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Five-minute Practitioner: December 08

Only got five minutes? Then just read these key points on: osteoporosis, osteoarthritis and CRP and CVD risk

Only got five minutes? Then just read these key points on: osteoporosis, osteoarthritis and CRP and CVD risk

Osteoporosis

Osteoporotic fractures are a major health problem in older people, affecting one in two women and one in five men over 50. These fractures are associated with significant morbidity and increased mortality.

The diagnosis of osteoporosis has traditionally been based on the measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry at the lumbar vertebrae and proximal femur.

A T-score (the number of SDs below normal peak bone mass) of -2.5 indicates osteoporosis.

The risk of fracture increases progressively with decreasing BMD. However, the use of BMD alone to predict fracture risk has a high specificity but low sensitivity, and the majority of fractures occur in patients with a BMD T-score higher than -2.5.

Recently, it has been shown that prediction of fracture risk can be improved by the use of clinical risk factors independent of BMD. These risk factors, alone or in combination with BMD measurement, form the basis of the WHO-supported FRAX tool for predicting fracture risk. This is available free online at www.shef.ac.uk/frax and can be used to assess the 10-year probability of a patient developing a major osteoporotic fracture (wrist, spine, hip and humerus) or hip fracture.

Falls risk assessment and prevention is important in the management of osteoporosis. Other measures include maintenance of mobility, advice about smoking cessation and alcohol intake, and correction of vitamin D deficiency.

Osteoarthritis

Osteoarthritis (OA) is the most prevalent joint disease in the UK. It is a common cause of pain and disability and the main reason for hip and knee replacement. Three million GP consultations for OA took place in the UK in 2000.

OA is a syndrome of joint pain and stiffness with associated inability to participate in usual activities; consequently, it has a major impact on quality of life.

Prevalence increases with age, and the condition is more common in women. Many patients will have had symptoms for months before they seek medical help, and often patients never seek help, perhaps reflecting a negative community outlook on OA treatment. However, OA is not a necessary association of ageing and often does not deteriorate over time.

The most common symptom of OA is joint pain, usually when the patient is weight bearing through the joint. Patients often feel worse at the end of the day, with symptoms worsening after repetitive weight bearing, for example after a walk or using stairs.

Exercise is essential for people with OA, regardless of comorbidity or age. Pain should not be a barrier to exercise. Patients should be encouraged to undertake and continue regular aerobic, muscle-strengthening and range of motion exercises, for example quadriceps-strengthening and forearm-strengthening exercises for knee OA and hand OA respectively.

CRP and CVD risk

The JUPITER trial has found that rosuvastatin reduces the risk of major cardiovascular events in patients with elevated C-reactive protein (CRP) levels.

The randomised, controlled trial enrolled 17,802 patients with a median age of 66 years. Participants had no apparent vascular disease, an LDL cholesterol of less than 3.4mmol/l and a high sensitivity CRP concentration of 2.0mg/l or higher.

Although the relative risk reductions seen were impressive, the actual number of events was low (142/8,901 or 1.6% in the statin group and 251/8,901 or 2.8% in the placebo group), and therefore the absolute risk reduction is less impressive.

It is not clear if testing for CRP provides an incremental benefit over and above traditional risk factors in identifying cardiovascular risk.

If a trial can show the benefit of CRP measurement in cardiovascular risk assessment, it may find a place to aid clinical decision making in patients with intermediate cardiovascular risk who sit on the threshold of intervention. However, even then lifestyle modification should be the first-line intervention. Drug therapy should only be considered if lifestyle changes are unsuccessful, and treatment should not be dependent on a single agent targeting a single risk factor.

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