management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance...

Management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance Fragility fracture definition: Fracture site excluding fingers, toes, scaphoid and skull Fracture force excluding major RTA or fall from more than 6 feet All patients should be assessed for osteoporosis and to rule out secondary ca Lowest T score > -2 General guidance, Smoking cessation, Alcohol moderation, Dietary calcium advice (~ 1g/day) Lowest T score -2 to -2.5 Lowest T score < -2.5 / DXA inappropri Current steroids planned for 3+ mont Multiple fractures, vertebral fracture, Or secondary cause Aim Total 25OH-vitaminD >20ng/ml (>50nM) OR Rx Calcium/vitamin D 1g/1000iu. INDICATIONS for Referral to bone clinic: 1.Pre-menopausal or men under the age of 60 years presenting with osteoporosis 2.Fracture after one year of compliant therapy 3.Inability to take or tolerate oral treatments 4.Osteoporosis due to complex medical diseases including cancer therapies and kidney disease. ional Investigations if indicated: iac screen if ever history of unexplained anaemia m & urine electrophoretic strip if unexplained high ESR our urinary calcium (esp if hypercalcaemia/ renal stones) m testosterone, LH and SHBG, PSA <men> our urinary cortisol BLOOD/ URINE INVESTIGATIONS 1: Bone function (Serum calcium, phosphate, ALP, Albumin,25OH vitamin D), Renal function, ALT/ AST, FBC, ESR, TSH DXA Not essential If over 75 years and DXA clinically inappropriate Repeat BMD in 2-5 years or sooner if further fracture DURATION OF THERAPY: Oral agents: Assess adherence @ 3mth then annually Review treatment after 5 years At end of treatment cycle Consider DXA/ bone markers Consider 3-5 years off treatment If on-going high risk consider continuing Rx for 10 years i.e. DXA still < -2.5, on steroids. Zoledronate/ Dmab: 3 yrs then reassess Bone markers if available: Serum PINP or Fasting serum CTXI NO Start Bone specific Therapy + condary causes: flammatory arthritis including Rheumatoid flammatory bowel disease ronic liver disease labsorption pogonadism nopause < 45 years pe I diabetes YES

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$Page 1: Management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance Fragility fracture definition: Fracture site excluding$

Management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance

Fragility fracture definition:Fracture site excluding fingers, toes, scaphoid and skull

Fracture force excluding major RTA or fall from more than 6 feet

All patients should be assessed for osteoporosis and to rule out secondary causes

Lowest T score > -2

General guidance, Smoking cessation, Alcohol moderation, Dietary calcium advice (~ 1g/day)

Lowest T score -2 to -2.5 Lowest T score < -2.5 / DXA inappropriate/Current steroids planned for 3+ months

Multiple fractures, vertebral fracture,

Or secondary cause

Aim Total 25OH-vitaminD >20ng/ml (>50nM) OR Rx Calcium/vitamin D 1g/1000iu.

INDICATIONS for Referral to bone clinic: 1.Pre-menopausal or men under the age of 60 years presenting with osteoporosis2.Fracture after one year of compliant therapy3.Inability to take or tolerate oral treatments4.Osteoporosis due to complex medical diseases including cancer therapies and kidney disease.5.Acute painful vertebral fractures

1Additional Investigations if indicated: • Coeliac screen if ever history of unexplained anaemia• Serum & urine electrophoretic strip if unexplained high ESR • 24 hour urinary calcium (esp if hypercalcaemia/ renal stones)• Serum testosterone, LH and SHBG, PSA <men>• 24 hour urinary cortisol

BLOOD/ URINE INVESTIGATIONS1: Bone function (Serum calcium, phosphate, ALP, Albumin,25OH vitamin D), Renal function, ALT/ AST, FBC, ESR, TSH

DXA Not essential If over 75 years and DXA clinically inappropriate

Repeat BMD in 2-5 years or sooner if further fracture

DURATION OF THERAPY:

Oral agents:Assess adherence @ 3mth then annuallyReview treatment after 5 yearsAt end of treatment cycle

Consider DXA/ bone markersConsider 3-5 years off treatmentIf on-going high risk consider continuing Rx for 10 years i.e. DXA still < -2.5, on steroids.

Zoledronate/ Dmab: 3 yrs then reassess

Bone markers if available: Serum PINP or Fasting serum CTXI

Start Bone specific Therapy

Secondary causes:Inflammatory arthritis including RheumatoidInflammatory bowel diseaseChronic liver diseaseMalabsorptionHypogonadismMenopause < 45 yearsType I diabetes

YES

$Page 2: Management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance Fragility fracture definition: Fracture site excluding$

Alendronate for 5-10 yrs70mg once a week+ With Ca + Vit D

Compliance review at 3 months

Re-education and additional support

Risk assess need for treatment

Side effect: Dyspepsia Side effect: Swallowing issue

COMPLIANT – continue for 5 yrs andreview compliance annually

Benefit of treating outweighedby poor compliance / side effects

Prescriber: Ask about swallowing, dyspepsiaCheck GFR/eGFRdiscuss administration /compliancediscuss potential side effects

+ Risedronate+ Strontium

+ Zoledronate + Denosumab

+ Strontium+ Zoledronate + Denosumab

Medical management of men and women over 50yrs who have sustained a fragility fracture: 2010 draft guidance

NON Compliant

NON Compliant after further 3 months of

support

Intolerant to Alendronate

Fracture after one year of adherent therapy

Continue+ Teriparatide

+ strontium

Bone marker suppressed Bone marker non- suppressed

+ Zoledronate+ Denosumab Bone markers:

Serum PINP orFasting serum CTXI

$Page 3: Management of men and women over 50yrs who have sustained a fragility fracture: 2011 draft guidance Fragility fracture definition: Fracture site excluding$