Prevention, Diagnosis and Treatment of Osteoporosis

Prevention, Diagnosis and Treatment of Osteoporosis PowerPoint PPT Presentation

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Objectives. Outline prevalence and cost of OsteoporosisDiscuss preventive measuresLearn whom to screen or test and howReview treatment options . Osteoporosis Epidemic. Osteoporosis is a serious, worldwide, and growing health problem. More than 75 million people in Japan, Europe and the U.S. hav

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Prevention, Diagnosis and Treatment of Osteoporosis

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1. Prevention, Diagnosis and Treatment of Osteoporosis Stella Hayes, MD CDR MC USN Geriatric Fellow East Carolina University (Home of the Pirates – aaarrrgh) [email protected] 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; 9:1139 50% lifetime osteoporosis risk for women The World Health Organization defines osteoporosis as having a T score of less than -2.5.

5. Thinning bones (It’s just a matter of time.)

7. Broken bones cost a bundle $40,000 per hip fracture Osteoporosis International 1998;8(Supplement4):S7-80 $17 billion osteoporosis $7.5 billion congestive heart failure $6.2 billion asthma Epstein S, Goodman GR. Menopause 1999;6:242-250

8. Osteoporotic Fractures Compared to Other Diseases

9. Osteoporotic fractures on the rise US AHRQ Report (Agency for Health Research and Quality) Hip & other osteoporotic Fx increased by 55% 55 per 100,000 people in 1995; 85 per 100,000 people in 2006. (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

12. How we weaken our bones… Caffeine- Increased urinary Ca excretion for 1-3 hrs Alcohol- Decreases osteoblast activity Sodium- >2 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 Dairy Fortified juice or soy milk Adequate calcium intake Lowers risk of kidney stone

14. Calcium Recommended Intake

15. Calcium Absorption Absorption 6-20% Food improves absorption by 20-25% Heaney, RP et al. Am J Clin Nutr. 1989; 49(2): 372-6 Low stomach acid reduces absorption (Long term use of PPI correlated to low BMD) Only a small amount can be absorbed at one time, so more frequent intake is better

16. Calcium supplements

17. Vitamin D & Calcium Supplements

18. Vitamin D

19. Positive Effects of Vit D Increases Calcium absorption Strengthens Bones Reduces Falls - Increases muscle function, decreases muscle pain, and reduces body sway. Bischoff-Ferrari 2004 JAMA 291;16:1999-2006 Glerup H, et al. 2000 J Int Med 247:260-8 Reduces Fractures As effective as Alendronate in cardiac transplant patients Alendronate 10 mg vs. Calcitriol 0.5 mcg daily Shane E, et al. N Engl J Med. Feb 19 2004;350(8):767-776

20. Vitamin D Requirements increase with age 600 IU <70 yo 800 IU >70 yo IOM report 11/30/2010 In Osteoporosis give 1,000 IU daily

21. Exercise Back strengthening exercise lead to fewer vertebral fractures over 10 years 1.6% in exercising group 4.3% in control group Sinaki M, et al. Bone 2002;30:836-841 Increased spine BMD over 9 months 3.5% vs. 1.5% Villareal DT, et al. JAGS 2003;51(7):985-90 Kemmler W, et al. Arch Int Med 2004;164(10):1084-91

22. Summary Break Osteoporosis is a growing epidemic Prevention through lifestyle modification is important Calcium and vitamin D are key Exercise

23. Whom to Test United States Preventive Services Task Force (USPSTF) Recommendation All women over 65 Women over 60 with risk factors There are multiple risk factors Low body weight, <70 kg (154 lb) is the single best predictor of low BMD (2002)

24. Risk Factors Age Self-reported health Height Weight Hx of fracture after the age of 55 years Race/ethnicity Poor exercise Smoking Hx of parental fracture after the age of 40 years Diabetes treated with medications Rheumatoid Arthritis Corticosteroid use

26. DEXA Measures x-ray absorbed by calcium in bone Reported as T-score: Compares with cohort of young adult Caucasian female BMD Z-score: Age matched Gold standard Sensitivity = 95% Specificity = 68%

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 >65 And other high risk women Scan every 2 years? Less frequent if stable More frequent if changes anticipated Use DEXA Hip and spine <70yo Hip and forearm >70yo Use T-score Osteoporosis <–2.5 Osteopenia/Low Bone Density <-1.0- >-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%

32. Causes of Secondary Osteoporosis Tobacco Excess alcohol Vitamin deficiencies Vit D, B12, Vit K Medications Anticonvulsants Steroids >5mg/d for >6 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

35. Bisphosphonates Binds to bone Inhibits osteoclast activity Supports osteoblast bone formation First line treatment for osteoporosis

36. Bisphophonates Block Bone Resorption

37. Bisphosphonates Alendronate (Fosamax) generic Risedronate (Actonel) better GI profile Ibandronate (Boniva) no hip protection Zoledronic Acid (Reclast) once a year

38. Unusual Complications of Bisphosphonates Osteonecrosis of jaw- Rare 1/100,000 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

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) MORE trial 7705 women mean age 66.MORE trial 7705 women mean age 66.

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 2002;13(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 osteoblast>osteoclast activity Weak evidence for hip Fx ACP Practice Guideline. Ann Int Med 2008;149:404-415

44. Parathyroid Hormone (PTH) Forteo (Teriparatide) Approved for use of <2 years Neer, RM et al. NEJM 2001;344(19):1434-41 Do not use in combination with bisphosphoonate- Black et. al. N Engl J Med 2003;349(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 19:1059-66 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 > 30 Calcitonin only for spine, good for pain Estrogen good for osteoporosis SERM need long term data, only spine PTH <2 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 Balloon kyphoplasty is a minimally invasive option which addresses both the deformity and pain by stabilizing the fracture and helping to correct the vertebral body deformity. Balloon kyphoplasty is a minimally invasive option which addresses both the deformity and pain by stabilizing the fracture and helping to correct the vertebral body deformity.

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 Don’t 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 Lilly’s 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 > 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 50,000 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 2006;332(7541):571-4

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