OSTEOPOROSIS Prevention, Diagnosis, and Treatment Melanie Barron, DO, FACOI Rheumatology Fellow UNTH

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OSTEOPOROSIS Prevention, Diagnosis, and
TreatmentMelanie Barron, DO, FACOIRheumatology
FellowUNTHSC/Plaza Medical Center
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Introduction

• 10 million Americans have osteoporosis (8 million
  women, 2 million men).
• Another 34 million have osteopenia of the hip.
• 1.5 million fragility fractures occur annually in
  the US.
• Hip fractures cause significant morbidity and
  mortality.

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Change in Age Distribution Over a Decade
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2001
2006
2011
10
8
6
Million
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2
0
5054
5559
6064
6569
7074
7579
8084
85
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ONE IN TWO CAUCASIAN WOMENandONE IN FIVE
MENwill have an osteoporosis-related fracture
in his/her lifetime.
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• The annual incidence of osteoporosis-related
  fractures in women is greater than the incidence
  of MI, CVA, and breast cancer combined.

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Lifetime Probability of Hip Fracture at age 50 ()
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Hip Fractures Patient Outcomes

• 10-25 die within one year.
• 25-30 require long-term nursing home care.
• 15 regain limited function.
• Only 20-40 return to pre-fracture level of
  independence.
• Men tend to have poorer outcomes.

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Direct Cost Estimate for Treatment of
Osteoporotic Fractures

• 18 Billion Dollars/Year in 2005
• Due to our aging population, the Surgeon General
  estimates that the number of hip fractures and
  the associated costs will double to triple by
  2040.

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Risk Factors for Fractures

• Low Bone Mineral Density
• Falling

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Risk Factors for Low BMDNon-modifiable
Modifiable
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Women can lose 20 of their bone mass in the
first 5 years after menopause.
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Risk Factors for Falling

• Reduced physical function
• Slow gait
• Decreased quadriceps strength
• Impaired cognition
• Impaired vision
• Environmental hazards

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Secondary Osteoporosis

• Males 50
• Females 50 (pre and peri menopausal)

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Secondary Osteoporosis

• Genetic
• Hypogonadal
• Endocrine
• Gastrointestinal
• Hematologic
• Rheumatic disease
• Nutritional
• Chronic systemic disease
• Iatrogenic

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Secondary Osteoporosis in Men

• Hypogonadism
• Glucocorticoids
• Alcohol?

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Secondary Osteoporosis in Women

• Low estrogen states
• Glucocorticoids
• Thyroid hormone excess
• Anticonvulsants
• Heavy alcohol use

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Secondary Osteoporosis Oral Glucocorticoid
Induced

• 25 of cases of osteoporosis
• Up to 30 decrease in bone mineral density after
  6 months
• 400 increase in fractures at 7.5 mg/day
• No safe dose

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Secondary Osteoporosis Laboratory Testing

• CBC
• CMP
• TSH
• ESR or CRP
• 24 Hr. Urinary Calcium
• PTH
• SPEP/UPEP
• Testosterone
• 25OH - Vitamin D

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Most Important Determinant of Life-Long Skeletal
Health?
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Most Important Determinant of Life-Long Skeletal
Health?

• Bone mass attained early in life

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Childhood Dietary Recommendations
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What of Children Meet Dietary Recommendations?
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What of Children Meet Dietary Recommendations?

• 25 of boys
• 10 of girls

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What about adults?

• Calcium
• Under age 50 need 1,000 mg/day
• Age 50 need 1,200 mg/day
• Vitamin D
• Under age 50 need 400-800 IU/day
• Age 50 need 800-1,000 IU/day

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Exercise?

• Early contributes to higher peak bone mass
• Later reduce risk of falls by 25

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Who should be tested?

• All women 65 and older
• All men 70 and older
• Adults 50-70 with fractures or other risk factors

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Measuring Bone Mineral Density DEXA
Interpretation

• T-score
• (young/healthy)
• -1 to -2.5 osteopenia
• -2.5 osteoporosis
• Z-score
• (same age)
• FRAX risk (coming soon)

• Hip
• total score femoral neck
• Spine
• total score individual levels
• (more accurate in
• younger patients)

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FRAXwww.shef.ac.uk/FRAX

• Online fracture risk calculator
• Developed by WHO
• Gives 10-year probability of hip fracture and of
  major osteoporotic fracture
• Treatment recommended for osteopenic patients
  with 10-year hip fracture risk 3 or major
  osteoporotic fracture risk 20

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Who should be treated?

• Osteoporosis
• Osteopenia with
• -history of fracture
• -secondary causes that increase risk
• -10 year probability of hip fracture 3 or
• 10 year probability of major osteoporotic
• fracture 20 based on FRAX

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ManagementCorrect modifiable factors to reduce
risk of osteoporosis and fractures

• Smoking
• Alcohol
• Nutrition
• Medications

• Vision
• Fitness
• Cognition
• Hazards

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ManagementFracture Prevention and Treatment

• Non pharmacologic
• Physical therapy, home safety evaluation
• Surgical
• Vertebroplasty
• Kyphoplasty
• Hip

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Management Drugs

• Calcium and vitamin D
• Bisphosphonates
• HRT
• Raloxifene
• Calcitonin
• N 1-34 PTH (teriparatide, Forteo)

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Drug Differentiation
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Ibandronate(Boniva)

• 150mg monthly oral dose
• 3mg IV every 3 months
• Reduced spine fractures by 50 over three years

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Zoledronate(Reclast)

• Yearly 5mg IV infusion over gt15minutes
• Reduced spine fractures by 70, hip fractures by
  41 over 3 years
• Infusion reactions in 32 of patients with the
  first dose, 7 with the second dose, 3 with the
  third dose

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BisphosphonatesConcerns and Issues

• GI side effects
• Infusion reactions
• Osteonecrosis of the jaw
• Arrhythmias

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N 1-34 PTH (teriparatide)

• Female postmenopausal OP with high fracture
  risk
• Male - primary or hypogonadal OP with high
  fracture risk
• Decreased spine fractures by 65 and non-spine
  fracture by 53 after 18 months

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N 1-34 PTH (teriparatide)Concerns and Issues

• Black box warning osteosarcoma
• Contraindications Pagets disease,
  pregnant/nursing, pediatrics/young adults, prior
  radiation therapy, bone mets, skeletal
  malignancies, hypercalcemia
• Sequencing with bisphosphonates
• 2 years only

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Conclusions

• Osteoporosis is a major public health issue and
  will remain so, due to our aging population.
• Osteoporosis-related fractures create significant
  patient morbidity and mortality and also lead to
  tremendous healthcare expenditures.
• We have the opportunity to make a difference.

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Recommendations

• Encourage exercise across the lifespan
• Earlyto increase peak bone mass
• Laterto reduce falls
• Calcium and Vitamin D
• -Start early!

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Recommendations

• Screen for osteoporosis appropriately
• -All women 65 and older
• -All men 70 and older
• -Earlier if fractures or other risk factors
  (especially patients on steroids)
• Evaluate for secondary causes
• -Low Z scores are a red flag

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Recommendations

• Medicate to prevent and treat osteoporosis
• Address modifiable risk factors
• Adjuncts to prevent falls and fractures

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Resources

• NATIONAL OSTEOPOROSIS FOUNDATION
• 2008 Clinicians Guide to the Prevention and
  Treatment of Osteoporosis
• www.nof.org
• World Health Organization Fracture Risk
  Assessment Tool (FRAX)
• www.shef.ac.uk/FRAX

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Thank you!mbarron_at_hsc.unt.edu