Senin, 03 Juli 2017

osteoporosis clinic

osteoporosis clinic

hello, i'm geraldine moses. welcome to this program on the clinical guideline for the prevention and treatmentof osteoporosis in post-menopausal women and older men. osteoporosis is under-recognisedand under-treated. the deterioration of bone can proceedwith no outward symptoms until a symptomatic fracture occurs. recent research indicatesthat only 7% to 20% of people

who have sustainedan osteoporotic fracture receive treatment for osteoporosisto prevent further fractures. this program is the finalin a series of four programs on the new musculoskeletal guidelinesfor general practitioners and other primary health careprofessionals, which have been developed by the royal australian collegeof general practitioners and approved by the national healthand medical research council. the guideline provides recommendations

for prevention and treatmentof osteoporosis our program will discuss how local health servicesand general practices can improve their treatmentand management of osteoporosis. you'll find a numberof useful resources available on the rural health educationfoundation's website - now let's meet our panel. firstly, professor john eisman is a professor of medicineat the university of new south wales,

a staff endocrinologistat st vincent's hospital in sydney and director of osteoporosisand bone biology at the garvan instituteof medical research. john was the chair of the working partyfor developing this guideline. - welcome, john.- thank you, geraldine. cecily barrack is a physiotherapist. she works forthe north coast area health service and the northern rivers universitydepartment of rural health as a research clinician to look atlocal osteoporosis management.

- welcome, cecily.- thanks, geraldine. dr dan ewald is a general practitioner who works in rural general practice and with the northern riversgeneral practice network. dan was alsoon the guideline working party. - welcome, dan.- hello, geraldine. and judy burrows is a pharmacist, and she has a backgroundin hospital pharmacy. she also lectures in thepostgraduate clinical pharmacy program

at the university of queensland and is the queensland healthand university of queensland pharmacy training coordinator. welcome, judy, and welcome to you all. cheers. so, let's just startwith a definition question. john, i wonder if you couldquickly explain - what is osteoporosis? well, osteoporosisis a problem that is common and it developsparticularly as we get older

when, with the remodellingof the skeleton, the bones become a little bit weaker, more fragile, and they really breakwith minimal force. and that's really what the problem is. right, and just so that our audience can understand our panellists'involvement in this, cecily, can you just briefly explain -what's your involvement in osteoporosis? my involvement is looking, perhaps,

at how fragmented carefor people with osteoporosis can be and how we can better organiseour health services and systems so that peopleactually don't fall through the gap and are connected withevidence-based care. right. and, dan, you were involvedin writing the guideline, but i believeyou've got a special interest in what the evidence is showing? well, i'm particularly drawnto this area because of the gap between

what the evidence tells usis good practice and what we can do, and what we actually end up doingin the real world. and also that it's an area wherewithin the last 10, 15 years we've got available to ussomething very useful we can do. so it's relatively new still. and, judy, you're a pharmacist, so what do you seeas the role of pharmacists in the management of osteoporosis? well, i think irrespective of whether

pharmacists workin the community, hospital, or an accredited pharmacistdoing home medicine reviews in the homes or in the nursing homes, i think pharmacists,as part of a multidisciplinary team, have a really big role to play in optimising the healthof patients with osteoporosis. right, now, john, back to you, if i may, can you please explain the extentof the problem of osteoporosis? well, it's a huge problemin the community.

older women, say, over the age of 60 - one in two of themwill have an osteoporotic fracture during their lifetime. and for men,even though the risk is lower, it's perhaps one in three. and these are associated,once you've had one fracture, with increased riskof further fractures and with premature mortality. and we've known these statsfor quite a long time.

are there any trends?are these figures changing? um... well, if anything, the trend is thatwe are seeing more fractures, because we're havingan ageing community. people are living longer, and,as they live longer, the risk goes up. but still, having said that, the peak incidence of the problemsof osteoporotic fractures are in people in their 60s and 70s,not in the really older age groups. - just because there are more people.- right.

so, what's the burdenof all these osteoporotic fractures? well, at the momentthe estimated cost in australia, including direct and indirect costs, is something like $7 billion a year. so it'll cost australia about $1 millionwhile we are talking about it tonight. wow. do we know what causes osteoporosis? well, there's a major part of itwhich is genetic, a very high part of it.

as i always point out to people,choose your parents wisely, but it's usually a bit late. but then there are thingslike environmental factors and there are things like lifestyle,exercise, nutrition and so forth. and then partly it's just advancing age. there are many secondary factors, which i guesswe'll talk about a bit later, but these are also thingsthat contribute to the risk. and are there any medical conditionsthat contribute to the risk?

well, there area lot of health conditions - anyone who's onthings like cortisone, prednisone, people who have got malabsorption, things like celiac disease,which is often not recognised, women who have an early menopause, or men who are on treatment,let's say, for prostate cancer, where the male hormone levelsare dropped - they're also at increased risk. and there are a number of other things -

lung disease,people with a lot of asthma, people witha lot of inhaled corticosteroids - not the normal doses, but thevery high doses can also affect it. now, i think most of us know that osteoporosis is measuredto a certain extent with bone mineral density testing, but the results that people get aren't immediately obviousin what they mean. so can you please explain

the relationship betweenthe t-score and the z-score and what that really meansto real people? ok. when you measure something, you've alwaysgot to know what you expect. so the z-score is the comparison withother people of the same age and sex. now, if you're withina couple of standard deviations - 'cause that what it's measured in -of that value, then the implication isthat whatever your value might be

it doesn't look likeyou should be terribly worried that there's some other secondary cause. but if it's lower,you should really worry that there's something elsethat you haven't thought about yet that you needto be doing something about. but the actual diagnosis, if you like,of osteoporosis relates to the t-score, which is the comparisonto young normal. and there's a very...

somewhat arbitrary definitions that if you're withinone standard deviation of young normal, we'd say it's normal, if you're between 1 and 2.5,we say that's osteopenia, and if you're more than 2.5,we say that's osteoporosis. but these are sort of steps along a gradientof exponentially increasing risk. there's no sudden step in any of these. and, dan, i believe that you like to say

that bone mineral densityis just a risk factor, it's not the disease itself,is that right? i think it's usefulto remind people of that. like we're used to paying attentionto blood pressure or cholesterol, which doesn't present with anysymptoms, but we know it's important because it marks a riskfor something dramatic. and that really should be the way we're thinking aboutbone densities as well. it's a very important risk factor,

but the event that countsis their fracture. so, since we're talking with you, and you know a lot aboutwhat the royal college did in terms ofdeveloping these guidelines, what was the impetus? surely we know enough about osteoporosisalready, we don't need more guidelines? well, a lot of usdidn't learn about osteoporosis and what to do about it,in our training. even in our post-graduate training.

it's only come to us,depending on our age, in later years. and there's been a lot of promotionfrom the drug companies and there's been some presencefrom other agencies as well. so it's very appropriateto try and clear up some misnomersand some misunderstandings, and it's a hugely important issue, still grossly under-recognisedand under-treated. and particularly in rural areas. when we looked at how much bone densityis being done in rural areas

compared to urban areas, it's markedly less,suggesting that rural areas might be missing outon looking after osteoporosis even more than their urban counterparts. oh, that's very interesting. i believe you've gota copy of the guidelines with you. would you like to show the audiencehow beautiful it is? if you download it from the royal australian collegeof general practitioners website,

you can make yourself a little booklet. and there you'll find somenicely summarised evidence around most of the topicsthat might be troubling people. all those debatesabout how long to treat for and when to treat, and age,and the risk factors, etc, are discussed withwhatever evidence is available. how long did it taketo put the guideline together? it's a lot of work,and there's been a lot of hours. - years?- it's been years in the making.

and there's a number ofsupporting documents and programs that are availableto help the uptake of the guidelines. and so there areguidelines for practices to do small group learning exercises and do clinical auditswithin their practice. there's a summary guideline. to fit the whole thing onto two sidesof an a4 page was a challenge, and we've done that as well. and those who getthe australian family physician

will be getting a copy of thatnext month. there's a practice nurse guide, and we might look in the future to the collaboratives programtaking up osteoporosis, there's an edition of the check programcoming out, and we've already had a national prescribing service programon osteoporosis. so there's a number ofother supporting activities out there. so it's available on the racgp website

and it will be inthe australian family physician. will it be advertisedto allied health professionals, like physios and pharmacists? anyone will be able to access thisthrough the college website. - and i'd encourage them to do so.- yeah. judy, do you think pharmacistswill be looking out for this? i mean,should we be raising awareness... absolutely. awareness should be raisedabout those guidelines

and that will be somethingthat we should address as a profession to improve the uptake of guidelines. cecily, do you think physioswill be interested in raising this? there might be a lot about drugs,which often doesn't interest... absolutely. they're at the interfacewith a lot of these patients in the acute and the convalescentrehabilitation phases, and they need to be very awareof what the current evidence is and to give the right advice. so, now let's take a look atour first case study, who's cheryl.

cheryl is 66 years old and she presents at the doctor's surgerywith an acute episode of back pain. she's experiencedepisodic back pain over the years, and she's been takingparacetamol for the pain. she has thoracic kyphosis and she had anorexia nervosawhen she was in her twenties. her bone density at her hipis a t-score of -2.7. so, dan, if she presentedto your general practice, what would you say indicatesthat cheryl might have osteoporosis?

well, i'd hope that my practice will be really tuned into thinking about osteoporosis, and that's the first big hurdle,is to think of it. and then the clues arethat she's female and her age, and that she's got a back painand a kyphosis, she's had a period of anorexia nervosa. all of these things are stacking up, and there's no surprisethat she's got a bone density of -2.7, which is significantly low

and in the rangewhere we call it osteoporosis by the standard who definition, and the evidence for treatment applies. but, clearly, you have to thinkof a differential diagnosis list, so what investigationsmight you have to consider to think of all possible scenarios? well, there's a couple of things,to answer that question. one is she's presented with back pain, so we have to approach back painin its own right

and sort that out in our normal way. and then if the back painis because of a... ..we think it's becauseof a vertebral fracture, a new vertebral fracturebecause of her osteoporosis, then she's also added to her risk, 'cause having one fracture makes her much more at riskof a subsequent fracture. then we've got to approach the issue of what might becausing her osteoporosis.

and we come back to john's mention ofthe z-score. might give us a clue there. if her z-score is close to zero,we're less worried that she's got some other unusualdisease process driving her bone loss. if her z-scores are very low, we'd be looking more closelyfor some underlying cause. what investigationswould you do first up for her, in terms of her potential osteoporosis? well, there's nohard and fast rules for this, but we do want to knowwhat her vitamin d levels are.

and we can't really tellby asking her and looking at her. much as we'd think thateveryone who lives in sunny queensland is going to have normal vitamin d,it doesn't happen that way. we know her bone density,that we can look for... we can do some blood tests to rule out the most commonother causes of secondary osteoporosis. so we can do liver-function tests, we can look at her serum calcium, we can do a full blood count,look at an egfr,

we can do her protein electrophoresisand thyroid-stimulating hormone. but, as i say,you can use some clinical judgement on how much of that battery of testsyou'll apply in every case. now, you're going to end upwith a t-score and z-score, but perhaps i can ask john about the roleof the fracture risk calculator, which i believe your teamat the garvan institute developed. can you tell us about that, please? yes, well, this came out of the workthat we'd done in dubbo,

looking at the factorsthat would predict risk. and this is a population of abouttwo-thirds of the older people in dubbo, who we've been following nowfor almost 20... ..actually, for over 20 years. and what we found is the things that, in a sense, following on what dan said, the things thatreally predict the fracture is what your age is - the risk is higher in womenthan in men -

whether you've had falls, because that alsopredicts your risk of fractures, whether you've had any prior fractures, and what the bone density is. and with those,you can really, very accurately separate peoplewho are at low risk of another fracture from people who are at much higher risk. and it gives you a riskof what their risk of any fracture is or what their hip fracture isover the next five years

and over the next ten years. how is this risk expressed?is it a per cent? it's a percentage - what is your chance? obviously,100% means that you're going to, and if it's 5% or 10%, you could say,well, maybe it's not so high. that must be so much more meaningfulthan a t-score. well, i mean, i includes the value from the t-score, but it takes inall this other information. it allows people to evaluate risk.

i mean, we're not entirely happythat we're there yet, because i think it's still hardfor people to understand risk, absolute risk, in real terms. so we're still working on that. but if people want touse the fracture risk calculator, that's how you'd find it. it's called 'fracture risk calculator'. or you can go to the garvan website,and it'll come up and it's there. and it works for both men and women,and from the age of about 55 onwards.

so, back to you, dan. what are the challenges for gps in diagnosing osteoporosisin general practice? the challenge is to think of it, and recognisethat we need to be thinking of it. once you've switched your brain onto being alert to it and you've got your practice teamswitched on to it - 'cause it's not only the gp who needs to be picking up the conceptof osteoporosis and bone density -

the practice nurse, and all the alliedhealth providers that we work with have to be part of that - then what to dois really quite clearly set out, and you can turn to the guidelinesand even the summary guide to step you through it. i think the big hurdle is to recognisewe need to be doing something about it. mmm. picking it up as early as possible. judy, i wonderif you could comment here. possibly, cheryl was purchasingher paracetamol in a pharmacy.

what's the role of pharmacists in early detection and screeningfor osteoporosis? well, i think, as dan said, if the whole multidisciplinary teamis switched on to the idea of being mindful of osteoporosisas a consideration, then, if someone did come inlooking for some analgesia and they were a regular customerand complained of back pain, that's somethingthat should initiate a referral, a referral to the gp,to have that investigated,

not just assume it's musculoskeletal. that's right,'cause isn't there an old saying that any sudden onset of painin the central back region should be thought of as an osteoporoticfracture in the first instance? is that right, john? i think, if you have somebodywho has an acute episode, particularly if it persists for, youknow, more than a few hours or days, i think you need to think about thatas an osteoporotic fracture. and the other thing too is if somebodysays, 'look, i've really lost height.'

'cause most people can rememberwhat their height was when they were in their 20s. if they'resubstantially down from that - more than 1cm or 2cm,that we all get from disc wear - you really need to think about thatas potentially a fracture. and an x-ray, as happened in this lady, is a very useful way of clarifying that. and if they've got a fracture,that's osteoporosis, really. moving on now to oursecond case study, who is charles.

charles is 68, and he slips and falls whilst playing with the grandchildrenin the backyard. he has considerable wrist pain. he goes to the emergency department,and an x-ray reveals a wrist fracture. after treatment at the hospital, he visits his gp with the dischargereferral, but he has no x-ray. charles has a historyof smoking and of asthma. dan, if charles was your patient,how would you proceed here? he's had a fragility fracture.

that's the first thingwe have to recognise. what do you mean by that? well, he slipped and fell.he's had a fall. he's had a fracture from a fallfrom a standing height or less is an easy way to think of that. it's not a definition set in concrete, and you oftenhave to adapt it to the story, but, basically, he shouldn't havebroken a bone by falling over. and it's his bones that are fragile,you mean?

- it tells us he's got fragile bones.- right. and we want to then start to explorewhy and how fragile, and what are the indicators we can get to get an ideaof his risk for further trouble. so he should get a bone density done. do we have a men's health issue here? do men thinkthey don't get osteoporosis? we do have a men's health issue here. and we found that also, in looking atthe utilisation of bone densitometry,

that the rates per populationare much lower for men than for women. so it's one of the myths out therethat osteoporosis is a women's disease. mm. and do you think that there'sa role here for population screening? i'm happy to hear from any of you here. should we just be doingmass bone density screening to overcome this problem? john, what do you think? mass screening, i think,is always difficult. the only point of doing screening

is if you know exactly whatyou are going to do when you find it. we do have an element of screeningavailable in australia now. if you're a man or a womanand you're 70 years of age, you can get a bone density done. you don't have to have had a fracture. get a bone density done,covered by medicare. at this stage,as i understand it, the uptake is less than 10% of australianshave actually had one of those. - that's very low.- of the people who are eligible.

and so i think there is an issuethat people don't understand. and i think,to follow on from dan's point, is that if you're a manand you have a fracture, your risk of another fracture goes upmuch more than it does for a woman. so although a man and a womanhave different risks when they start, if a woman has a fracture, her riskof other one goes up about two-fold, a man goes up about four-fold. and they're exactly the same, they're about the same assomebody who's 20 years older.

and the only reason that it's actuallyperhaps got a little worse than that is both of them are increased riskof premature mortality, and it's worse in men than in women. and why would they diefrom an osteoporotic fracture? well, that's what we'retrying to understand, but they do, and it's not explicable just bytheir co-morbidities, in our studies. so it really looks like it's a signalthat there's a real problem there and that people needto have something done about, and there's the actually evidence now

that treatment of the osteoporosisreduces that premature mortality risk. does charles' smokingcontribute to his osteoporosis? well, i think it probably plays a part. it depends really how heavily he smokes,and so forth. but i think there are other reasons to convince himthat smoking is not a good idea. assuming that you diagnosed charleswith osteoporosis as well, what would be an appropriatetreatment management plan for him? well, he needs to understand...

part of the plan isthat he understands the condition and what the risk isand what we're talking about. we're talking abouta long-term condition. so, the engagement of the patientin understanding that is critical. otherwise we'll run into the problems of them going out the doorand having forgotten it, not understanding it,and certainly not persisting with it, the changes that he'll need to make. and then it's going to goacross the whole spectrum

of medication choiceand a bunch of lifestyle changes. so, cecily,what sort of lifestyle changes do you think we'd be thinking aboutfor someone like charles? charles needs to consider whetherthere are things in his lifestyle that will accelerate his chances of losing more than the averageamount of bone micro-architecture. and they would be his smoking, and if he has a high alcohol intake. and then there are protective factorsfor his bone density.

and those factorsare an adequate calcium intake, and that can be, in the first instance, achieved through just a dietthat has adequate calcium. and that's three to four serves a daythat he should be advised to take. he should also consider exercisethat would be appropriate, and, if he is provento have osteoporosis, then that needs to bequite individualised and to be made surethat it is appropriate and it's not going to actuallyexacerbate any problems for him

or in fact cause fractures. and the other one is, is he getting enoughexposure to sunlight? and that will actuallykeep his vitamin d levels at a satisfactory level, and that's one of the essential things - for his body to formand keep forming enough bone. i think we'll come back to all thosepoints when we talk about prevention. so, let's now look at ourthird case study, which is belinda.

she's the daughterof charles and cheryl, and she accompanies her fatherto the doctor's surgery on charles' follow-up visit. she's in her early 40s and has become awareof her family history of osteoporosis. she wants to know what she can do to help prevent osteoporosisand future fractures. so, john, what advice would you givebelinda on prevention of osteoporosis? well, she ignoredmy first bit of advice,

which is to choose her parentsappropriately. silly her. but, i mean, you just needto look at all the risk factors. cecily's talked about how we canmake sure that she has a healthy diet, that she's not too underweight,which some women pursue still, that she getsan adequate calcium intake, and, following on cecily's comment, this means dairyor calcium-supplemented foods, of which there are not a lot, really.

that she needs some of those each day. to make sure thatshe's getting adequate sunlight. and if she's tryingto balance this issue of too much and too little sunlight, then checking her vitamin d level, and, if it's low, then she needs to knoweither she has to get more sunlight or take a supplement,both of which are perfectly reasonable. all the healthy nutritional messagesand lifestyle messages -

not smoking, not too much alcohol. but perhapsthe really critical thing for her is that if she's concerned about it,she could get a bone density. unfortunately, she'd have to pay for it. but that might give her an idea of whether she should bemore worried about it, or indeed whether she just knows, ten years' timeshe'll be coming up to menopause, should she bemore worried about it then?

and if she's already low now, then, really, she'd need to bethinking about it very carefully as she approaches menopause. do you think there are any issues,if she has children, that she should be thinkingfor the next generation as well? if she ends up beingat high risk of osteoporosis, then it might be three generations. well, again, she can choose her partner,one who's got better bones. i don't know. but i think...

there's a lot of discussion abouttrying to make sure that with kids... we do encourage them to havemore exercise in their lifestyle. and again, you know, a good diet,with calcium and protein and so forth - the old balanced dietthat we use to talk about. and, hopefully, young kidswill get more exercise playing with wiis than they will playing withjust computer games like this. judy, i wonder if you can commentfrom a pharmacist's perspective about calcium. people seem to misconstruethe dose that they need,

and where you get calcium from, and the messages are very mixed. so i wonder, in your experience, what do you think are the big issueswith calcium intake? well, calcium, really, you can't tell if someone'sdietary intake is adequate by doing a calcium level. but you need to assesswhat someone's calcium intake is. and post-menopausal women,as cecily said,

need four servesof dietary calcium a day. what that means is quite difficult. in some of the studies it means that about 80% of womenin that age group don't get adequate calcium intake. so it's really aboutassessing what the dietary intake is, whether you can maximiseand optimise that by diet alone. if you can't, if someone doesn'tparticularly like dairy, for example, then there is a rolefor supplementing calcium intake.

but we certainly don't needsuper doses of calcium over and above, if you're havingadequate dietary intake. so it's really not calcium for everyonenecessarily, but there will be a lot of peoplewho don't have adequate intake and will require some supplementation. so there is a role to look at that. there's issues around calcium, as the tablets are quite bigand they're chalky. they're not subsidised by the pbs.

but, yes. and compliance is notoriously lowwith that along with other things. is there a rolefor any other dietary supplements? you often see people taking magnesiumalso for osteoporosis. i think the evidencesits around calcium. there's not a lot of evidencefor mineral supplementation. it's similar with vitamin d. you need to supplement that if you're not having adequatefrom the sunlight.

dietary intake of vitamin dis very minimal. cecily, if we could get backto lifestyle issues for belinda, i think exercise oftenplays a great role in younger people who want to help their bonesas much as possible. what would you say would beappropriate exercise interventions or, indeed,what exercises might she avoid? ok, so we have belinda, who, at thisstage, doesn't have osteoporosis. and it would be really importantfor her to understand that there's a scale of exercisethat will help her.

and those exerciseswould be high-impact exercises. they'd be things like joggingor playing netball or tennis in this sort of age group. and that they need to bethree to four times a week, about 30 minutes of duration. but short and sharp and intense is muchbetter than something that's just a leisurely sort of, you know,walk for an hour, because to actually get the bodyto really kick in and form as much bone as possible,

you need to put a certain amount ofstrain and increasing levels of strain on the bones to achieve that. so quite a bit of detail with her about the types of exercise that shemight be prepared to adopt. and it's true thatswimming doesn't help? they're low-impact. swimming, cycling - things that don'tinvolve contacting the surface, and therefore getting that jarringeffect back up through the bones are not going to actually stimulateas much of the normal process

that the body can actually doof actually forming more new bone. aren't there the funny machinesthat vibrate? you can stand on them and it's justjarring your bones but nothing else. is there any evidence to support those? i know that the machines exist, but a level of scientific evidencei'm not aware of. is that covered in the guidelines? there is some evidencefor one of the types of machines, which is actuallya very low energy vibration.

it's actually quite hard to evenfeel it. it feels a bit like buzzing. it's not one of these thingsthat throws you around. but these are still to be... and they've shown they can havebeneficial effects on the skeleton. they haven't been translated yet toshowing that they reduce fracture risk, which is really the bottom linethat we're all talking about. right. judy, over to you. there are some medications that put people at risk of a decreasedbone mineral density.

can you quickly cover those, please? john covered a couple before. steroids - whether they are oralsteroids or high-dose inhaled... geraldine: corticosteroids.- corticosteroids, yes. they're the ones that come to mind. but there's also lots of others.excessive thyroxine intake. proton-pump inhibitors, 'cause theyreduce the absorption of calcium. ssris, aromatase inhibitors, glitazones. anti-epileptic drugs are another group

that can decreaseyour bone mineral density. well, the mentionof proton-pump inhibitors is actually one of the questionswe've had from an audience member. marissa from queensland asks, 'could the increased use of ppisin post-menopausal women cause an increase in the incidence offractures and thus osteoporosis? what should we do, if anything,or is the evidence just theoretical?' john, do you havean expert view on that? do we really believe proton-pumpinhibitors

increase osteoporotic fractures? well, i think it's certainly clear thatproton-pump inhibitors decrease your ability to absorb, let'ssay, calcium carbonates in particular because they require some gastric acidto be absorbed. so... but the evidence that this,on a global scale, is translating toan increase in fractures i think isn't quite there. i think the relevance isthat if you've got a patient who is on a proton-pump inhibitor,

if they're going to usea calcium carbonate, you have to tell themto have it with a meal. 'cause with a meal,they'll still make some acid. or to use one of the calcium citrates, which do not depend on acidfor absorption. other than that, do you thinkthere's any big difference between different calcium supplements? no, i think the major issueis the amount of calcium. and i think, as judy said before,

the evidence that any ofthe other minerals are required - magnesium, manganese, zinc, silica,aluminium, boron and any other that you'd like to name - the evidence that any of thoseare specifically required is approximately zero. yeah. marissa from queensland also asks, 'should all post-menopausal womenbe on calcium supplements due to most being at higher risk?' do you think we should just all be oncalcium supplements

as a matter of course? i think judy has described it perfectly.if you've got a good calcium intake, no. it's more asking the questionand saying, right, you know, 'are you havingreasonable calcium intake?' occasionally, you have to sort oftry and get around the issues. you ask people, you know,'how much calcium do you have?' and they say, 'oh, i have twoor three glasses of milk a day.' and then you ask them,'well, how long does a litre last you?' and they say, 'oh, about a week.'

and those two thingsdon't quite add up. but if you get past that, i think if people have dairyor one of the dairy alternatives like calcium-supplemented soy or some of the othercalcium-supplemented foods - yoghurts, cheeses -they may not need it. but if they don't have it,there's not much point telling people, 'have these things,' when they're notgonna really add them to their diet. and then some improvementin calcium intake with a supplement

makes good sense. what dose does the guideline sayis the appropriate daily dose for calcium supplementation? 1,200 milligramsis what we should be going for. - you had another comment, dan?-yeah. i think we need to... there may be a mistaken notion out therethat dealing with the calcium is... and then you've got it done. you know, we're going to look afterthe calcium and then they'll be right,

they won't get osteoporosis,they won't get fractures. the evidence that calcium -getting the right amount of calcium - can help preserve bone mass is good, but the evidence that taking goodamounts of calcium prevents fractures is not good. so what you really need to dois properly assess the person's risk... geraldine: mm. ..and they may need a lot morethan just thinking about calcium, or they may need nothing at all.

but just doing the calcium-diet historyis not an adequate assessment of osteoporotic risk. yes, it's just the first step, isn't it?that's a very good point. cecily: and one thing with calcium toois there's a lot of aversion to 'high-fat foods', and a lot of the dairy products havebeen dropped out of people's diets because of an assumption that it's notgood for their cardiovascular health. oh, yes. there was a study a couple of years ago,wasn't there,

that people on calcium supplementswere at higher risk of cardiovascular disease? is there any truth to that? well, there's a study -it's actually quite recently, in fact - saying that if you looked at peoplewhose calcium... as a group, the calcium intakefor these people was reasonably good. and if you added on top of thisa calcium supplement, there was a smallbut statistically significant increase in the risk of heart attacks -

not in deaths, but in heart attacks. um, that's led, i think, people to sayperhaps even more, as dan has said, you know, making sure people havea reasonable calcium intake makes sense if people's calcium intake is low, but giving it more and more and moredoesn't make sense. and also, it is only, as you said,the first step in the management. that's sort of the...that's the background - calcium and vitamin d,the lifestyle, the exercise, and then, depending on what the restof the evidence is about their risk,

then you have to build onto that. another question has come in asking whether the treatmentfor men and women is ever different. uh, dan, perhaps you'd like tocomment on that with your view from the guidelinesas well. well, it's different when it comes tochoosing some of the medications, the specific anti-osteoporoticmedications, because a number of themare only relevant to females. that's tricky, isn't it? i mean,how do you get around that?

if a man needs to use strontium,for example, and it's not on the pbs, for men, what do you say? well, you'd be looking closelyat finding an alternative, and there's nowa range of bisphosphonates and, for men,the evidence of effectiveness is much better established forbisphosphonates than anything else. i guess we'll talk about treatmentsshortly. we're supposed to be talking aboutprevention right now,

and, on that point,we've been asked by ben from cairns whether he really needs to measurevitamin d levels in everyone. what's your view on that, john? it's the old storyabout flossing your teeth. you floss the teeth you want to keep. if you want to know if somebody'svitamin d level is low, you have to measure it, but to answer it is thathe might be thinking, 'look, i'm in cairns,there's so much sun around.

my patients won't have that issue.' and the evidence is it actuallydoesn't matter where you are, north and south of australia,in the tropics, in asia, a high proportion of people -probably more than 50% of people - have levels of vitamin d in their bloodthat we would consider to be suboptimal, and the only way you can knowis measuring it. a question that comes acrossmy desk a lot is if the vitamin d levelis critically low, like, say, 20, what dose should be usedto replenish that vitamin d?

should people be using a super big doseonce a week or once a month, or would a daily dose of a normalamount, like 1,000 units a day, be ok but be a bit delayed in its effect? i guess my view of it is,if you start with 1,000 units a day, that's what people needto keep themselves in balance. if they're already depleted, that'lltake you forever and a day or two to get 'em up to a replete status. i tend to use, you know, 5,000 or even10,000 units a day for some months. do i know that that'sa better way of doing it?

well, no, but i think it makes sense to try and get them up to a normal levelfaster and then replace it. sometimes people look at 1,000 units, and they think,'oh, that's a huge amount,' but, of course, it was derivedfor the amount you needed to give a neonatal rat to fix rickets. so it's not... you know,it's a bit misleading. it sounds like a big number,but it just isn't. yeah. but i think there isone other side of it,

is that there was a studythat's just been published where community-dwelling peoplein victoria were given 500,000 units of vitamin donce a year with the idea that this would havea beneficial effect. and, to the distress of the peoplewho were doing the study, it turned out if anything,that people got this super-large - and it's very much biggerthan we're talking about - actually had more fallsand even a few more fractures. so we don't understand why that is.

but i think it means, you know,moderation might be a good idea. - that's what my mother always says.- i know. i was gonna say that. it's what my mother said. - judy, you have a comment?- yes. about vitamin d, it's important to know that vitamin dnot only is inherently important in improving the absorption of calciumfrom your foods, but also in muscle strengthand stability and gait. and so vitamin d supplementationin those who are deficient

will decrease your risk of falls, so that has a major impact as well. so, john, just froma historical point of view, are there any drugsthat are on the market that are no longer recommendedfor osteoporosis? well, when i started in this areaapproximately 40 years ago, one of the most commonly used drugswas deca-durabolin. geraldine: ah, yes. and it was givenas a weekly injection...

testosterone.anabolic steroid, isn't it? yeah, it's an anabolic steroid. and it was given as a weekly injection. and if you gave it to somebody,in six weeks their pain settled, and if it didn't,it took a month and a half. but the evidence thatthat makes any difference, unfortunately, is that almost certainlyat the doses that are used, it made no difference, and if you used enoughto make a difference to bone density,

then you almost certainly hadunacceptable androgenising side effects. there are a few other agentsthat are around where i would argue that the evidenceis less strong for their benefit, and, i think, youknow, really the evidence is that the drugs thatare now considered front-line are things like the bisphosphonatesand some of the other treatments - that i believe judy's gonnaspeak about too - are the ones that you'd thinkthere's really good evidence for. cecily, i wonder if you can commentfor us on fall prevention.

we've been talking a lotabout fracture prevention, but i think your professionplays a big role in fall prevention, which is often a major causefor the fractures. yeah, there has been, i think,increased recognition that the risk of falls actually doessort of overlay in this group of people who also may have a risk of osteoporosisor fractures, and it's very important thatwe do intervene for that falls risk. so there are components to that, and certainly some of those are aroundsomebody's strength and balance,

and, if we can improve those things,they're much less likely to fall. we've already heard aboutimproving their vitamin d levels, or normalising those has a direct impacton people's strength and likelihood of falls. we also need to think very muchabout the home environment, and just simple things likehaving lights that go on at night when someone gets up to go to the toilet has actually been shownto reduce the risk of falls. we need to think aboutpeople's footwear,

we need to know whether people have hada recent eye check, are they wearing their old glassesbecause the other ones broke, all of those things. and they are part ofquite a good checklist of things that should mean thatevery health professional and gps can actually go throughquite a systematic review of all the factorsthat could contribute. dan, i wonder if youcould comment on that as well, as a general practitioner,

how you get your patients reviewedfor their falls risk. i tend not to deal with the interventionaround that myself, and, depending on where i'm working, i'll either get the practice nursesto review that stuff with the person or i may have the capacity to refer theminto a community health service. and that's gonna be fairly patchy inrural settings, your ability to do that. it's not rocket science, and i think we all should be ableto get our head around doing it. it's just a matter of fitting it inand making sure someone does it.

i think all health professionalshave a role to play here, especially pharmacists, as well. judy, you've beena home medicines review pharmacist. is that another opportunity to assesspeople for their fall and fracture risk? absolutely, have a look atthe situation at home, whether there's mats on the floors,pets to fall over, all those sort of thingsthat can play a role that doesn't always get assessedin the home. geraldine: there are medicationsthat contribute to falls risk too?

absolutely - anything that actsin the brain or makes you feel dizzy - antihypertensives, opiates,benzodiazepines - lots of drugs can increaseyour falls risk, and they should be assessed. things with anticholinergic side effectsshould be looked at and reviewed in people who havea high risk of falls. in terms of treatment, what arethe sorts of drugs that we're looking at for osteoporosis treatment? well, as john said,20 years ago we had hormones,

but there are lots of evidence-basedtherapies around now. i mean, hormone replacement therapystill has good evidence. then, about 15 years ago, thebisphosphonates came on the market. they're now given weekly, butthey have very specific instructions about how they should be taken. raloxifine or sermscame on the market since then. for women only, strontium has comeon the market since more recently. for women only, there's parathyroid hormone -it's a subcutaneous injection

which has become availablein the last couple of years. and there's a new drug on the market - denosumab,which is a monoclonal antibody, which i believe is now being marketedin australia, which adds another agentto the armamentarium to treat osteoporosis. and what's compliance likewith all these potential treatments? well, compliance with medicationsin general is really poor - about 50% - and that's similarwith bisphosphonate therapy.

they're a weekly medication, although now there's an iv formwhich has also become available in the last year or so. so i guess there are ways aroundcompliance issues, but there's still a problemwith compliance with oral therapy. geraldine: right. and, john, you have a graphic,i understand, that talks about which kindsof interventions that can be used at different times of life?

john: well, i hope people can see this, but, basically, if you look at that sortof age going along the x axis there, it says 'calcium' and 'life style'. you really need to talk about itfor everyone and think about it. closer to the menopause,you might think, 'well, hormone treatmentis appropriate.' and if you had a hypergonadal male,it may be appropriate as well. in women who are a little bit older,it might be one of the serms, like raloxifine/evista,or tibolone/livial.

that's another option there. we tend not to continue thoseso long these days, but if you've got peoplewho've got very clear osteoporosis, and it's both for men and for women, the bisphosphonateshave really excellent evidence for being very effective, effectivelyhalving the rate of fractures that people might have,and very well tolerated. there's good evidencefor strontium ranelate, particularly in older people as well,

and the new one, denosumab,which has been passed by the tga. i'm not sure if it's on the market yet,but i hope it will be. and parathyroid hormone,or teriparatide, for the peoplewhere they've been treated yet their bone densityhasn't seemed to respond and they've continued to fracture. that is now available in australia. geraldine: it's quite exciting,isn't it? - there's so many options available.- that's exactly right.

- quite different from 15 years ago.- 15 years ago, we had nothing. so now let's look at a filmof a rural model of care that was trialled bythe north coast area health service. this model ensures that patientswho are seen at the local hospital for a minimal trauma fracture are given an osteoporosisrisk assessment by a nurse. this assessment,and any other test results, are then reviewed by a medical team and a referral letteris sent to the patient's gp.

cecily: every day in australia, there are a significant number of peoplewho are admitted to an acute hospital because they've had a fracture, and, whilst we're very goodat managing their fracture, we're not so goodat actually identifying that this is a flag that they may havean underlying chronic disease, which is osteoporosis. so, for these people, having a fractureis a major episode in their life. many of these people don't returnto their prior level

of independent functioning. many people do not return to being ableto live in their own residence again. and there's an increased mortalityat five years for any minimal trauma fracture. so, i just need to establishthat you've fractured your left wrist. - yes.- and how did you do that? i was at my daughter's wedding,and i fell. - ok. did you trip?- i tripped, yes. - ok, so it's just a simple fall.- and landed on my arm.

ok. so, a mechanical fall, we call that. cecily: in our model of care, it was looking atidentifying these people who have had a minimal trauma fracture, which is a fracture that results fromjust a slip, trip, or fall from a standing height or less, as that's one of the first symptomsthat occur for someone who may have a problemwith osteoporosis. so how much physical activity do you do?

- i don't do any.- ok. - is there a reason for that?- i think it's boring. (chuckles) ok. have you ever had a bone density study? - no, i haven't.- ok. that's ok. um, how much time do you spendoutside in the sun? i don't go in the sun.i've got red hair. i burn very quickly, so i just stayright out of the sun. and now we'll take some blood from you.

we'll do some blood tests. cecily: after the patienthas left hospital and gone home, then their osteoporosis risk screenthat was done is then passed through toa multidisciplinary case review session. we have specialist medical staffand nursing staff that come togetherto review that person's risk screen, to look at the pathology teststhat may have been done when the patient was in hospital, what additional tests would be indicated

and to write quite a detailed summaryof that person's risk and their recommendationsfor management back to the patient's gp. the gp does get the latestevidence-based management, so that the gp is then armed to workwith the patient on a one-to-one level to decide ongoing managementof osteoporosis. at the hospital,you did have some tests, and this has been a useful feedbackthe hospital's provided for me. whilst you were there, they measuredyour vitamin d levels,

and they were surprisingly low. woman: oh, ok. and perhaps your habitof not being in sunlight has contributedto you having low vitamin d levels. right. low vitamin d levels means thatyou'll lose more of your bone strength. i think it's important we think aboutboosting your vitamin d levels... ..and we've got an optionof giving you a catch-up dose... - ok.- ..for the first weeks,

or just starting inon a replacement dose. vitamin d also somehow helps peoplehave less falls - it seems to help the muscles and coordination and thingswork a bit better. woman: that'd be helpful. and how do you feel now aboutthe prospect of taking a tablet for many yearsto help protect your bone strength? i don't want it to happen again,so i'm prepared to do whatever it takes to stop this from happening again.

so can i make bones stronger...or just stop them from getting weaker? it's mostly about stopping themgetting weaker. we can't guarantee you'll never haveany more fragility fractures. but the good news is that,using these kinds of medicines, we can have a big impact onthe risk of you having another fracture. it's in the order of 30-50%. um, but it will involvelong-term medication use and long-term changesto some lifestyle factors. - ok.- the diet, the exercise.

perhaps checkingif there's any particular risks of tripping and fallingaround your home. maybe looking at the types of shoesyou wear would be important. getting you into an exercise activity that involves retraining and maintainingyour balance skills. all of these things will be important. ok, that sounds great. cecily: when we developedthe model of care, we were very aware of trying tokeep that as a low-cost intervention,

and we went for as low as you could goand still hopefully be effective. so the model of care costsless than $16,000 per year to run, and that was for a small increasein nursing hours of six hours a week, and the once-a-month medical specialistswho came to do the case review session. we evaluated our model of care and we found that we hadstatistically significant increases in the number of peoplewho were informed of osteoporosis and their risk of fractures, increased numberswho were on effective medications,

and increased numberswho received other interventions, such as falls prevention interventions. so, for $150 per patient, it appears that this model of carecan be very effective. hmm... very interesting, cecily. so can you tell us whythis project was undertaken? um, it was undertaken in a rural area, partly because we perceivedthat we also had a treatment gap similar to our metropolitan cousins,

but we weren't actually sure because there was no sort of studyhad been done in a rural area, and we also wanted to not just know whether or notthere was a treatment gap - we wanted to actually see whetherthere was something we could do about that treatment gap. and that was the model of care that wedeveloped to work in that rural setting where we're not going to have access to so many specialistsor specialised clinics,

and it really is the domainof the general practitioner to manage these people. and how widely employedis that model of care in australia? the model of carewas actually a funded pilot. it was successful, but, at this stage,what we're trying to do is to incorporate this model of care as one of the sort of alternatives to belooked at at a statewide level for implementation throughan osteoporosis working party

that's currently being formedin new south wales. ok. jane, a remote area nurse, asks,'a lot of patients with osteoporosis seem to also have renal impairment. what medicationsare safe for this group?' john, i think your expert viewon this might be helpful. well, i mean, for the... if we just focused, let's say,on the bisphosphonates, which are the most commonly used, unless there is pretty markedrenal impairment

to the extent that you're talking abouta degree of renal failure, um, i don't think it makesa major issue. if you're aboveabout 30 millilitres per minute gfr, it's probably not an issue. if you are concerned about it... particularly, let's say,with the bisphosphonates, half the dose is excreted in the urine. so if somebody had no renal function, you'd argue that reducing your doseby half would be reasonably safe.

having said that, if somebody hasthat degree of renal disease, then they'd probably needexpert management. i know it's not always easyin those environments, but that's the recommendation. and also, judy, i guess a pharmacistcan help with the guidance of drugs used in renal impairment, can't they? - yes, absolutely.- ok. another audience questionis michael from south australia says, 'in some groups of people, vitamin ddeficiency is a known heath problem,

such as dark-skinned people. should we be givingvitamin d supplementation even if they're not yet deficient?' do you have a view on that,john or dan? no, i think, fundamentally, we shouldn'ttreat things that aren't a problem. and until it's a problem,we shouldn't treat it. now, there's another general practicequestion, just quickly - sam from portland asks,'how often should gps follow up known osteoporotic patientsafter initiating treatment?'

so, how frequently? i'm just gonna say -dan is the one that actually does it, but what i'll say is i don't... we've already heard the issue thatcompliance long-term with treatment is not good, and that's true of everychronic condition you can think about. i don't... i think with osteoporosis, your follow-up can be talking with them,discussing how they're going, seeingwhether they're taking their drug.

i mean, that's also a follow-up. and i think if you don't do that, then you're notmanaging your patient properly. and, in some situations, a bone densityor some other types of blood tests of what's going on in the bone are helpful waysof enhancing that interaction, but i think the primary thing is for you and the patient to knowthat you think that this is important. absolutely. dan,do you have anything to add to that?

no, i see it as part and parcelof chronic disease management, which is front and centrewhat general practice does. and it's all aboutthe long-term relationship. with these people, they're quite likely to have other issuesyou're seeing them for anyway, so you'd be melding their proactive carefor their other conditions along with their osteoporosis. it could easily becomepart of a gp management plan in a team care arrangement,

and how often you see them depends onhow often they need to be seen. very much aware of the issues thatcompliance is likely to be a struggle, and that appliesnot only to the medication but to the lifestyle changes as well. we need to wrap up now, so i wonderif we could start with you, judy, on what your take-home messagemight be for our audience. oh, well, i'd like to direct tothe pharmacists out there to really be proactive aboutthinking about bone health, and to really helpin assessing compliance

with anti-osteoporotic medicationto get the most out of the medicines, 'cause they're only as good as if peoplecan take them and take them correctly, so taking them correctly is a big issuewith these agents as well. and, dan, your take-home message? there's an evidence-practice gapwhich we can pretty easily fix. geraldine: that's it? and there'sa great new guideline out to do that. there's a great new just steps you through it. geraldine: cecily? every day, there's a large number ofpeople with minimal trauma fractures

who need to be hospitalisedto manage their fracture, and, at a local level,each of those orthopaedic centres needs to set up a local system and have designated peoplewhose job it is to pick up on osteoporosis,their risk of fractures, and make sure they get linkedto the appropriate ongoing care back in the community. geraldine: finally, john?- i think it's all been said. this is a hugely common problemin the community.

one in two older women,one in three older men, and it's a nasty condition. we should look at itas a 'malignant condition', 'cause people go on to fractureand die prematurely. we have treatments that work,we know the uptake is abominably poor, but they're things that can be done. it's a very straightforward approachin many ways, as dan has stressed. and i think if we can get peoplelooking at this guideline and saying, 'instead of ignoring it,we're gonna do something about it,'

there will be very substantialhealth benefits in the community, maybe reduction in premature mortality. and if you justonly worry about the dollars, just think - it's cost us $1 millionwhile we're talking tonight. goodness. well,important work for all of us to do. i hope you've enjoyed the programon the new osteoporosis guideline that's available on the racgp website. our thanks tothe department of health and ageing for making the program possible,

and thanks also to you for takingthe time to attend and contribute. if you're interestedin obtaining more information about the issues raised in the program, there are a numberof resources available don't forget to complete and send inyour evaluation forms to register for cpd points. and i'm geraldine moses.thank you very much and goodnight. captions bycaptioning & subtitling international funded by the australian government

department of families, housing, community servicesand indigenous affairs�

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