With aging populations worldwide, the number of osteoporotic hip fractures has increased- Dr. Humeira Badshah


Rheumatology Conference Proceedings-V

With aging populations worldwide, the
number of osteoporotic hip fractures has
increased - Dr. Humeira Badshah

Hip fracture is just like death sentence and one year
mortality after hip fracture is very high

LAHORE: Osteoporosis and Vitamin-D deficiency was the topic of presentation by Dr. Humeira Badshah Consultant Rheumatologist from Medical Center, Dubai in the scientific session –III during the rheumatology conference held at Lahore recently. Osteoporosis, she said, is defined as low bone density and low bone quality with increased risk of fractures.  She further pointed out that one year’s mortality after hip fracture is very high. In fact hip fracture is a death sentence. With aging populations worldwide, the number of osteoporotic hip fractures has increased. Relative risk of more fractures is also increasing.

Dr. Humeira Badshah

Continuing Dr. Humeira Badshah said that the incidence of osteoporotic hip fractures is much more if one compares it with heart disease, stroke and breast cancer. All fractures are associated with morbidity. Fracture risk increases exponentially with decreasing bone mineral density.  She described the practical definition of osteoporosis as any fall from a sitting or standing height that causes a fracture. While examining a patient one has to take care of any prior fragility fracture, multiple risk factors and the low T score.  She further stated that morbidity and mortality is much higher in men as compared to women with osteoporotic fractures. One should suspect a secondary cause in premenopausal women,   patients without risk factors, those with multiple health problems and worsening osteoporosis despite therapy. Speaking about general treatment and prevention of osteoporosis she mentioned Calcium and Vitamin D. The dose of calcium increases with age due to decreased absorption. It decreases bone loss by 1%. Its greatest benefit is in elderly, late menopausal and those with low baseline calcium intake.  The recommended intake of Vitamin D is 800-1000 IU. Fatty fish, fish liver and fortified foods are its natural source. Use of Vitamin K might help with bone metabolism and reducing urinary calcium excretion. Use of Vitamin A and Magnesium is also helpful.

As regards treatment of osteoporosis, anti resorbing medications, anabolic combination therapy of alendronate and Vitamin-D, Strontium Ranelate and biological preparations like Denosumab are very safe and effective. Side effects of SERMS (Raloxifene) include hot flashes, leg cramps and increased VTE. Calcitonin is used in those patients who are unable to tolerate other agents. It is used as daily nasal spray, SC injection and oral therapy. Its side effects include nasal irritation, nausea, local inflammation and flushing. Biphosphonates inhibit osteoclasts and increase bone mineral density. It is advisable to treat infections and getting routine dental care before starting therapy. Quoting results from one of the studies she said that biphosphonates can be used for treatment to prevent typical femoral fractures and the therapy should last for five years. After five yeas, there is a risk for atypical femoral shaft fractures though they are very rare. Biphosphonates decrease mortality and post hip fractures. Other benefits of biphosphonates therapy include decrease in breast cancer, colorectal cancer, decreased risk of stroke and gastric cancer besides decreased overall mortality.

Continuing Dr. Humeira Badshah said that patients who do not need treatment should never use biphosphonates and they must discontinue treatment immediately. One can consider a drug holiday after three to five years of treatment with biphosphonates. The available data do not show any benefit with biphosphonates therapy after three to five years hence the decision to continue treatment should be based on individual patient’s assessment of risk and benefits besides patient preference. Studies have showed that biphosphonates are useful for patients with high risk and length of treatment depends on fracture risk. She also referred to a number of other new and emerging treatment modalities. One should treat only to prevent fractures and also recognize risks and benefits of treatment. Vitamin D deficiency is widespread but not inconsequential. Tests should be restricted to high risk population. Start with high dose of Vitamin D followed by maintenance therapy.  Increased sun exposure, fortified foods and supplementation are also recommended, she remarked.

The next day Dr. Deirdre Shawe consultant rheumatologist from UK spoke on Scleroderma. He discussed in detail the spectrum of scleroderma and limited systemic sclerosis. Previously it was also known as crest syndrome.  Interstitial lung disease, he said,  accounts for 30-40%. Diffuse systemic sclerosis has a wide spread skin involvement and it starts abruptly. It is followed by development of firm thickened skin over extremities. There is universal esophageal involvement. This limited disease is slowly progressive and endothelial damage is the primary lesion.  He also talked about scleroderma renal crisis and pulmonary arterial hypertension. Diagnosis, it was stated, is made on characteristics of skin, thickening and varying degree of organ involvement. One should carry out routine assessment of all those internal organs likely to be affected. Treatment of Raynauds mild disease is life style measures and avoiding smoking. ACE Inhibitors and SSRIs are quite useful. In case of Reynaud’s severe disease, one should go for endothelial receptors antagonists, PDES inhibitors, IV prostacyclines six hourly infusion for five days. Causes of pulmonary hypertension in scleroderma were also discussed. RAH, it was stated, is the leading cause of death in such conditions. Signs and symptoms of RAH disease in early, intermediate and late stage were also mentioned in detail. DETECT study was conducted at sixty two centers in eighteen countries during 2008-2011. They screened 466 patients of which 87 patients (19%) had PAH.  Early detection and early treatment, he said, ensures improved prognosis. Skin diseases in SSC and which patients need to be treated were also discussed at length. There is no good evidence for D-Penicillamin. There are still limited options for treatment.  This presentation also covered pulmonary fibrosis in SSC, predictors of progressive fibrotic lung disease in SSC and how to treat lung disease. There is evidence that cyclophosphamide has some benefits, he added.

Dr. Humeira Badshah from Dubai was the next speaker and she talked about Large Vessel Vasculitis: Challenge in diagnosis and management. She presented a case history and then discussed its management.  She discussed the disease course up to remission and burn out stage. She also referred to the 1990 criteria for diagnosis of Taka Yasu Disease. To control disease activity prednisone 20-30mg was recommended.  In case of inactive disease, one can taper the steroids. One can start treatment with prednisone and then go on to Methotrexate and AZA. Safety and efficacy of biological drugs was also highlighted.  Speaking about indications for surgery in Taka Yasu Disease she mentioned aortic coarction and aortic root dilatation.  It is best to opt for surgery in inactive stage of the disease.  She also talked about differential diagnosis and referred to fibro muscular dysplasia and Giant cell arthritis.  She presented a case of Giant Cell Arthritis and discussed it clinical features. She was of the view that sudden blindness can result in such cases hence one should aim at early diagnosis to prevent blindness.

Dr.David D’Cruz from London discussed what should physicians and Gynaecologists know about APLS. Antiphospholipids, he said, can lead to thrombosis, affect pregnancy, and result in fetal death or premature birth if there is delay in diagnosis. Clinical features of APS vs. SLE with APS are the same.  These patients are most likely to have heart valve disease. Fetal loss can be up to 35% while up to 15% recurrent miscarriage has also been reported.  There is 30% second or third trimester loss. Pre pregnancy counseling, he said, was very important. One should also consider fertility issues. Frequent antenatal visits, multidisciplinary team approach is recommended.  In case there is no thrombosis, there is no need for treatment except careful monitoring.  There is no evidence that low dose Aspirin offers any benefits. In case of recurrent early miscarriages, combination of Low Dose Aspirin therapy with Heparin is recommended. In case of late fetal loss, use heparin and Low Dose Aspirin therapy but if it fails, consider using low dose steroids, IVIG, Hydroxychloroquines. Low Dose Aspirin therapy and Heparin are safe in pregnancy while warfare can also be used. With appropriate treatment success rate in APLS is up to 85%.

CNS involvement in APS, David D’Cruz said is very common. Patients may also complain of severe headache.  He also talked about MRI abnormalities in SLE/aPL,  APS and valve disease, APLS and nephropathy, labile hypertension, risk of renal biopsy in APS besides renal transplantation and APS.  In APL positive cases the use of Aspirin 75mg daily was recommended. There are many new drugs available which are also quite safe and useful. With novel anticoagulants there are no dietary restrictions but long term anticoagulation is recommended.

Dr. Aisha Lateef

Dr. Aisha Lateef from Singapore talked about Pregnancy and Rheumatic Diseases.  She highlighted the importance of planning and management of pregnancy in rheumatic disease patients. She referred to the effects of these diseases in fetus and pregnancy. SLE, she said, was a disease of young women. During pregnancy there is a risk of flare up of SLE. Most often there is renal involvement. It is extremely important to make sure that the disease is under control at the time of conception. There is high risk of gestational diabetes, hypertension and infections. Pregnancy loss could be up to 10-53%, pre term birth can take place in   16-58% cases while intra uterine growth retardation (IUGR) can result in 5-35% of cases. Active disease at the time of conception is the predictor. Neonatal lupus syndrome is the most feared complication. There is 2% chance of congenital heart block.  Rheumatoid Arthritis in pregnancy can lead to increase in intra uterine growth retardation, low birth weight and more C. sections. Certain rheumatic conditions may also lead to difficult deliveries.  In the past, systemic sclerosis was a contra indication for pregnancy, still there is a high risk but success can be achieved in majority of the cases. Successful pregnancies have been achieved in vasculitis but there is risk of high maternal, fetal morbidity. Contractions are very important which is often over looked. One of the studies showed that 59% of SLE patients had no counseling, 22% had inconsistent use of contraceptives. Oral contraceptive pills, (Progesterone) it was stated, are safe in stable SLE disease.  IUDs are safe and there is no evidence of increased risk.

She highlighted the importance of close monitoring in high risk pregnancy; ensure safe use of medications and these patients’ needs to be looked after by a multidisciplinary team. NSAIDs should be used very carefully and one should avoid them in third trimester.  Steroids in lowest possible dose can be used during pregnancy. Antimalarial can be continued in SLE patients. Immunosuppressants are relatively safe. Methyldopa and HCQ are also safe in pregnancy.  The patients should be advised to discontinue biological before conception. Once complete heart block occurs, there is no treatment, she remarked.

Prof. Syed Attiq Ul Haq

This was followed by an excellent presentation by Prof. Syed Attiq Ul Haq from Bangladesh who spoke on RED Hot Spots. He first talked about important findings in Gout and then presented a case history of a sportsman who complained of pain. He then described how to approach a patient, taking careful history, good physical examination, ordering appropriate investigations. Choice of investigations, Dr. Attiqul Haq opined, will depend on history and clinical examination. No set of investigations is routine in all scenarios. Investigations ordered must be cost effective. Some of the patients may not require any expensive investigations. While diagnosing mono arthritis, one should rule out soft tissue problems. Every patient needs customized treatment protocol and not routine treatment protocol. In case of Ankle Sprain, there is no need for further investigations. Errors in treatment of monoarthritis include failure or delay in aspiration. Redness of the wound, he stated, was an indication of an infection.

Dr. M. Harpoon’s presentation was on Psoriatic Arthritis. This, he said, was an inflammatory arthritis associated with psoriasis. Diagnostic criteria for this condition do not exist.  About 2-3% of general population will suffer from psoriasis and a significant number of them will have psoriatic arthritis.  The interval between onset of psoriasis and  psoriatic arthritis is just one year.

Prof. Rasker from Holland talking about asymptomatic hyper uricemia said that two third of these patients will never develop Gout. It is not a disease but a persistent risk for development of Gout. He also talked about primary and secondary hyperuricemia. Hypertension, obesity, high meat, sea food increase the risk.  While treating Gout, one should always use safe alternatives for the treatment of other diseases. Uric acid deposits up to 8, there is no need for treatment. It is a risk factor for Gout. If the uric acid deposits are more than eight, repeat it after a week. If it is confirmed, take history, physical examination, advice on diet and life style modifications and drug therapy. Soon you will find reasons for increased uric acid production or decreased clearance. There is no study promising benefits in asymptomatic disease. Adjust diet, give advice on body weight, avoid drugs which increase orate levels like thiazide, ACEIs. In case of very high level of uric acid, treat with drug therapy. Hyperuricemia in children and adolescents should be treated in any case.  His conclusions were that these patients need careful investigations and decision to treat should be made on individual basis.

During the discussion the side effects of alloperinol which has to be taken for life long were also highlighted but it was also emphasized that at times it is better than wheelchair.