GIPR rs10423928 and bone-mineral density in postmenopausal women in Shanghai

Our previous studies have demonstrated that there is a correlation between GLP-1R SNP and the BMD in postmenopausal women. GLP-1 and GIP are both incretins. Whether the mutation of GIPR gene affects bone metabolism. SNP rs10423928 is a GIPR gene polymorphism that has been studied more frequently. The aim of this study was to investigate the association between GIPR SNP rs10423928 and bone-mineral density (BMD) in postmenopausal women in Shanghai. The GIPR SNP rs10423928 was detected in 884 postmenopausal women in Shanghai, the correlation between the GIPR SNP and BMD was further assessed. The dominant T/T genotype of the GIPR SNP rs10423928 was significantly related to BMD of the femoral neck (P = 0.035) and Ward’s triangle area (P = 0.033). Our research found that the dominant T/T genotype of GIPR SNP rs10423928 in postmenopausal women is significantly associated with higher BMD. The T/T genotype seems to have bone protection.

P10 Treating osteoporosis, facing reality – adopting a holistic approach

Case report - Introduction Osteoporosis is a significant health problem; globally around 200 million women are affected. In Europe, osteoporosis is responsible for a higher disability encumber than cancer (with the exception of lung cancer). The treatment of osteoporosis is quite exacting. Although understanding of the diagnosis and treatment of osteoporosis has broadened considerably over the last few years, lack of bridging information still exists with guidance lacking on the appropriate management of complex comorbid clinical scenarios. Here we will present a scenario of a patient with osteoporosis and multiple risk factors and comorbidities, where choice of suitable anti osteoporotic treatment was quite challenging. Case report - Case description An 84-year-old lady with known osteoporosis with history of T-12 fracture (in 2009), sarcoidosis, coeliac disease (confirmed on duodenal biopsy), chronic hepatitis, history of acute kidney injury secondary to zoledronic acid infusion and urosepsis in 2017 was re-referred to the rheumatology clinic from respiratory team for optimisation of her bone protection. She was previously on risedronate for almost 5 years without any improvement of bone mineral density. She was last seen in rheumatology in 2018, because of ineffectiveness and intolerance to alendronate (gastritis) and intravenous zoledronate – a discussion about subcutaneous denosumab was had, but the patient refused that option because of needle phobia. So, the plan was to maintain her on optimisation of vitamin D and calcium level. She was discharged from the clinic. Her GP advised her against vitamin D or calcium supplements because of episodes of hypercalcaemia secondary to sarcoidosis. For the last 3 years she was not on any bone protection or even calcium or vitamin D supplements. Recently she noticed a worsening of exertional dyspnoea. She was reviewed by the respiratory team. Her lung function test showed slow progression of restrictive lung disease with FEV1/FVC ratio is 100.4%. In December 2020, she was started on prednisolone 30mg, which gradually stepped down; at the moment, she is on 15mg and will continue it as maintenance. The patient was an ex-smoker, and drinks alcohol at about 10 unit/week. Her mobility is slightly better compared to the last few years. She trys to keep active and is enjoy gardening in the sunny weather. It was difficult to convince her for blood tests; however, we succeeded after repeated counselling. Her blood tests showed microcytic anaemia, with normal inflammatory markers mild renal impairment with eGFR of 67, corrected calcium 2.19, alkaline phosphatase 78, vitamin D 49 (sub optimal) albumin 32. Case report - Discussion Considering her age, comorbidities, frailty, intolerance and doubt about the efficacy, selecting an appropriate bone protection for her was fairly hard. Starting denosumab had more risk than benefit and in future if it need to stop there is an increased chance of rebound fracture. Besides this, she re-expressed her reluctance to the subcutaneous option. Moreover, calcium and vitamin D level were low in her recent blood tests. She did not fulfil the criteria for considering teriperatide. We reviewed her DEXA scan in 2018, which showed an overall 19% reduction of BMD compared to 2009 (1.6% per year). She was on risedronate intermittently for about 4 years that time; however, she had not experienced any new fracture at that point. She had multiple hospital admissions during those years. Bone protection was withheld multiple times. Poor mobility, frailty status and other comorbidities during that period were also responsible for BMD decline. Her case was discussed with a consultant with special interest in metabolic bone disease. Treatment decisions should be individualised; risk versus benefit needs to be considered to ensure the best outcome for the patient. We have decided to put her back on risedronate for at least 3 years. She tolerated only this medication in the past. We have requested bone markers and a repeat DEXA scan. Case report - Key learning points Comorbidities adversely affect the management of osteoporosis. A comprehensive assessment of the comorbid list is necessary before considering changing a medication which suits the patient well and when there is limited option. Obstacles to offer high quality service are knowledge, expertise, and critical thinking from healthcare professionals, and knowledge and compliance to treatment from patients. Facing those challenges and treating patients judiciously will help to reduce the potential health and economic burden of osteoporosis.

SP9.1.12 Bone protection in neck of femur fracture patients in a DGH without a fracture liaison service

Introduction In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management. Method Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or DEXA scanning for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e. if parental hip fracture status was not known. Results A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate or high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation. Conclusion Following a local meeting; a proforma was piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid patients long-term wellbeing.

861 Bone Protection in Neck of Femur Patients in A DGH Without A Fracture Liaison Service

Introduction In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and is a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management. Method Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or require a DEXA scan for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e., if parental hip fracture status was not known. Results A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate/high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation. Conclusions Following a local meeting; a proforma has been piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid a patient’s long-term wellbeing.

1235 A Multi-Site Review of Second Hip Fractures Across 6 Dublin Teaching Hospitals

Introduction Hip fractures are a common presentation to Irish hospitals with 3,701 hip fractures recorded by 16 hospitals in the Irish Hip Fracture Database (IHFD) in 2019. Second hip fractures (HF2) make up a significant proportion of hip fractures and represent an opportunity to prevent subsequent fragility fracture. Method Hip fracture datasheets from 2019 in six Dublin hospitals were analysed. Results 1,284 hip fractures in total were recorded in 2019 in these six hospitals. 112 of these were second hip fractures (8.72%). 24.1% of patients had a HF2 in year 1 post their first hip fracture (HF1). 14.3% of patients had a HF2 in Year 2, 8% in Year 3, 8.9% in Year 4 and 6.3% in Year 5. 17.9% of patients had an HF2 at an unknown time in relation to their HF1. 57.6% of all patients with any hip fracture were started on bone protection medications (BPMs) during their admission. 18.9% continued a pre-admission prescription. 7% of all patients were previously assessed and determined not to require BPM. 6.9% of patients were awaiting outpatient department (OPD) assessment for bone protection. 8.6% had no assessment for bone protection conducted. Of all patients with an HF2, 48.2% were started on BPMs on admission with their HF2. 33% continued BPMs started pre-admission. Discussion In 2019, approximately 1 in 10 hip fractures were second hip fractures. Evidence suggests that fracture liaison services represent a viable, economic means of preventing second hip fractures to improve patient outcomes and reduce healthcare expenditure.

460 THE IMPACT OF THE BONE MDT: EXPLORING CHANGES IN BONE PROTECTION DECISIONS BETWEEN 2015 AND 2018

Introduction The Hip fracture Multidisciplinary metabolic bone Team (MDT) was developed in June 2016 as a collaboration between Orthogeriatricians and the Metabolic Bone Team. The objective was to improve the quality of bone protection treatment decisions. This audit aimed to assess the impact of the new MDT by reviewing treatment decisions prior to and post its introduction. Data collection and. Methodology Case notes were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decisions at discharge. Results In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9.4% at discharge. In 2018, 77% of patients were admitted on no form of bone protection. 5.4% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP. Conclusions There was a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. Individual case discussion enhanced the delivery of personalised medicine.

Improvement of quality of care in inflammatory bowel disease: the role of Steroid Assessment Tool (SAT)-results from a tertiary center trial

Corticosteroids play an important role in the treatment of inflammatory bowel disease patients. They are used for induction of remission but due to their numerous side-effects they are avoided in the long term treatments.In order to improve medical care for the IBD patients guidelines were developed to avoid steroid excess and to promote regular monitoring of corticosteroid use. The aim of this study was to evaluate corticosteroid treatment using an online tool in a tertiary IBD centre from Romania. Methods: An online monitoring tool – SAT (Steroid Assessment Tool) was used to assess disease characteristics, corticosteroid use, corticosteroid excess as defined by international guidelines and the use of bone protection medication associated to steroid treatment. Two successive evaluations of patients treated in a tertiary IBD center were made, the first one in March 2019 on 44 patients and the second one 12 month later, in March 2020, on 84 patients. Data were statistically analyzed with SPSS® software. Results: The results showed that in 2019 the rate of corticosteroid use was of 34%, while in 2020 there was a decrease of corticosteroid use up to 25%. Regarding steroid excess, in 2019 there were 20.4% of patients treated with steroids in excess, but we managed to reduce it to 5.95% in 2020, a decrease that was statistically significant. Bone protection medication was prescribed to only 6.6% of patients treated with corticosteroids in 2019, but a significant increase up to 95% was obtained in 2020. Discussions: Two SAT evaluations of a tertiary IBD centre from Romania revealed that despite new therapeutic options, the rate of steroid use was higher than that reported in other international studies. The objective evaluation of steroid use determined a change in managing IBD patients, thus we succeeded to decrease significantly the rate of steroid excess and increase the use of calcium and vitamin D associated to corticotherapy. Conclusions: The use of an objective tool for monitoring corticosteroid use determined an improvement in managing IBD patients and thus of quality of care.