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Hello, I'm Geraldine Moses.
Welcome to this program
on the Clinical Guideline
for the prevention and treatment of osteoporosis
in post-menopausal women and older men.
Osteoporosis is under-recognised and under-treated.
The deterioration of bone can proceed with no outward symptoms
until a symptomatic fracture occurs.
Recent research indicates that only 7% to 20% of people
who have sustained an osteoporotic fracture
receive treatment for osteoporosis to prevent further fractures.
This program is the final in a series of four programs
on the new Musculoskeletal Guidelines for General Practitioners
and other primary health care professionals,
which have been developed
by the Royal Australian College of General Practitioners
and approved by the National Health and Medical Research Council.
The guideline provides recommendations
for prevention and treatment of osteoporosis
in post-menopausal women and older men.
Our program will discuss
how local health services and general practices
can improve their treatment and management of osteoporosis.
You'll find a number of useful resources available
on the Rural Health Education Foundation's website -
Now let's meet our panel.
Firstly, Professor John Eisman
is a Professor of Medicine at the University of New South Wales,
a staff endocrinologist at St Vincent's Hospital in Sydney
and Director of Osteoporosis and Bone Biology
at the Garvan Institute of Medical Research.
John was the chair of the working party for developing this guideline.
- Welcome, John. - Thank you, Geraldine.
Cecily Barrack is a physiotherapist.
She works for the North Coast Area Health Service
and the Northern Rivers University Department of Rural Health
as a research clinician to look at local osteoporosis management.
- Welcome, Cecily. - Thanks, Geraldine.
Dr Dan Ewald is a general practitioner
who works in rural general practice
and with the Northern Rivers General Practice Network.
Dan was also on the guideline working party.
- Welcome, Dan. - Hello, Geraldine.
And Judy Burrows is a pharmacist,
and she has a background in hospital pharmacy.
She also lectures in the Postgraduate Clinical Pharmacy Program
at the University of Queensland
and is the Queensland Health and University of Queensland
Pharmacy Training Coordinator.
Welcome, Judy, and welcome to you all.
Cheers.
So, let's just start with a definition question.
John, I wonder if you could quickly explain - what is osteoporosis?
Well, osteoporosis is a problem that is common
and it develops particularly as we get older
when, with the remodelling of the skeleton,
the bones become a little bit weaker,
more fragile,
and they really break with 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 care for people with osteoporosis can be
and how we can better organise our health services and systems
so that people actually don't fall through the gap
and are connected with evidence-based care.
Right. And, Dan, you were involved in writing the guideline,
but I believe you've got a special interest
in what the evidence is showing?
Well, I'm particularly drawn to this area
because of the gap between
what the evidence tells us is good practice and what we can do,
and what we actually end up doing in the real world.
And also that it's an area where within the last 10, 15 years
we've got available to us something very useful we can do.
So it's relatively new still.
And, Judy, you're a pharmacist,
so what do you see as the role of pharmacists
in the management of osteoporosis?
Well, I think irrespective of whether
pharmacists work in the community, hospital,
or an accredited pharmacist doing 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 health of patients with osteoporosis.
Right, now, John, back to you, if I may,
can you please explain the extent of the problem of osteoporosis?
Well, it's a huge problem in the community.
Older women, say, over the age of 60 -
one in two of them will 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 risk of further fractures
and with premature mortality.
And we've known these stats for quite a long time.
Are there any trends? Are these figures changing?
Um... well, if anything,
the trend is that we are seeing more fractures,
because we're having an 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 problems of 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 burden of all these osteoporotic fractures?
Well, at the moment the estimated cost in Australia,
including direct and indirect costs,
is something like $7 billion a year.
So it'll cost Australia about $1 million while we are talking about it tonight.
Wow.
Do we know what causes osteoporosis?
Well, there's a major part of it which 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 things like 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 guess we'll talk about a bit later,
but these are also things that contribute to the risk.
And are there any medical conditions that contribute to the risk?
Well, there are a lot of health conditions -
anyone who's on things 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 levels are dropped -
they're also at increased risk.
And there are a number of other things -
lung disease, people with a lot of asthma,
people with a lot of inhaled corticosteroids -
not the normal doses, but the very high doses can also affect it.
Now, I think most of us know
that osteoporosis is measured to a certain extent
with bone mineral density testing,
but the results that people get
aren't immediately obvious in what they mean.
So can you please explain
the relationship between the T-score and the Z-score
and what that really means to real people?
OK.
When you measure something,
you've always got to know what you expect.
So the Z-score is the comparison with other people of the same age and sex.
Now, if you're within a couple of standard deviations -
'cause that what it's measured in - of that value,
then the implication is that whatever your value might be
it doesn't look like you should be terribly worried
that there's some other secondary cause.
But if it's lower, you should really worry
that there's something else that you haven't thought about yet
that you need to be doing something about.
But the actual diagnosis, if you like, of osteoporosis
relates to the T-score,
which is the comparison to young normal.
And there's a very...
somewhat arbitrary definitions
that if you're within one 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 gradient of exponentially increasing risk.
There's no sudden step in any of these.
And, Dan, I believe that you like to say
that bone mineral density is just a risk factor,
it's not the disease itself, is that right?
I think it's useful to remind people of that.
Like we're used to paying attention to blood pressure or cholesterol,
which doesn't present with any symptoms, but we know it's important
because it marks a risk for something dramatic.
And that really should be
the way we're thinking about bone densities as well.
It's a very important risk factor,
but the event that counts is their fracture.
So, since we're talking with you,
and you know a lot about what the Royal College did
in terms of developing these guidelines,
what was the impetus?
Surely we know enough about osteoporosis already, we don't need more guidelines?
Well, a lot of us didn'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 promotion from the drug companies
and there's been some presence from other agencies as well.
So it's very appropriate to try and clear up
some misnomers and some misunderstandings,
and it's a hugely important issue,
still grossly under-recognised and under-treated.
And particularly in rural areas.
When we looked at how much bone density is being done in rural areas
compared to urban areas,
it's markedly less, suggesting that rural areas
might be missing out on looking after osteoporosis
even more than their urban counterparts.
Oh, that's very interesting.
I believe you've got a copy of the guidelines with you.
Would you like to show the audience how beautiful it is?
If you download it from
the Royal Australian College of General Practitioners website,
you can make yourself a little booklet.
And there you'll find some nicely summarised evidence
around most of the topics that might be troubling people.
All those debates about how long to treat for
and when to treat, and age, and the risk factors, etc,
are discussed with whatever evidence is available.
How long did it take to 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 of supporting documents and programs
that are available to help the uptake of the guidelines.
And so there are guidelines for practices
to do small group learning exercises
and do clinical audits within their practice.
There's a summary guideline.
To fit the whole thing onto two sides of an A4 page was a challenge,
and we've done that as well.
And those who get the Australian Family Physician
will be getting a copy of that next month.
There's a practice nurse guide,
and we might look in the future
to the collaboratives program taking up osteoporosis,
there's an edition of the check program coming out,
and we've already had
a national prescribing service program on osteoporosis.
So there's a number of other supporting activities out there.
So it's available on the RACGP website
and it will be in the Australian Family Physician.
Will it be advertised to allied health professionals,
like physios and pharmacists?
Anyone will be able to access this through the college website.
- And I'd encourage them to do so. - Yeah.
Judy, do you think pharmacists will be looking out for this?
I mean, should we be raising awareness...
Absolutely.
Awareness should be raised about those guidelines
and that will be something that we should address as a profession
to improve the uptake of guidelines.
Cecily, do you think physios will be interested in raising this?
There might be a lot about drugs, which often doesn't interest...
Absolutely. They're at the interface with a lot of these patients
in the acute and the convalescent rehabilitation phases,
and they need to be very aware of what the current evidence is
and to give the right advice.
So, now let's take a look at our first case study, who's Cheryl.
Cheryl is 66 years old
and she presents at the doctor's surgery with an acute episode of back pain.
She's experienced episodic back pain over the years,
and she's been taking paracetamol for the pain.
She has thoracic kyphosis
and she had anorexia nervosa when she was in her twenties.
Her bone density at her hip is a T-score of -2.7.
So, Dan, if she presented to your general practice,
what would you say indicates that Cheryl might have osteoporosis?
Well, I'd hope that my practice
will be really tuned in to thinking about osteoporosis,
and that's the first big hurdle, is to think of it.
And then the clues are that she's female and her age,
and that she's got a back pain and a kyphosis,
she's had a period of anorexia nervosa.
All of these things are stacking up,
and there's no surprise that she's got a bone density of -2.7,
which is significantly low
and in the range where we call it osteoporosis
by the standard WHO definition,
and the evidence for treatment applies.
But, clearly, you have to think of a differential diagnosis list,
so what investigations might 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 pain in its own right
and sort that out in our normal way.
And then if the back pain is because of a...
..we think it's because of a vertebral fracture,
a new vertebral fracture because of her osteoporosis,
then she's also added to her risk,
'cause having one fracture
makes her much more at risk of a subsequent fracture.
Then we've got to approach the issue
of what might be causing her osteoporosis.
And we come back to John's mention of the 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 unusual disease process driving her bone loss.
If her Z-scores are very low,
we'd be looking more closely for some underlying cause.
What investigations would you do first up for her,
in terms of her potential osteoporosis?
Well, there's no hard and fast rules for this,
but we do want to know what her vitamin D levels are.
And we can't really tell by asking her and looking at her.
Much as we'd think that everyone 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 common other 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 electrophoresis and thyroid-stimulating hormone.
But, as I say, you can use some clinical judgement
on how much of that battery of tests you'll apply in every case.
Now, you're going to end up with a T-score and Z-score,
but perhaps I can ask John
about the role of the Fracture Risk Calculator,
which I believe your team at the Garvan Institute developed.
Can you tell us about that, please?
Yes, well, this came out of the work that we'd done in Dubbo,
looking at the factors that would predict risk.
And this is a population of about two-thirds of the older people in Dubbo,
who we've been following now for 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 that really predict the fracture
is what your age is -
the risk is higher in women than in men -
whether you've had falls,
because that also predicts 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 people who are at low risk of another fracture
from people who are at much higher risk.
And it gives you a risk of what their risk of any fracture is
or what their hip fracture is over 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 meaningful than a T-score.
Well, I mean, I think... It includes the value from the T-score,
but it takes in all this other information.
It allows people to evaluate risk.
I mean, we're not entirely happy that we're there yet,
because I think it's still hard for people to understand risk,
absolute risk, in real terms.
So we're still working on that.
But if people want to use 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 osteoporosis in general practice?
The challenge is to think of it,
and recognise that we need to be thinking of it.
Once you've switched your brain on to being alert to it
and you've got your practice team switched on to it -
'cause it's not only the GP
who needs to be picking up the concept of osteoporosis and bone density -
the practice nurse, and all the allied health providers that we work with
have to be part of that -
then what to do is really quite clearly set out,
and you can turn to the guidelines and even the summary guide
to step you through it.
I think the big hurdle is to recognise we need to be doing something about it.
Mmm. Picking it up as early as possible.
Judy, I wonder if you could comment here.
Possibly, Cheryl was purchasing her paracetamol in a pharmacy.
What's the role of pharmacists
in early detection and screening for osteoporosis?
Well, I think, as Dan said,
if the whole multidisciplinary team is switched on to the idea
of being mindful of osteoporosis as a consideration,
then, if someone did come in looking for some analgesia
and they were a regular customer and complained of back pain,
that's something that 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 pain in the central back region
should be thought of as an osteoporotic fracture in the first instance?
Is that right, John?
I think, if you have somebody who has an acute episode,
particularly if it persists for, you know, more than a few hours or days,
I think you need to think about that as an osteoporotic fracture.
And the other thing too is if somebody says, 'Look, I've really lost height.'
'Cause most people can remember what their height was
when they were in their 20s.
If they're substantially down from that -
more than 1cm or 2cm, that we all get from disc wear -
you really need to think about that as 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 our second case study, who is Charles.
Charles is 68, and he slips and falls
whilst playing with the grandchildren in 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 discharge referral, but he has no X-ray.
Charles has a history of 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 thing we 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 fall from a standing height or less
is an easy way to think of that.
It's not a definition set in concrete,
and you often have to adapt it to the story,
but, basically, he shouldn't have broken 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 explore why and how fragile,
and what are the indicators we can get
to get an idea of his risk for further trouble.
So he should get a bone density done.
Do we have a men's health issue here?
Do men think they don't get osteoporosis?
We do have a men's health issue here.
And we found that also, in looking at the utilisation of bone densitometry,
that the rates per population are much lower for men than for women.
So it's one of the myths out there that osteoporosis is a women's disease.
Mm. And do you think that there's a role here for population screening?
I'm happy to hear from any of you here.
Should we just be doing mass 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 what you are going to do when you find it.
We do have an element of screening available in Australia now.
If you're a man or a woman and 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 Australians have actually had one of those.
- That's very low. - Of the people who are eligible.
And so I think there is an issue that people don't understand.
And I think, to follow on from Dan's point,
is that if you're a man and you have a fracture,
your risk of another fracture goes up much more than it does for a woman.
So although a man and a woman have different risks when they start,
if a woman has a fracture, her risk of 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 as somebody who's 20 years older.
And the only reason that it's actually perhaps got a little worse than that
is both of them are increased risk of premature mortality,
and it's worse in men than in women.
And why would they die from an osteoporotic fracture?
Well, that's what we're trying to understand, but they do,
and it's not explicable just by their co-morbidities, in our studies.
So it really looks like it's a signal that there's a real problem there
and that people need to have something done about,
and there's the actually evidence now
that treatment of the osteoporosis reduces that premature mortality risk.
Does Charles' smoking contribute 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 him that smoking is not a good idea.
So, back to you, Dan.
Assuming that you diagnosed Charles with osteoporosis as well,
what would be an appropriate treatment management plan for him?
Well, he needs to understand...
Part of the plan is that he understands the condition
and what the risk is and what we're talking about.
We're talking about a long-term condition.
So, the engagement of the patient in understanding that is critical.
Otherwise we'll run into the problems
of them going out the door and 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 go across the whole spectrum
of medication choice and a bunch of lifestyle changes.
So, Cecily, what sort of lifestyle changes
do you think we'd be thinking about for someone like Charles?
Charles needs to consider whether there are things in his lifestyle
that will accelerate his chances
of losing more than the average amount of bone micro-architecture.
And they would be his smoking,
and if he has a high alcohol intake.
And then there are protective factors for his bone density.
And those factors are an adequate calcium intake,
and that can be, in the first instance,
achieved through just a diet that has adequate calcium.
And that's three to four serves a day that he should be advised to take.
He should also consider exercise that would be appropriate,
and, if he is proven to have osteoporosis,
then that needs to be quite individualised
and to be made sure that it is appropriate
and it's not going to actually exacerbate any problems for him
or in fact cause fractures.
And the other one is,
is he getting enough exposure to sunlight?
And that will actually keep his vitamin D levels
at a satisfactory level,
and that's one of the essential things -
for his body to form and keep forming enough bone.
I think we'll come back to all those points when we talk about prevention.
So, let's now look at our third case study, which is Belinda.
She's the daughter of Charles and Cheryl,
and she accompanies her father to the doctor's surgery
on Charles' follow-up visit.
She's in her early 40s
and has become aware of her family history of osteoporosis.
She wants to know what she can do
to help prevent osteoporosis and future fractures.
So, John, what advice would you give Belinda on prevention of osteoporosis?
Well, she ignored my first bit of advice,
which is to choose her parents appropriately.
Silly her.
But, I mean, you just need to look at all the risk factors.
Cecily's talked about how we can make sure that she has a healthy diet,
that she's not too underweight, which some women pursue still,
that she gets an adequate calcium intake,
and, following on Cecily's comment,
this means dairy or calcium-supplemented foods,
of which there are not a lot, really.
That she needs some of those each day.
To make sure that she's getting adequate sunlight.
And if she's trying to 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 know either she has to get more sunlight
or take a supplement, both of which are perfectly reasonable.
All the healthy nutritional messages and lifestyle messages -
not smoking, not too much alcohol.
But perhaps the 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 be more worried about it,
or indeed whether she just knows,
ten years' time she'll be coming up to menopause,
should she be more worried about it then?
And if she's already low now,
then, really, she'd need to be thinking about it very carefully
as she approaches menopause.
Do you think there are any issues, if she has children,
that she should be thinking for the next generation as well?
If she ends up being at 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 about trying to make sure that with kids...
We do encourage them to have more exercise in their lifestyle.
And again, you know, a good diet, with calcium and protein and so forth -
the old balanced diet that we use to talk about.
And, hopefully, young kids will get more exercise playing with Wiis
than they will playing with just computer games like this.
Judy, I wonder if you can comment from a pharmacist's perspective
about calcium.
People seem to misconstrue the 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 issues with calcium intake?
Well, calcium, really,
you can't tell if someone's dietary intake is adequate
by doing a calcium level.
But you need to assess what someone's calcium intake is.
And post-menopausal women, as Cecily said,
need four serves of dietary calcium a day.
What that means is quite difficult.
In some of the studies
it means that about 80% of women in that age group
don't get adequate calcium intake.
So it's really about assessing what the dietary intake is,
whether you can maximise and optimise that by diet alone.
If you can't, if someone doesn't particularly like dairy, for example,
then there is a role for supplementing calcium intake.
But we certainly don't need super doses of calcium over and above,
if you're having adequate dietary intake.
So it's really not calcium for everyone necessarily,
but there will be a lot of people who 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 big and they're chalky.
They're not subsidised by the PBS.
But, yes.
And compliance is notoriously low with that along with other things.
Is there a role for any other dietary supplements?
You often see people taking magnesium also for osteoporosis.
I think the evidence sits around calcium.
There's not a lot of evidence for mineral supplementation.
It's similar with vitamin D.
You need to supplement that
if you're not having adequate from the sunlight.
Dietary intake of vitamin D is very minimal.
Cecily, if we could get back to lifestyle issues for Belinda,
I think exercise often plays a great role in younger people
who want to help their bones as much as possible.
What would you say would be appropriate exercise interventions
or, indeed, what exercises might she avoid?
OK, so we have Belinda, who, at this stage, doesn't have osteoporosis.
And it would be really important for her to understand
that there's a scale of exercise that will help her.
And those exercises would be high-impact exercises.
They'd be things like jogging or playing netball or tennis
in this sort of age group.
And that they need to be three to four times a week,
about 30 minutes of duration.
But short and sharp and intense is much better than something that's just
a leisurely sort of, you know, walk for an hour,
because to actually get the body to really kick in
and form as much bone as possible,
you need to put a certain amount of strain 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 she might be prepared to adopt.
And it's true that swimming doesn't help?
They're low-impact.
Swimming, cycling - things that don't involve contacting the surface,
and therefore getting that jarring effect back up through the bones
are not going to actually stimulate as much of the normal process
that the body can actually do of actually forming more new bone.
Aren't there the funny machines that vibrate?
You can stand on them and it's just jarring your bones but nothing else.
Is there any evidence to support those?
I know that the machines exist,
but a level of scientific evidence I'm not aware of.
Is that covered in the guidelines?
There is some evidence for one of the types of machines,
which is actually a very low energy vibration.
It's actually quite hard to even feel it. It feels a bit like buzzing.
It's not one of these things that throws you around.
But these are still to be...
And they've shown they can have beneficial effects on the skeleton.
They haven't been translated yet to showing that they reduce fracture risk,
which is really the bottom line that we're all talking about.
Right. Judy, over to you.
There are some medications
that put people at risk of a decreased bone mineral density.
Can you quickly cover those, please?
John covered a couple before.
Steroids - whether they are oral steroids 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 they reduce the absorption of calcium.
SSRIs, aromatase inhibitors, glitazones.
Anti-epileptic drugs are another group
that can decrease your bone mineral density.
Well, the mention of proton-pump inhibitors
is actually one of the questions we've had from an audience member.
Marissa from Queensland asks,
'Could the increased use of PPIs in post-menopausal women
cause an increase in the incidence of fractures and thus osteoporosis?
What should we do, if anything, or is the evidence just theoretical?'
John, do you have an expert view on that?
Do we really believe proton-pump inhibitors
increase osteoporotic fractures?
Well, I think it's certainly clear that proton-pump inhibitors
decrease your ability to absorb, let's say, calcium carbonates in particular
because they require some gastric acid to be absorbed.
So... But the evidence that this, on a global scale,
is translating to an increase in fractures
I think isn't quite there.
I think the relevance is that if you've got a patient
who is on a proton-pump inhibitor,
if they're going to use a calcium carbonate,
you have to tell them to 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 acid for absorption.
Other than that, do you think there's any big difference
between different calcium supplements?
No, I think the major issue is the amount of calcium.
And I think, as Judy said before,
the evidence that any of the other minerals are required -
magnesium, manganese, zinc, silica, aluminium, boron
and any other that you'd like to name -
the evidence that any of those are specifically required
is approximately zero.
Yeah. Marissa from Queensland also asks,
'Should all post-menopausal women be on calcium supplements
due to most being at higher risk?'
Do you think we should just all be on calcium 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 question and saying, right, you know,
'Are you having reasonable calcium intake?'
Occasionally, you have to sort of try and get around the issues.
You ask people, you know, 'How much calcium do you have?'
and they say, 'Oh, I have two or 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 things don't quite add up.
But if you get past that,
I think if people have dairy or one of the dairy alternatives
like calcium-supplemented soy
or some of the other calcium-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 not gonna really add them to their diet.
And then some improvement in calcium intake with a supplement
makes good sense.
What dose does the guideline say is the appropriate daily dose
for calcium supplementation?
1,200 milligrams is what we should be going for.
- You had another comment, Dan? -Yeah.
I think we need to...
There may be a mistaken notion out there that dealing with the calcium is...
And then you've got it done.
You know, we're going to look after the 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 good amounts of calcium prevents fractures
is not good.
So what you really need to do is properly assess the person's risk...
GERALDINE: Mm.
..and they may need a lot more than just thinking about calcium,
or they may need nothing at all.
But just doing the calcium-diet history is 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 too is there's a lot of aversion
to 'high-fat foods',
and a lot of the dairy products have been dropped out of people's diets
because of an assumption that it's not good for their cardiovascular health.
Oh, yes.
There was a study a couple of years ago, wasn't there,
that people on calcium supplements were 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 people whose calcium...
As a group, the calcium intake for these people was reasonably good.
And if you added on top of this a calcium supplement,
there was a small but statistically significant increase
in the risk of heart attacks -
not in deaths, but in heart attacks.
Um, that's led, I think, people to say perhaps even more, as Dan has said,
you know, making sure people have a reasonable calcium intake makes sense
if people's calcium intake is low,
but giving it more and more and more doesn'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 rest of the evidence is about their risk,
then you have to build onto that.
Another question has come in
asking whether the treatment for men and women is ever different.
Uh, Dan, perhaps you'd like to comment on that
with your view from the guidelines as well.
Well, it's different when it comes to choosing some of the medications,
the specific anti-osteoporotic medications,
because a number of them are 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 closely at finding an alternative,
and there's now a range of bisphosphonates
and, for men, the evidence of effectiveness
is much better established for bisphosphonates than anything else.
I guess we'll talk about treatments shortly.
We're supposed to be talking about prevention right now,
and, on that point, we've been asked by Ben from Cairns
whether he really needs to measure vitamin D levels in everyone.
What's your view on that, John?
It's the old story about flossing your teeth.
You floss the teeth you want to keep.
If you want to know if somebody's vitamin D level is low,
you have to measure it,
but to answer it is that he 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 actually doesn'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 blood that we would consider to be suboptimal,
and the only way you can know is measuring it.
A question that comes across my desk a lot
is if the vitamin D level is critically low, like, say, 20,
what dose should be used to replenish that vitamin D?
Should people be using a super big dose once a week or once a month,
or would a daily dose of a normal amount, 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 need to keep themselves in balance.
If they're already depleted, that'll take you forever and a day or two
to get 'em up to a replete status.
I tend to use, you know, 5,000 or even 10,000 units a day for some months.
Do I know that that's a better way of doing it?
Well, no, but I think it makes sense
to try and get them up to a normal level faster 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 derived for 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 is one other side of it,
is that there was a study that's just been published
where community-dwelling people in Victoria
were given 500,000 units of vitamin D once a year
with the idea that this would have a beneficial effect.
And, to the distress of the people who were doing the study,
it turned out if anything, that people got this super-large -
and it's very much bigger than we're talking about -
actually had more falls and 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 D not only is inherently important
in improving the absorption of calcium from your foods,
but also in muscle strength and stability and gait.
And so vitamin D supplementation in those who are deficient
will decrease your risk of falls,
so that has a major impact as well.
So, John, just from a historical point of view,
are there any drugs that are on the market
that are no longer recommended for osteoporosis?
Well, when I started in this area approximately 40 years ago,
one of the most commonly used drugs was Deca-Durabolin.
GERALDINE: Ah, yes.
And it was given as 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 that that makes any difference,
unfortunately, is that almost certainly at the doses that are used,
it made no difference,
and if you used enough to make a difference to bone density,
then you almost certainly had unacceptable androgenising side effects.
There are a few other agents that are around
where I would argue that the evidence is less strong for their benefit,
and, I think, you know, really the evidence is
that the drugs that are now considered front-line
are things like the bisphosphonates and some of the other treatments -
that I believe Judy's gonna speak about too -
are the ones that you'd think there's really good evidence for.
Cecily, I wonder if you can comment for us on fall prevention.
We've been talking a lot about fracture prevention,
but I think your profession plays a big role in fall prevention,
which is often a major cause for the fractures.
Yeah, there has been, I think, increased recognition
that the risk of falls actually does sort of overlay in this group of people
who also may have a risk of osteoporosis or fractures,
and it's very important that we do intervene for that falls risk.
So there are components to that,
and certainly some of those are around somebody's strength and balance,
and, if we can improve those things, they're much less likely to fall.
We've already heard about improving their vitamin D levels,
or normalising those has a direct impact on people's strength
and likelihood of falls.
We also need to think very much about the home environment,
and just simple things like having lights that go on at night
when someone gets up to go to the toilet
has actually been shown to reduce the risk of falls.
We need to think about people's footwear,
we need to know whether people have had a recent eye check,
are they wearing their old glasses because the other ones broke,
all of those things.
And they are part of quite a good checklist of things
that should mean that every health professional and GPs
can actually go through quite a systematic review
of all the factors that could contribute.
Dan, I wonder if you could comment on that as well,
as a general practitioner,
how you get your patients reviewed for their falls risk.
I tend not to deal with the intervention around that myself,
and, depending on where I'm working,
I'll either get the practice nurses to review that stuff with the person
or I may have the capacity to refer them into a community health service.
And that's gonna be fairly patchy in rural settings, your ability to do that.
It's not rocket science,
and I think we all should be able to get our head around doing it.
It's just a matter of fitting it in and making sure someone does it.
I think all health professionals have a role to play here,
especially pharmacists, as well.
Judy, you've been a Home Medicines Review pharmacist.
Is that another opportunity to assess people for their fall and fracture risk?
Absolutely, have a look at the situation at home,
whether there's mats on the floors, pets to fall over,
all those sort of things that can play a role
that doesn't always get assessed in the home.
GERALDINE: There are medications that contribute to falls risk too?
Absolutely - anything that acts in the brain or makes you feel dizzy -
antihypertensives, opiates, benzodiazepines -
lots of drugs can increase your falls risk,
and they should be assessed.
Things with anticholinergic side effects should be looked at and reviewed
in people who have a high risk of falls.
In terms of treatment, what are the 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-based therapies around now.
I mean, hormone replacement therapy still has good evidence.
Then, about 15 years ago, the bisphosphonates came on the market.
They're now given weekly, but they have very specific instructions
about how they should be taken.
Raloxifine or SERMs came on the market since then.
For women only, strontium has come on the market since more recently.
For women only,
there's parathyroid hormone - it's a subcutaneous injection
which has become available in 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 marketed in Australia,
which adds another agent to the armamentarium
to treat osteoporosis.
And what's compliance like with all these potential treatments?
Well, compliance with medications in general is really poor - about 50% -
and that's similar with bisphosphonate therapy.
They're a weekly medication,
although now there's an IV form which has also become available
in the last year or so.
So I guess there are ways around compliance issues,
but there's still a problem with compliance with oral therapy.
GERALDINE: Right.
And, John, you have a graphic, I understand,
that talks about which kinds of 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 sort of age going along the X axis there,
it says 'calcium' and 'life style'.
You really need to talk about it for everyone and think about it.
Closer to the menopause, you might think,
'Well, hormone treatment is 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 those so long these days,
but if you've got people who've got very clear osteoporosis,
and it's both for men and for women,
the bisphosphonates have really excellent evidence
for being very effective, effectively halving the rate of fractures
that people might have, and very well tolerated.
There's good evidence for 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 people where they've been treated
yet their bone density hasn'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 film of a rural model of care
that was trialled by the North Coast Area Health Service.
This model ensures that patients who are seen at the local hospital
for a minimal trauma fracture
are given an osteoporosis risk assessment by a nurse.
This assessment, and any other test results,
are then reviewed by a medical team
and a referral letter is sent to the patient's GP.
CECILY: Every day in Australia,
there are a significant number of people who are admitted to an acute hospital
because they've had a fracture,
and, whilst we're very good at managing their fracture,
we're not so good at actually identifying
that this is a flag that they may have an underlying chronic disease,
which is osteoporosis.
So, for these people, having a fracture is a major episode in their life.
Many of these people don't return to their prior level
of independent functioning.
Many people do not return to being able to live in their own residence again.
And there's an increased mortality at five years
for any minimal trauma fracture.
So, I just need to establish that 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 at identifying these people
who have had a minimal trauma fracture,
which is a fracture that results from just a slip, trip, or fall
from a standing height or less,
as that's one of the first symptoms that occur
for someone who may have a problem with 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 spend outside in the sun?
I don't go in the sun. I've got red hair.
I burn very quickly, so I just stay right out of the sun.
And now we'll take some blood from you.
We'll do some blood tests.
CECILY: After the patient has left hospital and gone home,
then their osteoporosis risk screen that was done
is then passed through to a multidisciplinary case review session.
We have specialist medical staff and nursing staff
that come together to review that person's risk screen,
to look at the pathology tests that may have been done
when the patient was in hospital,
what additional tests would be indicated
and to write quite a detailed summary of that person's risk
and their recommendations for management
back to the patient's GP.
The GP does get the latest evidence-based management,
so that the GP is then armed to work with the patient on a one-to-one level
to decide ongoing management of osteoporosis.
At the hospital, you did have some tests,
and this has been a useful feedback the hospital's provided for me.
Whilst you were there, they measured your vitamin D levels,
and they were surprisingly low.
WOMAN: Oh, OK.
And perhaps your habit of not being in sunlight
has contributed to you having low vitamin D levels.
Right.
Low vitamin D levels means that you'll lose more of your bone strength.
I think it's important we think about boosting your vitamin D levels...
OK.
..and we've got an option of giving you a catch-up dose...
- OK. - ..for the first weeks,
or just starting in on a replacement dose.
Vitamin D also somehow helps people have less falls -
it seems to help the muscles
and coordination and things work a bit better.
WOMAN: That'd be helpful.
And how do you feel now about the prospect of taking a tablet
for many years to 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.
OK.
So can I make bones stronger... or just stop them from getting weaker?
It's mostly about stopping them getting weaker.
We can't guarantee you'll never have any more fragility fractures.
But the good news is that, using these kinds of medicines,
we can have a big impact on the risk of you having another fracture.
It's in the order of 30-50%.
Um, but it will involve long-term medication use
and long-term changes to some lifestyle factors.
- OK. - The diet, the exercise.
Perhaps checking if there's any particular risks
of tripping and falling around your home.
Right.
Maybe looking at the types of shoes you wear would be important.
Getting you into an exercise activity
that involves retraining and maintaining your balance skills.
All of these things will be important.
OK, that sounds great.
CECILY: When we developed the model of care,
we were very aware of trying to keep that as a low-cost intervention,
and we went for as low as you could go and still hopefully be effective.
So the model of care costs less than $16,000 per year to run,
and that was for a small increase in nursing hours of six hours a week,
and the once-a-month medical specialists who came to do the case review session.
We evaluated our model of care
and we found that we had statistically significant increases
in the number of people who were informed of osteoporosis
and their risk of fractures,
increased numbers who were on effective medications,
and increased numbers who received other interventions,
such as falls prevention interventions.
So, for $150 per patient,
it appears that this model of care can be very effective.
Hmm... Very interesting, Cecily.
So can you tell us why this project was undertaken?
Um, it was undertaken in a rural area,
partly because we perceived that we also had a treatment gap
similar to our metropolitan cousins,
but we weren't actually sure
because there was no sort of study had been done in a rural area,
and we also wanted to not just know
whether or not there was a treatment gap -
we wanted to actually see whether there was something we could do
about that treatment gap.
And that was the model of care that we developed to work in that rural setting
where we're not going to have access
to so many specialists or specialised clinics,
and it really is the domain of the general practitioner
to manage these people.
And how widely employed is that model of care in Australia?
The model of care was 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 be looked at at a Statewide level
for implementation through an osteoporosis working party
that's currently being formed in New South Wales.
OK. Jane, a remote area nurse, asks, 'A lot of patients with osteoporosis
seem to also have renal impairment.
What medications are safe for this group?'
John, I think your expert view on 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 marked renal impairment
to the extent that you're talking about a degree of renal failure,
um, I don't think it makes a major issue.
If you're above about 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 dose by half would be reasonably safe.
Having said that, if somebody has that degree of renal disease,
then they'd probably need expert management.
I know it's not always easy in those environments,
but that's the recommendation.
And also, Judy, I guess a pharmacist can help with the guidance of drugs
used in renal impairment, can't they?
- Yes, absolutely. - OK.
Another audience question is Michael from South Australia says,
'In some groups of people, vitamin D deficiency is a known heath problem,
such as dark-skinned people.
Should we be giving vitamin 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't treat things that aren't a problem.
And until it's a problem, we shouldn't treat it.
Now, there's another general practice question, just quickly -
Sam from Portland asks, 'How often should GPs follow up
known osteoporotic patients after 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 that compliance long-term with treatment
is not good,
and that's true of every chronic 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,
seeing whether 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 not managing your patient properly.
And, in some situations, a bone density or some other types of blood tests
of what's going on in the bone
are helpful ways of enhancing that interaction,
but I think the primary thing is
for you and the patient to know that you think that this is important.
Absolutely. Dan, do you have anything to add to that?
No, I see it as part and parcel of chronic disease management,
which is front and centre what general practice does.
And it's all about the long-term relationship.
With these people, they're quite likely
to have other issues you're seeing them for anyway,
so you'd be melding their proactive care for their other conditions
along with their osteoporosis.
It could easily become part of a GP management plan
in a team care arrangement,
and how often you see them depends on how often they need to be seen.
Very much aware of the issues that compliance is likely to be a struggle,
and that applies not only to the medication
but to the lifestyle changes as well.
We need to wrap up now, so I wonder if we could start with you, Judy,
on what your take-home message might be for our audience.
Oh, well, I'd like to direct to the pharmacists out there
to really be proactive about thinking about bone health,
and to really help in assessing compliance
with anti-osteoporotic medication to get the most out of the medicines,
'cause they're only as good as if people can take them and take them correctly,
so taking them correctly is a big issue with these agents as well.
And, Dan, your take-home message?
There's an evidence-practice gap which we can pretty easily fix.
GERALDINE: That's it? And there's a great new guideline out to do that.
There's a great new guideline. It just steps you through it.
GERALDINE: Cecily?
Every day, there's a large number of people with minimal trauma fractures
who need to be hospitalised to manage their fracture,
and, at a local level, each of those orthopaedic centres
needs to set up a local system
and have designated people whose job it is
to pick up on osteoporosis, their risk of fractures,
and make sure they get linked to the appropriate ongoing care
back in the community.
GERALDINE: Finally, John? - I think it's all been said.
This is a hugely common problem in the community.
One in two older women, one in three older men,
and it's a nasty condition.
We should look at it as a 'malignant condition',
'cause people go on to fracture and 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 approach in many ways, as Dan has stressed.
And I think if we can get people looking at this guideline
and saying, 'Instead of ignoring it, we're gonna do something about it,'
there will be very substantial health benefits in the community,
maybe reduction in premature mortality.
And if you just only worry about the dollars,
just think - it's cost us $1 million while we're talking tonight.
Goodness. Well, important work for all of us to do.
I hope you've enjoyed the program on the new osteoporosis guideline
that's available on the RACGP website.
Our thanks to the Department of Health and Ageing
for making the program possible,
and thanks also to you for taking the time to attend and contribute.
If you're interested in obtaining more information
about the issues raised in the program,
there are a number of resources available
on the Rural Health Education Foundation's website -
Don't forget to complete and send in your evaluation forms
to register for CPD points.
And I'm Geraldine Moses. Thank you very much and goodnight.
Captions by Captioning & Subtitling International
Funded by the Australian Government
Department of Families, Housing,
Community Services and Indigenous Affairs�