – Father of Modern Endocrinology This presentation is for private study only. It should not be given as a public presentation or otherwise disseminated. To do so may place the presenter in breech of copyright BSMS Student Symposium April 2023 The disaster of the “Fragility fracture” Epidemic What should we be doing? Conflict of Interest NONE It’s about Fragility Fractures NOT just “Osteoporosis” & Bone Densitometry scans What is a Fragility ( Low Energy ) Fracture? A Fracture which occurs without excessive trauma or follows a fall from (nearly) a standing height or less Facts About Fracture! They are very common! In The EU someone fractures their Hip Every 30 secs • • • • 1/3 women > 50 years 2/3 women > 80 years 1/12 men > 50 years 1/5 men eventually 10 Annual incidence x 1000 Osteoporotic fractures: comparison with other diseases 2000 annual incidence all ages 1 500 000 1500 1000 250 000 hip 250 000 forearm 250 000 other sites 500 0 annual estimate women 29+ 513 000 annual estimate women 30+ 750 000 vertebral Osteoporotic fractures 228 000 Heart attack Stroke 1996 new cases, 184 300 all ages Breast cancer The Aging Population Population > 65 years in Europe • 12-17 % in 2002 • 20-25 % by 2025 & it will get worse! The Serious Sequele ofConsequences Hip fracture of Hip Fracture Vertebral Fracture The “Physical Sign” Clinical & Silent vertebral fractures Increase pain & Reduce activity Moderate Back Pain Severe Back Pain 400 Limited Activity 300 Bed Rest 100 250 200 150 100 50 0 No Incident Fracture Radiographic Clinical Fracture Fracture Percent (%) of Patients Mean Number of Days 350 75 50 25 0 No Incident Fracture Radiographic Clinical Fracture Fracture Vertebral Fractures What the patients say • • • • • Struggling to understand their body “Breakthrough pain” fueling fear Fearing eventual isolation Concerns of dependency Fear of an uncertain future H Svensson et al, Osteoporosis Int 2016 27; 1729 Fractures are Expensive! • Fractures / year (UK) – Hip 70,000 – Wrist 50,000 – Spine 120,000 • COST = £ 4 billion / year = > £11 million / day! Fragility Fractures What do we know so far? • Common • Cause significant – Morbidity • Physical • Psychological – Mortality • Very Expensive Why do people break bones? • Bone strength is reduced – Sub optimal peak bone mass – Reduced bone quality • Reduced bone Mineral ( Calcium ) • Deteriorating architecture • Change in crystal size & composition • Abnormal collagen Why do people break bones? • Bone strength is reduced •They fall (often badly ) – Various predisposing factors • Some preventable / correctable Fracture Prevention A Logical, cost effective strategy • Children / Adolescents / Young Adults – Optimize Peak bone Mass • Adults – Prevent deterioration of bone quality – Prevent falls – Identify people at high risk of fracture – Prioritize the highest risk subjects for treatment – Select special treatment for very high risk How to Identify Risk in Older People History & Examination • • • • • • • Age Previous Fracture Light weight ( BMI < 18 ) Family History Smoking Alcohol Medical Disorders Predicting Fragility Fracture 65 years Steroids > 3 months Preventative Treatment Rheumatoid Nodule Sex Hormones Prostate Cancer on Androgen Deprivation Therapy GENETICS Osteogenesis Imperfecta Other Medical Disorders Predisposing to Osteoporosis • Endocrine disorders – Thyrotoxicosis – Hyperparathyroidism – Pituitary disease • Conditions causing Nutritional Deficiency – Malabsorption conditions – Eating disorders – Alcoholism • Inflammatory conditions • Many chronic general medical conditions Chronic Respiratory disease Learning Point Most clinicians working in adult medicine will be looking after people who have fractured or who are at increased risk of Osteoporosis & Fracture! BUT Many do nothing! Using Technology to predict Risk Every 1 standard deviation below the BMD mean for young adults Doubles the fracture risk FRAX FRAX THE NORA STUDY Peripheral Measurements Predict Fracture E Siris Jama Dec 2001 Heel Ultrasound scanning device SUMMARY Facts About Fragility Fracture • • • • Cause significant Morbidity Common Expensive Predictable • Partly preventable Nutrition & Bone Health Dr Kathy Martyn Principal Lecturer, School of Sport and Health Sciences University of Brighton Fragility Fracture Prevention Clinical Objectives of Drug Treatment • Prevent ALL types of fracture – Vertebral – Nonvertebral • HIP • Others Daily s/c PTH 1-34 for 2 years PRE POST Female 65 years Bisphosphonates Inhibit Osteoclast action by inhibiting an important enzyme How to Take Oral Bisphosphonates ie. Alendronate, Risedronate & oral Ibandronate • Take – In the morning – With a full glass of water – Standing up • Do not lie down after • No food for 30 minutes – Food inhibits absorption Contact Stomatitis due to Alendronate Oesophageal ulcer due to Alendronate Buffered Oral Bisphosphonate pH 4.8 – 5.4 Atypical Femoral Shaft Fracture (1/10,000) Ask about Femoral shaft pain! Atypical Femoral Fracture . 2016;102(2):545-550. doi:10.1210/jc.2016-2787 Osteonecrosis of the Jaw (ONJ) Rank Ligand & Osteoclasts 1,25D 3 PTH/PTHrP RANK Ligand OPG ( osteoprotogerin ) Secreted by osteoblast PGE 2 IL-11 RANK Stromal Cell Osteoblast Osteoclast Precursor Osteoclast Denosumab 60 mg S/C Fully Human Monoclonal antibody • IgG2 isotype • Binds to RANK Ligand – Decoy Receptor – High affinity – High specificity – No complement activation Denosumab 60 mg S/C Fully Human Monoclonal antibody • Rapidly absorbed • Long half-life – 26 days ( 34 days with max dose ) – 6 monthly injection • Cleared by Reticuloendothelial system – No renal excretion • Reduces spine & Hip Fractures BEWARE Stopping long term Denosumab increases the risk for vertebral fractures Selective Estrogen Receptor Modulators No evidence for hip fracture prevention Menopausal Hormone therapy ( HRT ) & Fracture prevention • • • • • Prevents reduction of BMD Prevents spine, Hip and other fractures ( WHI) Preserves muscle power Reduces Disc degeneration Improves balance PREVENTING FRACTURE Antiremodelling Drugs with evidence Prevention of HIP & Vert. FRACTURE • ALENDRONATE oral (weekly) – Standard – Buffered • RISEDRONATE oral (weekly) • ZOLENDRONATE IV ( annually) • DENOSUMAB s/c ( 6 monthly ) • Estrogen & Testosterone • Calcium & Vitamin D (In elderly ) Anabolic Drugs with Evidence £ For patients at very high risk £ • Teriparatide ( PTH 1-34 ) – s/c Daily for 2 years • Abaloparatide ( not in UK ( – PtHRP analogue • Romosozumab i/m monthly for 1 year – Antisclerostin antibody – Increases Wnt Signaling in bone Mechanism of Romososumab Contraindications to use Romo Small significant increased risk of Stroke and Heart attack in 1 RCT with older subjects Questions