A GP's guide to osteoporosis TF Te lites Ste-Ti eM Ceo Calg * 4.74 million Australians * >1 million have osteoporosis’ >, © By 2022, 6.2 million Australians >50 years will have osteoporosis or osteopenia — resulting in nearly 200,000 fractures in that year alone’ 5 CrP Devastating consequences = * Minimal trauma fractures oeee affect one in four men 7 7 qT T ae and one in two women older than 60? * Awoman older than 60 has a 44% risk of having a minimal trauma fracture in her lifetime’ * Even minor minimal trauma fractures increase morbidity a and mortality ii * One minimal trauma fracture: 2-4 fold risk of fracture at a different site’ Many people with a minimal trauma fracture are treated only for the fracture — not the underlying cause” Despite the increased availability of effective drugs, fewer than 20% of Australians with minimal trauma fractures are investigated or treated for osteoporosis” How GPs can help * Assess patients older than 50 for risk of osteoporosis and fracture * Address the problem of under-treatment * Use the T-score to assess bone mineral density (BMD)’ — T-score: the number of standard deviations of the BMD measurement above or below that of young healthy adults of the same sex’ — The PBS uses the WHO T-score range to determine eligibility for osteoporosis medications' BMD not more Normal BMD Tscore -1.0 or above. |) trans Osean young adult 7a BMD between 1.0 Osteopenia C0 e eal and 2.5 SDs bel: -1.0 and -2.5 young adult Osteoporosis - low BMD — micro-architectural deterioration of bone tissue BMD 2.5 or more T-score -2.5 or below | SDs below you adult mean v,V X Vhy are GPs not diagnosing those at risk x * BMD is only one of several factors that contribute to an individual's risk of fracture’ * About 50% of minimal trauma fractures occur in people { with “normal” or “osteopenic” T-scores' * About 30% of radiographically visible vertebral fractures in women with osteoporosis are not detected’ Making a diagnosis : Diagnostic assessment: * Medical history’ * Clinical examination’ * BMD measurement by dual energy X-ray absorption (DXA)' If applicable: * Laboratory tests and radiographs of the thoracic and lumbar spine! The MBS reimburses BMD testing for: eo f=. * Anyone older than 70 years? * Patients with a minimal trauma fracture® * Patients older than 50 with no minimal trauma fracture but with major risk factors’? eR Orn Rea DCC itite tek eueca PT Utd DY ented Rheumatoid arthritis Glucocorticoid use for at least three months Thyroid disease Anti-androgen therapy Chronic liver or kidney disease Coeliac disease/malabsorption disorders Premature menopause TN etereroue tele * See RACGP Guidelines.’ z oe : z ; t I = J z 2 bt Height loss of 3cm or more’ _Thoracic kyphosis New-onset back pain (hunchback)* suggestive of fracture’ ¥ MBS changes x As of November 2017: * DXA scans must be performed by a specialist or a person with a radiation licence and overseen by a specialist or consultant physician? * New intervals for people over 70 years: T-score 2 -1.5: one scan every 5 years T-score of -1.5 to -2.5: one scan every 2 years Osteoporosis treatment is recommended for patients with a high absolute fracture risk * Post-menopausal women and men older than 60 with T scores < —2.5 at: a the lumbar spine ‘ femoral neck » CT aa a FIRST-LINE Bisphosphonates Denosumab Raloxifene Daily, weekly or monthly Monoclonal antibody Aselective oestrogen- tablets (alendronate, receptor modulator risedronate) v Annual infusion 6-monthly subcutaneous Daily tablet (zoledronic acid) injection PBS subsidy for: PBS subsidy for: PBS subsidy for: minimal trauma fracture minimal trauma fracture postmenopausal women a a with previous minimal F F t fracti > 70 years with > 70 years with aaneeceaae T-score < -2.5 (< -3.0 for T-score < -2.5 on zoledronic acid) my o . v or Ze T-score < -1.5 taking bere long-term oral corticosteroids 5 Teriparatide Recombinant parathyroid hormone. PBS subsidy for: T-score < -3.0 and very high fracture risk and 22 minimal trauma fractures and new fracture after 12 months on another osteoporosis medicine and treatment must be initiated by a specialist or consultant physician =) References: 1. RACGP & Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men ‘over 50 years of age. 2nd edition 2017. Available from: hitps://wmw.osteopoross.org,au/sites/default/iles/iles/20439%200steoporosis%20guidelines pal Accessed 20/3/18. 2. Milat F and Ebeling PR. Med J Aust 2016; 205 (4): 185-90. 3. Australian Government Department of Health. Bone Densitometry. Available online: worw.health.gov.au/internet/main/publishing.nst/content/diagnosticimaging-bd.htm Accessed 20/3/18. 4. Osteoporosis Australia Medical and Scientific Advisory Committee. Therapeutic Management 2017. Available from: https://www.osteoporosis.org.aultherapeutic-management 5. NPS MedicineWise. Decision pathway for PBS:lsted treatment selection: management of conficmed osteoporosis 2016. Available from: hitps://wwwenps.org.2u/_servito/decsion-pathway-for-pbs-listed.treatment-selection-managoment-of-confizmed-osteopoross-7ed5e5af0817eb This content is produced by Australian Doctor Group, with an independent educational grant from Amgen.