Microsoft word - central lancs bone health _pmd, author & librarian changes_ 08-06-11.doc
CENTRAL LANCASHIRE BONE HEALTH PATHWAY REFERENCE NUMBER APPROVING COMMITTEE(S) AND DATE
Clinical Governance and Risk Management Forum
AUTHOR(S) / FURTHER INFORMATION
Central Lancashire Osteoporosis work stream
LEAD DIRECTOR THIS DOCUMENT REPLACES REVIEW DUE DATE RATIFICATION DATE/DRAFT No VALIDATION SIGNATURE Introduction
Osteoporosis is described as a progressive systemic skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture (World Health Organisation) The clinical significance of osteoporosis is fracture, with more than one third of adult women and one in five men sustaining one or more fractures in their lifetime. The most commonly associated age related fractures are wrist, spine, hip, humerus and pelvis. Injuries such as fractured vertebrae and wrist fractures disable the older person in terms of pain, loss of independence and an inability to cope. Hip fractures place heavy demands on the health service and significant health and social costs on the older person, family and carers. Hip fractures alone account for more than 20% of orthopaedic bed occupancy in the UK, and the majority of direct health service cost of osteoporosis. Approximately 50% of patients sustaining a hip facture can no longer live independently, and within 12 months of hip fracture 20% of patients will have died. Over the next 50 years the ageing UK population will see a rise to a doubling of the osteoporotic hip fractures, if changes are not made in present practise. Scope The Central Lancashire Bone Health Pathway determines locally agreed best practise for patients who are at risk of osteoporosis and fracture for men and women. The pathway includes both primary and secondary prevention and management. Compatibility with NICE/other guidelines
• Bone and Tooth Society, National Osteoporosis Society, Royal College of
Physicians (2002) Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment
• NICE (2008) Alendronate, etidronate, risedronate, raloxifene, strontium
renelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
• NICE (2008) Alendronate, etidronate, risedronate, raloxifene and
strontium renelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women
• National Osteoporosis Guideline Group (2008) Guideline for the diagnosis
and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK
• NICE (2010) Denosumab for prevention of osteoporotic fractures in post
Primary and Secondary Prevention of Osteoporotic Fracture in Men and Post- menopausal Women Supplementary notes to pathway and guidelines Abbreviations used in flow chart CRF Clinical Risk Factor (listed below) FRAX Fracture Risk Assessment Tool (link below) DXA Dual X-Ray Absorptiometry (technique of measuring bone density – see below) NOGG National Osteoporosis Guideline Group (link below) HRT Hormone replacement therapy How to use the guideline Simply identify into which of the top 3 blue balloons your patient belongs. If you cannot do this then do not use the guideline and seek expert advice. After locating your patient within a blue balloon, follow the arrows and directions of the flow chart. If your patient passes through the central portion of the pathway, you are first directed to assess the absolute fracture risk (using FRAX, link given below) and then you are directed to NOGG, (link given below) for advice on treatment thresholds. In NOGG by using your patient’s age and the absolute fracture risk from FRAX, you will be able to put the patient into a higher or lower risk group and hence determine the need for treatment. Author Comment: Please replace the above para highlighted in red with If the Guideline recommends you to use either FRAX or NOGG, they can be accessed by using the links HTTP://shef.ac.uk/FRAX/ and Field Code Changed
HTTP://shef.ac.uk/NOGG. FRAX gives you the absolute fracture risk for your patient, ( for any fragility fracture and specifically hip fracture) and NOGG indicates whether this level of risk lies above the treatment threshold. Clinical risk factors (Author comment OK) for the assessment of fracture Deleted: used probability (NOGG) Low body mass index (≤19kg/m2) Previous fragility fracture, particularly of the hip, wrist and spine including morphometric vertebral fracture Parental history of hip fracture Current glucocorticoid treatment (any dose, by mouth for 3 months or more) Current smoking or significant smoking history Author comment OK Alcohol intake of 3 or more units daily Secondary causes of osteoporosis including: •
What about Chronic kidney disease Author comment. Chronic Kidney disease not
Formatted: Bullets and Numbering
specifically mentioned by NOGG. Don’t ask me why!
Formatted: Bullets and Numbering
Falls – not a risk factor for assessment purposes, but needs to be considered DXA scanning Where there has been a fracture, a DXA scan should be requested by the Deleted: it is preferable for
orthopaedic team in the fracture clinic. However all further bone health
Deleted: to be
advice/management should be undertaken by the General Practitioner (GP).
The scan result will be sent to the GP, with a copy filed in hospital notes. Request forms for DXA scans should be available in all relevant clinical areas.
Nearby DXA scanning facilities exist at Blackpool (Clifton Hospital, Lytham) and Lancaster Royal Infirmary. Author comment OK Discharge summary/ communication to primary care For communication from secondary to primary care Author comment OKinformation Deleted: suggested
for inclusion is: • Site of any fracture
• Details of prescribing commenced/considered
• Whether a DXA scan referral has been made/ not required • Details of Falls assessment or referral to Falls services Specialist Referral 1) Not all fragility fractures are caused by primary osteoporosis. If the clinician
suspects that other disease weakens the bone e.g. cancer, then a specialist referral should be considered.
2) Patients who have a Z score of –1 or less are markedly different from their peers
(what is the significance) Author comment- please continue sentence with
“and are in the lowest quartile as regards bone strength”. They may need referral for further investigations(which patients ). Author comment Change ‘They may need etc’ to “ They should be referred if this situation does not already have a clear explanation or management.
After one year ofcompliance with prescribed treatment and adequate duration( define) have has been checked, any fractures occurring on treatment
here, should be referred to a specialist clinic.
4) Consideration should be given to specialist referral for men 5) When referring to the osteoporosis clinic, PLEASE REMEMBER TO GIVE FULL
NUMERICAL DETAILS OF ALL DXA SCANS or copy of scan Author comment
Deleted: e Deleted: A Deleted: . Investigations to exclude other bone disease: Please note, selection of the appropriate test(s) depends on the clinical setting. FBC, ESR, U&E, LFT, Bone chemistry TSH, sex hormone levels, gonadotrophins myeloma screen, PSA, Vitamin D (25OHD3), PTH. OK Deleted: v
Also breast examination, CXR and bone isotope scan may be required If in doubt, seek specialist advice.
Patients on Glucocorticoids See accompanying LTHTR guidelines on prophylaxis of glucocorticoid induced osteoporosis. To quantify absolute fracture risk and check treatment threshold The Fracture Risk Assessment Tool FRAX can be accessed at: HTTP://shef.ac.uk/FRAX/ This provides a 10-year absolute fracture risk for all osteoporotic fractures and also specifically for hip fracture. On its own this information is limited because of the need to have a treatment threshold. It is therefore recommended that the absolute risk values from FRAX and the patient’s age be entered into NOGG. This will inform the clinical decision by plotting the patient in relation to the treatment threshold. Usually while using FRAX your patient will be automatically put into NOGG by clicking on the NOGG link. In case of difficulty the e-address for NOGG is: HTTP://shef.ac.uk/NOGG Lifestyle Advice Formatted: Font: Bold
You are recommended to ensure adequate Calcium and Vitamin D status, see below. Also to advise your patients not to smoke, to consume less than 4 units of alcohol daily and to take regular weight bearing exercise.
Deleted: ¶ Calcium and Vitamin D status Assessment of calcium and vitamin D status, lifestyle advice and consideration of falls assessment should be made for all patients with or at risk of osteoporosis. Patients in all treatment groups should have an adequate calcium intake and vitamin D status. Daily calcium intake should be at least 700mgs daily (as recommended by NOS) and can be checked using the calcium calculator found on www.prestonhipday.org.uk Vitamin D status generally depends on regular exposure to natural sunlight. In case of any doubt measure serum Vitamin D3. For elderly individuals in institutional care or housebound, supplementation is recommended. 1000mg calcium & 800IU vitamin D (NOGG) is the evidence- based dose. Treatment Choices Agents mentioned in the algorithm
Alendronate is the first treatment option in all guidance, due to the evidence base, licensed indications and cost effectiveness. Alendronate is contraindicated:
• abnormalities of the oesophagus, which delay emptying
Deleted: in the presence of
• inability to stand or sit upright for at least 30 minutes
Formatted: Bullets and Numbering Deleted: , Deleted: and
It should be used with caution in patients with other upper gastrointestinal disorders and is not recommended in patients with renal impairment (creatinine clearance <35 ml/min). Alendronate is also licensed in the treatment of men and also glucocorticoid-induced osteoporosis.
Deleted: Avoidance of Risedronate is an alternative bisphosphonate. It is licensed in the treatment of post- Alendronate in known upper GI Disorder¶
menopausal osteoporosis, glucocorticoid-induced osteoporosis and men.
1.Bijisma. Ann Rheum Dis. 2003; 62: 1033 – 1037¶
Strontium can be used if bisphosphonates are contraindicated or not tolerated.
Severe allergic reactions (DRESS) have been reported. Symptoms include rash,
fever, swollen glands and increased white cell count and can cause liver, kidney
Deleted: ¶ Deleted: a Deleted: re Intraveneous (IV) Zoledronate injection This is another alternative when oral bisphosphonates are not suitable. It consists of Deleted: ;
a once yearly IV injection. This should be administered under specialist
Deleted: affect Deleted: V Deleted: iv Sub-cutaneous (SC) Denosumab injection This is an option when none of: oral bisphosphonates, strontium nor iv zoledronate Deleted: . It is necessary to liaise with secondary care to arrange this.
are suitable. It consists of a twice yearly SC injection. It is necessary to liaise with
Author comment OK Agents not mentioned in the algorithm Raloxifene is a further alternative but evidence indicates its efficacy only for vertebral fracture prevention. It is contra-indicated with a history of venous thromboembolism. NICE has approved its use in secondary prevention (not primary) after oral Deleted: only sanctions
bisphosphonates and strontium have been found to be unsuitable. Author comment OK Monthly Ibandronic acid is an oral bisphosphonate licensed for postmenopausal osteoporosis. It has efficacy to prevent vertebral fractures and may be preferred by some patients. Compliance/Monitoring It is accepted that compliance and persistence with medication, particularly the bisphosphonates is variable. Some patients may persist with the medication but not properly observe the full administration precautions; others will simply stop the drug and may not even inform the medical practitioner. Full advice should therefore be given to all patients starting new medication. Periodic fol ow-up to check for side effects and encourage concordance has been shown to make a difference. Patients should be offered an annual medicine use review (MUR) by the community Deleted: Another aid is to consider Deleted: What is an MUR?¶
Author comment OK This wasn’t my idea anyway!
A medicine use review (MUR) is a service, which can be offered to
Other links to resources:
under the Advanced Services of the pharmacy contract.¶
For individuals prone to falls, consideration should be given to local or national
guidelines (NICE, November 2004) and possible referral to exercise/balance classes.
An MUR can be conducted every 12 months and is intended for patients
Useful links to the NICE falls guideline are:
2) http://www.nice.org.uk/nicemedia/pdf/CG021quickrefguide.pdf 3) Central Lancashire Falls Pathway (available on both NHS Central Lancashire
and Lancashire Teaching Hospitals Trust intranets)
Falls Falls services locally available are: Primary Care Falls Prevention Service
1) Preston & South Ribble localities: Community Equipment & Resource Centre Unit 5 Centurion Court, Leyland PR25 3UQ Telephone: 01772 678042 FAX: 01772 644739 2) Chorley and West Lancashire localities Old Pharmacy Building, Ormskirk DGH Wigan Rd, Ormskirk Lancashire L39 2JW Tel: 01695 598270 Fax: 01695 598246 Falls Clinics (consultant led) Dr Agrawal Consultant Physician consulting at: Falls Clinic (Preston) Brock Day Hospital Medical Rehabilitation Unit, Royal Preston Hospital Sharoe Green Lane Fulwood Preston R2 9HT 01772 524380 And also at: Falls Clinic (Chorley) Belmont Day Hospital Chorley & South Ribble District Hospital Preston Rd 01257 245540 FAX:01772 524368
Bone and Tooth Society, National Osteoporosis Society, Royal College of Physicians (2002) Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment. London, Royal College of Physicians. NICE (2004) Falls: the assessment and prevention of falls in older people. London: National Institute for Health and Clinical Excellence NICE (2008) Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. London, National Institute for Health and Clinical Excellence. NICE (2008) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. London, National Institute for Health and Clinical Excellence. NICE (2008) Final appraisal determination: Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. London, National Institute for Health and Clinical Excellence. National Osteoporosis Guideline Group (2008) Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Sheffield, NOGG. NICE (2010) Denosumab for prevention of osteoporotic fractures in post menopausal women. London, National Institute for Health and Clinical Excellence. Locke, G.R et al (1997) Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology, 112 (5), pp. 1448-1456. Bijlsma, J.W.J et al (2003) Glucocorticoids in the treatment of early and late RA. Annals of the Rheumatic Diseases, 62 (11), pp. 1033-1037.
Dr John F McCann and Louise Winstanley first developed this document in April 2009. Its basis was the Lancashire Teaching Hospital secondary prevention guideline, written by JFM. Membership of the Central Lancashire Osteoporosis work stream:
Catherine Baines Falls Project Manager NHS Central Lancashire Dr Kanitkar GP Central Lancashire Alison Johnson Associate Director Commissioning NHS Central Lancashire Dr Binymin Consultant Rheumatologist Southport & Ormskirk
Dr John McCann Consultant Physician Lancashire Teaching Hospitals Foundation Trust Mr George McLauchlan Consultant Orthopaedic Surgeon Lancashire Teaching Hospitals
Dr Satyendra Singh GP Central Lancashire Claire Wedge Fal s Coordinator NHS Central Lancashire Louise Winstanley, Pharmacist Independent Prescriber, NHS Central Lancashire Nicky Roe Pharmacist Liz Stafford LPC Pharmacist
Osteoporose Gesamtüberblick - Osteoporose Gesamtüberblick - Osteoporose 1. Was ist Osteoporose? Osteoporose ist charakterisiert durch eine Verminderung der Knochenfestigkeit, die einhergeht mit einer zunehmenden Einschränkung der Mobilität und dem Auftreten von Schmerzen, vorrangig im Bereich des Rückens. Das Risiko von Knochenbrüchen ist gesteigert bei: • Frauen • im höh
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