The video version of this podcast can be found here:

·      https://youtu.be/GmCg9TskZNA

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

This video refers to a number of medical articles on ADHD published by a number of organisations (details below). Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of them.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I cover ADHD increasing incidence, especially in adults, always focusing on what is relevant in Primary Care only. The information is based on a number of published medical articles. The links to them are below.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
• Free Download / Stream: https://alplus.io/halfway-through 

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE clinical guideline on osteoporosis can be found here:

·      https://www.nice.org.uk/guidance/cg146

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are looking at the NICE guideline on osteoporosis, specifically how we diagnose it and how we assess the risk of fragility fractures, always focusing on what is relevant in Primary Care only.

The links to the NICE guideline is the episode description.

Right, let’s jump into it.

Let’s start by saying that we should consider assessing fracture risk in all women aged 65 and over, and all men aged 75 and over.

Additionally, we should also consider assessing fracture risk in women under 65 and men under 75 if they have risk factors. Examples of these risk factors include:

• a previous fragility fracture,

• current or frequent recent use of oral or systemic glucocorticoids,

• a history of falls,

• a family history of hip fracture,

• a low BMI, below 18.5,

• smoking,

• drinking more than 14 units of alcohol per week

• and any cause of secondary osteoporosis

Causes of secondary osteoporosis can include endocrine conditions such as hypogonadism in either sex — including untreated premature menopause — and treatment with aromatase inhibitors or androgen-deprivation therapy. They also include hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing’s disease, and diabetes.

Other causes include gastrointestinal conditions such as coeliac disease, inflammatory bowel disease, chronic liver disease, chronic pancreatitis, and other causes of malabsorption.

Then we have rheumatological conditions like rheumatoid arthritis and other inflammatory arthropathies as well as haematological diseases such as multiple myeloma, and haemoglobinopathies.

And finally we have respiratory conditions like cystic fibrosis and COPD and other conditions like CKD and immobility due to neurological disease or injury.

We should not routinely assess fracture risk in people under the age of 50 unless they have major risk factors — such as current or recent glucocorticoid use, untreated premature menopause, or a previous fragility fracture — because they are unlikely to be at high risk.

Now, how should we actually assess the risk of fracture?

We can use either FRAX — which we can use without a bone mineral density (BMD) value if a DXA scan hasn’t been done — or QFracture, to estimate the ten-year absolute risk. FRAX can be used for people aged 40 to 90, with or without a bone mineral density (BMD) value. QFracture can be used for people aged 30 to 84, but a bone mineral density (BMD) value cannot be added into that tool. If someone is older than the age range covered by these tools, we should assume they are at high risk.

Additionally. we should interpret fracture-risk estimates with caution in people over 80, because a ten-year prediction may underestimate their short-term risk.

We should not routinely measure bone mineral density with a DXA scan before doing a FRAX or QFracture assessment. These tools estimate a ten-year fracture risk using simple clinical information and help us decide whether a scan is actually needed.

Skipping this step can lead to unnecessary DXA scans in people who are clearly low risk. It can also lead to missed scans in those whose risk is borderline, and it is therefore an inefficient use of resources.

We only need to measure bone density when the FRAX or QFracture score is close to the intervention threshold, where a DXA result could change the treatment decision.

So, the NICE guideline recommends using FRAX or QFracture first, and then requesting a DXA scan only if it is likely to influence management. If we do a DXA scan, once we have the bone mineral density result, we should recalculate the absolute risk using FRAX with the bone mineral density value included.

The intervention threshold is the level of risk at which treatment is recommended. The NICE guideline does not define that threshold; instead, we, as clinicians, should follow local protocols or national guidance. I will cover this in a different episode on osteoporosis treatment.

We should also consider measuring BMD before starting treatments that can rapidly reduce bone density, such as sex-hormone deprivation therapy for breast or prostate cancer.

People under 40 should have BMD measured to assess fracture risk only if they have a major risk factor, such as multiple fragility fractures, a major osteoporotic fracture, or current or recent use of high-dose oral or systemic glucocorticoids — meaning more than 7.5 milligrams of prednisolone, or equivalent, per day for three months or longer.

We should consider recalculating fracture risk in the future if the original risk was close to the intervention threshold and only after at least two years, or if the person’s risk factors change. Again, for intervention thresholds we will need to follow local protocols or national guidelines.

We should also remember that risk-assessment tools can underestimate fracture risk in certain situations. This includes people with multiple fractures, previous vertebral fractures, high alcohol intake, high-dose glucocorticoid use, or other causes of secondary osteoporosis.

As mentioned earlier, causes of secondary osteoporosis include endocrine, gastrointestinal, rheumatological, haematological, respiratory, metabolic, renal, and neurological conditions, as well as prolonged immobility.

Finally, we should keep in mind that fracture risk can also be affected by factors not included in the risk tools — for example, living in a care home, or taking drugs that impair bone metabolism, such as anticonvulsants, SSRIs, thiazolidinediones, proton-pump inhibitors, and antiretroviral medications.

So that is it, a review of the NICE guideline on osteoporosis.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.