P195 Outcome of blood analysis and spinal radiology secondary marker assessments of osteoporosis (OP) patients seen in the bone health service in a large urban London borough
Authors: Rajak Rizwan , Mahendrakar Suma , Perren Amanda , Zaman Momina 
Published: April 2020

Background

Almost all national/international OP management guidelines emphasise the importance of ruling out ‘secondary markers’ of OP, that is, biochemical, haematological, serological and hormonal blood anomalies that might indicate underlying undetected diagnoses that might contribute to bone loss and/or fracture risk. Moreover, these assessments may identify sub-optimally controlled established diagnoses. Identifying vertebral fragility fractures (VFFs) at baseline/initial review is scarcely undertaken despite numerous studies that indicate the predictive capacity of the high risk of fractures at any site conferred by the presence of moderate-to-severe VFFs. There is little in the literature on rates of 'secondary marker' anomalies and VFFs at initial review appointments in OP clinics, the data of which is essential to understand when developing OP services and management pathways. We assessed the rates of blood test abnormalities and VFFs in OP patients seen at the bone health clinic, Croydon Health Services NHS Trust.

Methods

We conducted a retrospective review of OP patients seen between February-June 2018 at Purley Memorial Hospital. We assessed the results of secondary markers of OP blood tests: FBC, U&Es, LFTs, ESR, CRP, TFTs, HbA1c/fasting glucose, immunoglobulins, electrophoresis, coeliac antibodies, vitamin-D, calcium, phosphate, alkaline phosphatase, PTH, vitamin-B12, folate and ferritin and when required testosterone, FSH, LH, magnesium, cortisol, urinary calcium and urinary paraproteins. We also reviewed for the presence of moderate-to-severe VFFs using thoracolumbar spine X-rays (Ghent classification).

Results

201 patients were included. Mean age was 70 years (range:37-96), with approximately 9:1 female:male ratio. 45% (90/201) had blood test abnormalities on secondary marker testing identifying new diagnoses: 5% had coeliac antibodies, 3% hypercalcaemia & hyperparathyroidism, 3% hypothyroidism, 2% haematological disorders (3 MGUS and 1 myeloma), 30% (6/21 male cohort) had testosterone deficiency, 20% vitamin-D deficiency, 12% had either vitamin-B12, folate or ferritin deficiency. Of the 18% with pre-existing thyroid-disorders, a third of these patients were not euthyroid. 30% (29/90) of patients with blood abnormalities had multiple anomalous results. In total, 48% (96/201) patients were identified with moderate-to-severe VFFs; 71% (68/96) of these had either more VFFs than previously known by the patient/referrer (35%) or -the majority- had newly identified VFFs (65%).

Conclusion

Just under half-of-subjects had blood test anomalies indicating previously unknown diagnoses that could lead to bone loss and increased fracture risk if left unaddressed. Almost 1/3 of these had multiple abnormalities increasing their risk even further. The commonest diagnoses included endocrinopathies (especially hypothyroidism), vitamin deficiencies (especially vitamin D), coeliac disease and haematological disorders. Given the incidences of these issues, it is essential that OP services undertake thorough 'secondary marker' investigations to identify and improve the overall management of OP patients. Furthermore, there was a high rate of VFFs (48%) with almost half of these patients being newly identified at the clinic and 25% having had more VFFs than previously known. Therefore, 1/3 of the whole cohort had previously unknown moderate-to-severe VFFs. This clearly indicates that VFFs are being underdiagnosed in OP patients despite the important prognostic and predictive value that the presence of VFFs confer when assessing patients' fracture risk.

Disclosures

R. Rajak Honoraria; Speaker fees from Roche, Eli Lilly, Amgen, Internis. Chair fees Roche, Eli Lilly, Norvartis, Abbvie, UCB. S. Mahendrakar None. A. Perren None. M. Zaman None.