Title:Prevention, Diagnosis and Treatment of Osteoporosis Stell
Description:
Prevention, Diagnosis and Treatment of Osteoporosis Stella Hayes, MD CDR MC USN Geriatric Fellow East Carolina University (Home of the Pirates aaarrrgh) – PowerPoint PPT presentation
Title: Prevention, Diagnosis and Treatment of Osteoporosis Stell
1 Prevention Diagnosis and Treatment of Osteoporosis
Stella Hayes MD
CDR MC USN
Geriatric Fellow
East Carolina University
(Home of the Pirates aaarrrgh)
hayess_at_ecu.edu
Special thanks to Irene Hamrick MD Geriatric Division Family Medicine Department Brody School of Medicine at ECU
2 Objectives
Outline prevalence and cost of Osteoporosis
Discuss preventive measures
Learn whom to screen or test and how
Review treatment options
3 Osteoporosis Epidemic
Osteoporosis is a serious worldwide and growing health problem.
More than 75 million people in Japan Europe and the U.S. have osteoporosis.
4 Osteoporosis Incidence
50 over 80 yo have osteoporosis
Kanis et al. J Bone Miner Res 1994 91139
50 lifetime osteoporosis risk for women
http//www.nof.org/osteoporosis/stats.htm
The World Health Organization defines osteoporosis as having a T score of less than -2.5.
5 Thinning bones(Its just a matter of time.)
BMD decreases with age.
Osteoporosis (BMD lt -2.5 SD) increases with age
Kanis Melton Christiansen. Perspective The diagnosis of osteoporosis. J Bone Miner Res 1994 91139 6 Kassem Melton Riggs. Involutional osteoporosis. In Feldman Kelsay (eds) 1996. Osteoporosis. New York Academic Press pp 691-702 7 Broken bones cost a bundle
40000 per hip fracture
Osteoporosis International 19988(Supplement4)S7- 80
17 billion osteoporosis
7.5 billion congestive heart failure
6.2 billion asthma
Epstein S Goodman GR. Menopause 19996242-250
8 Osteoporotic Fractures Compared to Other Diseases National Osteoporosis Foundation 2002. Available at http//www.nof.org American Heart Association. Heart Stroke Facts1999 Statistical Suppl. American Cancer Society. Breast Cancer Facts Figures 1999-2000. 9 Osteoporotic fractures on the rise
US AHRQ Report (Agency for Health Research and Quality)
Hip other osteoporotic Fx increased by 55
55 per 100000 people in 1995
85 per 100000 people in 2006.
http//www.ahrq.gov/news/nn/nn071709.htm
(One more danger of the Silver Tsunami!)
10 Why are rates of Osteoporosis increasing
We are living longer
More illnesses and medications
Soda caffeine alcohol tobacco salt
Decreased Ca Vit D and exercise
11 Why are rates of Osteoporosis increasing
Soda caffeine alcohol tobacco salt
Decreased Ca Vit D and exercise
Modifiable Risk Factors 12 How we weaken our bones
Caffeine- Increased urinary Ca excretion for 1-3 hrs
Alcohol- Decreases osteoblast activity
Sodium- gt2 g/d increases Ca excretion
Tobacco- Decreases estradiol
Inadequate Ca and/or Vit D
Inadequate exercise
Use it or lose it
13 Preventing Osteoporosis
Pay attention to your modifiable risk factors mainly what you put in your mouth!
Anyone not taking in adequate dietary Calcium and Vitamin D should get supplements
27 (No Transcript) 28 (No Transcript) 29 QUS vs. DEXA
Pro
Cheap (40 vs. 135)
No ionizing radiation
Readily available
Hip Fx correlation
(Bauer 1997 Hans 1996)
Good for high or low BMD
Sensitivity 94.1 Specificity 60.6
Con
Poor correlation with DEXA
(Krestan 2001 Nayak 2006)
Poor Precision
Over time
Between machines
(Cummings 2002)
Still need to get DEXA for most results
Medicare pays only for 1 screening test q 2 years
30 Summary of Testing
Scan all women gt65
And other high risk women
Scan every 2 years
Less frequent if stable
More frequent if changes anticipated
Use DEXA
Hip and spine lt70yo
Hip and forearm gt70yo
Use T-score
Osteoporosis lt2.5
Osteopenia/Low Bone Density lt-1.0- gt-2.5
31 Primary vs. Secondary Osteoporosis
Women
Primary osteoporosis
70-90
Secondary osteoporosis
10-30
Men
Primary osteoporosis
36-50
Secondary osteoporosis
50-64
Stein E Shane E. 2003 Metabolism Clinics of North America 32115-34 32 Causes of Secondary Osteoporosis
Tobacco
Excess alcohol
Vitamin deficiencies
Vit D B12 Vit K
Medications
Anticonvulsants
Steroids gt5mg/d for
gt6 months
Diseases
Rheumatoid or other inflammatory arthritis
Multiple myeloma lymphoma
Hyperthyroidism
Hyperparathyroidism
33 Tests to consider to r/o secondary osteoporosis
25-Hydroxy-Vitamin D3 Vit B12
TSH
PTH
Testosterone (in men)
Serum and urine Calcium
Phosphate Cr LFTs
CBC
34 Treatments- Medications
Anabolic Agents
Parathyroid hormone
Sodium flouride
Growth hormone
Insulin-like growth factor-1
Statins
RANK-L Denosumab
Antiresorptives
Estrogens
Selective estrogen receptor modulators
Bisphosphonates
Calcitonin
Others Calcium Vitamin D 35 Bisphosphonates
Binds to bone
Inhibits osteoclast activity
Supports osteoblast bone formation
First line treatment for osteoporosis
36 Bisphophonates Block Bone Resorption Inhibits osteoclasts. Binds to bone 37 Bisphosphonates
Alendronate (Fosamax) generic
Risedronate (Actonel) better GI profile
Ibandronate (Boniva) no hip protection
Zoledronic Acid (Reclast) once a year
38 Unusual Complicationsof Bisphosphonates
Osteonecrosis of jaw-
Rare 1/100000 patient years
94 in cancer patients receiving zoledronic acid or pamidronate
Woo S-B et al. 2006 Ann Int Med 144(10)753-61
Unusual Fx in some patients with nl BMD
Neviaser AS et al. 2008 Journal of Orthopaedic Trauma 22(5) 346-350
Lenart et al. 2008 NJEM 358 (12) 1304
39 (No Transcript) 40 Estrogen
ERT increases BMD and reduced bone markers more than SERM
Prestwood KM et al. J Clin Enodocrinol Metab. 2000 85(6) 2197-2202
WHI raised concerns about CV risks
E2 still approved for hot flashes
Low-dose ERT at menopause will delay bone thinning (but not recommended as first-line therapy)
41 Selective Estrogen Receptor Blocker (SERM)
Raloxifene (Evista) preferentially binds to the alpha estrogen receptor
fewer estrogen breast cancers
fewer vertebral fractures
more venous thromboembolism
more fatal stroke
No difference in coronary deaths
No difference in hip fractures
RUTH trial Barrett-Connor et al. 2006 NEJM 355(2)125-37
42 Calcitonin
Calcitonin is effective for osteoporosis fracture pain. Effect takes about 2 weeks.
Silverman SL. Osteoporos Int. Nov 200213(11)858-867.
No significant effect in the hip
Cost
Miacalcin 112
Fortical 54
43 Parathyroid Hormone (PTH)
Forteo (Teriparatide)
Daily 20mg or 0.08ml SQ injection
PTH draws Ca out of cortical bone
Hip 50 cortical bone
Spine 10 cortical bone
Intermittent antiresorptive effect
Preferential osteoblastgtosteoclast activity
Weak evidence for hip Fx
ACP Practice Guideline. Ann Int Med 2008149404-415
44 Parathyroid Hormone (PTH)
Forteo (Teriparatide)
Approved for use of lt2 years
Neer RM et al. NEJM 2001344(19)1434-41
Do not use in combination with bisphosphoonate- Black et. al. N Engl J Med 2003349(13)1207-15
Increases BMD 6
Not very effective for preventing fractures
Risk of osteosarcoma in animal trials
45 Denosumab - new kid on the block (Brand name Prolia)
Denosumab (formerly AMG-162)
Monoclonal antibody
Inhibits bone resorption by blocking
KB-ligand (RANKL)
Bekker et al. 2004 J Bone Miner Res 191059-66
Injected twice yearly
Expensive 1650 per year
Effect on immune system
46 Summary of Medications
Bisphosphonates- First line therapy
Boniva no hip benefit
Must have GFR gt 30
Calcitonin only for spine good for pain
Estrogen good for osteoporosis
SERM need long term data only spine
PTH lt2 yrs not in combination
Denosumab monoclonal antibody 2x/yr
47 Balloon Kyphoplasty
Stabilizes the Fracture and Corrects Spinal Deformity caused by one or more VCFs
Indicated for vertebral compression fracture if pain not controlled with meds 48 Conclusion
Osteoporosis is a growing epidemic
Save yourselves! Preach prevention!
Test all women over 65 and others at risk for osteoporosis (DEXA)
Treat all elderly and patients at risk with Calcium and Vitamin D
Dont be afraid of bisphosphonates
49 Case 1 - Lilly
52 year old Caucasian Female
Hot flashes
No hx fx no height loss
Average height and weight
No FHx of osteoporosis
T-score -1.8 at LS -1.5 fem neck
50 Case 1 Lilly (cont)
What is Lillys diagnosis
What should we do for sure
What could we do for good measure
51 Case 1 Lilly (cont)
Lilly has low BMD (old term osteopenia)
Calcium and Vit D
Exercise
Tx can reduce bone loss but not fracture NNT 2000
ERT (0.625mg) can use for hot flashes. Or use low-dose i.e. 0.3mg (be sure to add progesterone if uterus intact)
52 Case 2 Ms. Greer
Mrs. Greer is a 68 yo AAF on HRT since menopause.
Wants to stop HRT d/t WHI study.
Does not take Ca or Vit D.
Lost 2 inches in height. Fx forearm 2 yrs ago.
T-score spine -2.0 hip -2.2
53 Case 2 Ms. Greer (cont.)
What labs should we get
How should we treat her bones
When should we recheck her BMD
54 Case 2 Ms. Greer (cont.)
Labs TSH 25-hydroxyvitamin D PTH 24-h urinary calcium were normal
Start calcium 1200mg Vit D 800 IU
Bisphosphonate Alendronate 70 mg once a week.
Recheck BMD in 2 years
55 Case 3 Mrs. Pickens
80 yo frail community-dwelling CF lives alone
No hx fx but has fallen 3 x in 1 yr
Takes 1000mg Ca in AMs plus MVI
Stays out of the sun d/t fear of skin Ca and wrinkles
Walks very little d/t fear of falling
T-score -2.8 at hip -2.0 at spine
GERD controlled on PPI
HTN controlled on beta blocker
What shall we do for Mrs. Pickens
56 Mrs. Pickens (cont.)
Falls risk assessment
Meds (hypotension)
Home assessment
Strength training exercises
Eval for secondary causes of osteoporosis
Vit D 8
How will you treat her Vit D
57 Mrs. Pickens (cont.)
Anti-osteoporosis medications
Which med(s) would you chose
Bisphoshphonates
PTH
HRT
Raloxifene
Hip protectors
58 Mrs. Pickens (cont.)
10/yr hip fx risk so focus on meds that reduce hip fx
Bisphoshphonates OK if GERD controlled and GFR gt 30 (Reclast if esophagus problem)
PTH second best choice - daily SQ injection
Denosumab (Plolia) candidate
HRT risky for CV EM
Raloxifene not shown to reduce hip fx (only vertebral) Increased risk of DVT stop it for periods of inactivity.
59 Mrs. Pickens (cont.)
Vit D 50000 IU ergocalciferol per week for 12 weeks
Risondronate 35mg once a week
Physical Therapy
Hip protectors
60 Hip Protectors
Benefit of hip protectors on fracture when worn
Rubenstein L. NEJM 2000 343(21)1562-3
No benefit of hip protectors intention to treat analysis
Cummings P and Weiss NS. JAMA 2003 290(7)884
No benefit with 80 adherence
Kiel DP et al. JAMA 2007 298(4)413-22
Cochrane review of 11 studies Marginally statistically significant reduction in hip fractures
Parker MJ et al. BMJ 2006332(7541)571-4
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