Special Considerations in Management of the Osteoporosis Fracture Patient

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Special Considerations in Management of the
Osteoporosis Fracture Patient
Steven A. Olson, MD Duke University

• Slides adapted from Susan V. Bukata, MD

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• As Orthopaedic Surgeons we take care of a large
  number of people with undiagnosed osteopenia and
  osteoporosis

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Why Is This Important?

• Osteoporosis affects 45 of women aged 50 and
  older
• Osteoporotic fractures are 4 X more common than
  stroke
• Annual hip fractures
• US gt300,000
• Europe gt400,000
• Incidence expected to double over the next 50 yrs

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Osteoporosis Fracture Incidence vs. Heart
Attack, Stroke, Breast Cancer
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Why Is This Important?

• Osteoporotic fractures pose a lifetime risk of
  death comparable to breast cancer
• Cummings, Archives of Internal Medicine (1989)
• Osteoporotic fractures are a major risk factor
  for subsequent fractures
• 10 - another fragility fracture within 1 yr
• 17-21 - another fragility fracture within 2 yrs

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What Should We Do?

• Care for their fracture
• Make sure these patients receive care for their
  osteoporosis
• Reinforce good bone health habits in our younger
  patients

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How are we doing?

• Hip fractures
• Excellent job of orthopaedic surgical care
• Inadequate job of treating underlying disease
• Fractures are undertreated medically
• Patients discharged without diagnosis or
  management of underlying osteoporosis
• Assumption that primary MD is responsible
• Poor communication with PCP - Patients remain
  untreated

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How are we doing?

• Average initiation of osteoporosis treatment
  after a fragility fracture 11-16
• Intervention programs improved to 30-45
• WHAT ABOUT THE REST OF THE PATIENTS?

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Osteoporosis Defined
A metabolic bone disease characterized by low
bone mass and microarchitectural deterioration of
bone tissue leading to enhanced bone fragility
and a consequent increase in fracture risk
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Osteoporosis Diagnosis

• DXA
• gold standard
• Low radiation exposure
• Ultrasound
• May be a good tool for preliminary screening
• Only evaluate sucutaneous bones
• Fracture risk at hip/spine not correlate (only
  70)
• QCT
• More radiation, less precise
• assess both trabecular and cortical areas

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DXA Scan

• T score (This is the important one!)
• Compares density relative to peak bone mass
  (Normal healthy 25 year old)
• Matched to sex and race
• Z score
• Compares density to peers

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WHO Definitions

• Bone mass measured at hip and spine
• 1 to 2.4 Std deviations below peak bone mass
• Osteopenic (Low bone density)/ mild to moderate
  bone deficiency
• gt 2.5 Std deviations below peak mass (T score)
• Osteoporotic
• Fragility fracture
• -- osteoporosis regardless of T-score

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High Turnover Osteoporosis

• High Turnover (big bone losers)
• primary form at menopause
• enhanced osteoclastic bone resorption
  osteoblasts unable to replace resorbed bone
• bone loss rate
• 2-3 per year
• lasting 6-10 years
• avg age natural menopause 51

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Low Turnover Osteoporosis

• Low Turnover (bad bone formers)
• most commonly seen in elderly
• individuals with underlying genetic collagen
  disease
• osteoclastic bone resorption normal or slightly
  decreased
• failure of osteoblasts to form bone
• bone formation markers decreased levels

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OSTEOPOROSIS RISK FACTORSINDEPENDENT OF BONE MASS

• LOW BODY WEIGHT (127 pounds)
• RECENT LOSS OF BODY WEIGHT(gt10)
• PERSONAL HX OF FRAGILITY Fx
• MATERNAL HX OF FRAGILITY Fx
• SMOKING

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What is a fragility fracture?

• Fracture that occurs with low energy
• Fall from standing height or less

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So what do I do if I think my patient might have
a fragility fracture?

• DXA scan for bone density
• Endocrine/Medicine Consult
• Labs
• Intact PTH
• 25 vit D level, 1,25 vit D level
• serum calcium, 24 hour urinary calcium
• serum alkaline phosphatase
• urine N-telopeptide
• TSH

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Why order these things?

• One third of patients will have another metabolic
  disorder that is damaging the bone
• Hyperthyroid/Hypothyroid
• Hyperparathyroid (primary or secondary)
• Renal calcium leak
• Undiagnosed kidney disease
• Cancer

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Osteomalacia

• Total amount bone normal,
• mineralization inadequate
• True deficiency cause 4-8 hip fractures in US
• Nutritional deficiency more common (Ca/Vit D)
• inadequate intake
• impaired hepatic/renal hydroxylation
• intestinal malabsorption
• lack of sunlight (activate Vit D)

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THE 25(OH)D CONTINUUM
20
0
10
60
30
40
50
(ng/ml)
(ng/mL)
50
0
25
150
75
100
125
(nmol/L)

modified after Heaney
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Osteoporosis Treatment Principles

• Prevention is most important
• Attainment of peak bone mass (age 20-30)
• Prevention of postmenopausal resorption and age
  related bone loss
• Calcium and Vitamin D
• Bisphosphonates
• Calcitonin
• PTH

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DAILY CALCIUM REQUIREMENTS

• CHILD 700 mg
• TEEN - YOUNG ADULT 1300 mg
• ADULT 800 mg
• PREGNANCY 1500 mg
• LACTATION 2000 mg
• POST MENOPAUSAL 1500 mg
• MAJOR FRACTURE 1500 mg

Almost all individuals regardless of age wind up
short of required calcium intake
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DRUGS WHICH DECREASE CALCIUM RETENTION

• CORTICOSTEROIDS
• FUROSEMIDE
• HEPARIN
• CAFFEINE?
• NICOTINE
• LUPRON

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Calcium sources

• Milk (8oz, skim) 302mg
• Nonfat yogurt (8 oz) 452mg
• Frozen yogurt (1/2 cup) 90mg
• Cottage cheese (1 cup) 155mg
• Collard greens (1 cup) 357mg
• Broccoli (1 cup) 178mg
• Cheese pizza (1 slice) 290mg
• Vanilla ice cream (1/2 cup) 85mg
• Calcium fortified orange juice
• (1 cup) 300mg

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Calcium Supplements

• Calcium carbonate (Oscal, TUMS)
• Needs acid environment to dissolve
• Beware elderly
• Beware H2 blockers
• Calcium citrate (Citrical)
• Dissolves in absence of acid
• Beware if history of citrate kidney stones (lt10
  of all kidney stones)

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Bisphosphonates

• Mode of action
• binds to surface of hydroxyapatite crystals
• Inhibits activity of osteoclasts
• Not metabolized
• excreted in urine intact
• Long half life
• est 6-10 years in bone
• 21 to 180 days in circulation

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Bisphosphonates

• Oral medications
• Alendronate (Fosamax)
• Risedronate (Actonel)
• Ibandronate (Boniva)
• Bone density gains for at least 4 years
• 2 to 4 /yr for spine
• 1 to 2 /yr for hip
• Gains due to more mineralization not actually
  gain in bone quantity

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Bisphosphonates

• IV forms
• (Pamidronate, zolendronate, ibandronate)
• Comparable bone mass accretion
• Longer dosing intervals (3-12 months)
• Options when oral bisphosphonates not well
  tolerated

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Zoledronic Acid and Clinical Fractures and
Mortality after Hip Fracture Kenneth W. Lyles,
M.D., Cathleen S. Colón-Emeric, M.D., M.H.Sc.,
Jay S. Magaziner, Ph.D., Jonathan D. Adachi,
M.D., Carl F. Pieper, D.P.H., Carlos Mautalen,
M.D., Lars Hyldstrup, M.D., D.M.Sc., Chris
Recknor, M.D., Lars Nordsletten, M.D., Ph.D.,
Kathy A. Moore, R.N., Catherine Lavecchia, M.S.,
Jie Zhang, Ph.D., Peter Mesenbrink, Ph.D.,
Patricia K. Hodgson, B.A., Ken Abrams, M.D., John
J. Orloff, M.D., Zebulun Horowitz, M.D., Erik
Fink Eriksen, M.D., D.M.Sc., Steven Boonen, M.D.,
Ph.D., for the HORIZON Recurrent Fracture Trial
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• Methods In this randomized, double-blind,
  placebo-controlled trial, 1065 patients were
  assigned to receive yearly intravenous zoledronic
  acid (at a dose of 5 mg), and 1062 patients were
  assigned to receive placebo. The infusions were
  first administered within 90 days after surgical
  repair of a hip fracture. All patients (mean age,
  74.5 years) received supplemental vitamin D and
  calcium. The median follow-up was 1.9 years. The
  primary end point was a new clinical fracture.
• Results The rates of any new clinical fracture
  were 8.6 in the zoledronic acid group and 13.9
  in the placebo group, a 35 risk reduction with
  zoledronic acid (P0.001)
• In the safety analysis, 101 of 1054 patients in
  the zoledronic acid group (9.6) and 141 of 1057
  patients in the placebo group (13.3) died, a
  reduction of 28 in deaths from any cause in the
  zoledronic acid group (P0.01)..

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Calcitonin(Miacalcin)

• Non-sex / non-steroid hormone
• Dose 200 units/day sprayed in alternate nostrils
• Binds to osteoclasts
• decrease activity/number
• Analgesic effect with painful vertebral fractures
• Effective at spine
• No effect on hip fractures

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PTH

• First approved therapy that actually builds
  significant bone (anabolic agent)
• Daily low dose injections increase bone mass in
  animals and humans
• Both cortical and trabecular
• Increase life span of osteoblasts
• reducing apoptosis

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PTH

• General Indications
• Bone mass decline on bisphosphonates
• Fracture on bisphosphonates
• Steady state lt-3.5SD
• Low turnover osteoporosis
• Premenopausal women
• Men

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PTH

• Forteo is amino acids 1-34 of PTH
• Dose is 20 mcg daily for 2-3 years
• Spine BMD increases at 6-12 months
• Hip BMD increases delayed as much as 18-24 months
• Follow therapy with bisphosphonates
• Contraindications include
• previous radiation therapy
• Pagets disease
• very young patients(open growth plates)

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• As Orthopaedic Surgeons we take care of a large
  number of people with undiagnosed osteopenia and
  osteoporosis

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Summary

• Make sure fragility patients are started on
  calcium and vitamin D supplements
• Communicate with PMD regarding fragility fracture
  and need for treatment for disease
• Fragility fractures in patients already on
  therapy may require a change in treatment course
  and medication choice