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Radisson Hotel at Opryland Nashville, Tennessee May 31, 2008. 2008. Symposia Series 2. 1. Osteoporosis Update: Prevention, Diagnosis, and Treatment. Mary D. Knudtson, DNSc, NP Clinical Professor Department of Family Medicine University of California, Irvine Irvine, California.

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radisson hotel at opryland nashville tennessee may 31 2008
Radisson Hotel at Opryland

Nashville, Tennessee

May 31, 2008

2008

Symposia Series 2

1

osteoporosis update prevention diagnosis and treatment

Osteoporosis Update: Prevention, Diagnosis, and Treatment

Mary D. Knudtson, DNSc, NP

Clinical Professor

Department of Family Medicine

University of California, Irvine

Irvine, California

faculty disclosure
Faculty Disclosure
  • Dr Knudtson: consultant/speakers bureau: Procter & Gamble
how confident are you addressing modifiable risk factors for osteoporosis with your patients

0

How confident are you addressing modifiable risk factors for osteoporosis with your patients?
  • Very confident
  • Somewhat confident
  • Not at all confident

Use your keypad to vote now!

learning objectives
Learning Objectives
  • Assess the risk factors associated with osteoporosis
  • Manage osteoporosis in the context of comorbidities
  • Evaluate nonpharmacologic preventive approaches as well as the efficacy and safety of pharmacologic management
osteoporosis defined
Osteoporosis Defined
  • Osteoporosis, primary or secondary, is characterized by compromised bone strength predisposing to an increased risk of fracture
  • Osteoporosis = bone mineral density (BMD) ≤2.5 SD below young normal mean at hip or spine [WHO]

Bone density=grams of mineral/area, volume

Bone quality=architecture, turnover, damage accumulation, mineralization

Bone strength = density + quality

SD = standard deviation; WHO = World Health Organization.

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008; NIH Consensus Statement. 2000;17:1-45

prevalence of osteoporosis
Prevalence of Osteoporosis*

*Estimates based on 2000 census data.

Ebeling PR. N Engl J Med. 2008;358:1474-1482; National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

  • Osteoporosis is a major health threat in the United States
    • 10 million Americans have osteoporosis, 34 million are at risk
    • Osteoporosis disproportionately affects Caucasian and Asian women; other races/ethnicities are also significantly affected
    • Under-recognized problem in men
    • In men, involvement of all races and ethnicities is significant
  • In the United States, women and men aged ≥50 years
    • 55% have low bone mass
    • 8 million women and 2 million men have osteoporosis
    • 1 of 2 white women, 1 of 5 men will suffer an osteoporosis-related fracture
    • Asian Americans with osteoporosis have same fracture risk as white persons
which of the following best characterizes the burden of osteoporosis

0

Which of the following best characterizes the burden of osteoporosis?
  • Osteoporotic fractures are more common than MI, stroke, and breast cancer combined
  • Only MIs are more prevalent than osteoporotic fractures
  • Incidence of osteoporotic fractures is equal to that of MIs
  • None of the above

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MI = myocardial infarction.

osteoporotic fractures are more common than mi stroke and breast cancer combined

2,000,000

1,500,000*

1,500,000

250,000hip

250,000forearm

Annual incidence of Common Diseases

1,000,000

250,000 other sites

513,000†

500,000

228,000**

750,000 vertebral

184,300

0

Osteoporotic

MI

Stroke

Breast Cancer

Fractures

Osteoporotic Fractures Are More Common Than MI, Stroke, and Breast Cancer Combined

*Annual incidence all ages; †annual estimate women 29+; **annual estimate women 30+.

American Cancer Society. Cancer Facts and Figures: 2003. Available at: www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf. Accessed April 15, 2008; American Heart Association. Heart and Stroke Statistics: 2003 Update. Available at: www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf. Accessed April 15, 2008; Riggs BL, Melton LJ III. Bone. 1995;17(5 Suppl):505S-511S.

which of the following is a common cause of secondary osteoporosis

0

Which of the following is a common causeof secondary osteoporosis?
  • Proton pump inhibitors (PPIs)
  • Treatment for ulcerative colitis
  • Glucocorticoids
  • TNF-α receptor blockers and IL-1 receptor antagonists for the treatment of rheumatoid arthritis

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factors contributing to secondary osteoporosis
Factors Contributing to Secondary Osteoporosis

CHF = congestive heart failure; ESRD = end-stage renal disease; GI = gastrointestinal; MS = multiple sclerosis.

AACE Osteoporosis Task Force. Endocr Prac. 2001;7:293-312; National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 30, 2008.

glucocorticoid use and fracture risk
Glucocorticoid Use and Fracture Risk

6

All nonvertebral

5.18

Forearm

5

Hip

Vertebral

4

Relative Risk of Fracture

Compared With Control

3

2.59

2.27

1.77

2

1.64

1.55

1.36

1.19

1.17

1.1

1.04

0.99

1

0

n = 2192 531 236 191 2486 526 494 440 1665 273 328 400

Low Dose

Medium Dose

High Dose

(<2.5 mg/d)

(2.5-7.5 mg/d)

(>7.5 mg/d)

Van Staa TP, et al. J Bone Miner Res. 2000;15:993-1000.

pathophysiology of osteoporosis

Mineralization

Osteoid

Pathophysiology of Osteoporosis

Bone Remodeling

Activation

Resting

Resorption

Osteoclasts

Bone

Bone

Reversal

Formation

Osteoblasts

Bone

Bone

pathophysiology of osteoporosis14
Pathophysiology of Osteoporosis

Early menopausal bone loss

Inadequate peak bone mass

Low bone mass/

impaired bone quality

Decrease in bone mass/bone quality

Fractures

Calcium/

vitamin D deficiency

Trauma

Other

factors

changes in trabecular architecture
Changes in Trabecular Architecture
  • Decrease in trabecular thickness, more pronounced for non load-bearing horizontal trabeculae
  • Decrease in connections between horizontal trabeculae
  • Decrease in trabecular strength and increased susceptibility to fracture

20 years

50 years

80 years

Mosekilde L. Calcified Tissue Inter. 1993;53(Suppl 1):S121-S126.

location of cortical and trabecular bone
Location of Corticaland Trabecular Bone

Trabecular Bone

20% of skeletal mass

80% of bone turnover

Thoracic andLumbar Spine

75% trabecular25% cortical

Distal Radius

25% trabecular75% cortical

Cortical Bone

80% of skeletal mass

20% of bone turnover

Femoral Neck

25% trabecular75% cortical

Hip: Intertrochanteric Region

50% trabecular50% cortical

Favus MJ, ed. Primer on the Metabolic Bone Disease and Disorders of the Mineral Metabolism. 4th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 1999:30-32.

fracture patterns by age
Fracture Patterns By Age

Vertebrae

4000

3000

Hip

Annual Fracture

Incidence /100,000

2000

1000

Colles'

0

35 45 55 65 75 85+

Age (years)

Riggs B. N Engl J Med 1986;314:1676.

behavioral lifestyle measures to prevent osteoporosis
Behavioral/Lifestyle Measures to Prevent Osteoporosis
  • Adequate intake of dietary calcium, vitamin D, and protein throughout life
  • Regular physical activity; load-bearing exercise
  • Minimal alcohol intake
  • Stop smoking
  • Take measures to prevent falls
  • Use of hip protectors by patients prone to falling

Ebeling PR. N Engl J Med. 2008;358:1474-1482; National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

which of the following is true with regard to vitamin d and bone health

0

Which of the following is true with regard to vitamin D and bone health?
  • Oral vitamin D reduces the risk of hip fractures by 26%
  • Oral vitamin D has no benefit in preventing falls in osteoporotic patients
  • Only vitamin D absorbed through the skin is effective in preventing osteoporosis
  • Vitamin D supplementation has no effect on nonvertebral fractures

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vitamin d protects against osteoporosis
Vitamin D Protects Against Osteoporosis
  • Oral vitamin D supplementation 700-800 IU/d reduces risk of
    • Hip fracture by 26%
    • Nonvertebral fracture by 23%
    • Falls by 22% (↑ muscle strength, better balance)
  • Optimal fracture prevention achieved with 25-hydroxyvitamin D mean serum level 100 nmol/L
  • Best sources
    • Milk, salmon, canned tuna, sardines, eggs, liver, sunlight

Bischoff-Ferrari HA , et al. JAMA. 2005;293:2257-2264.

national osteoporosis foundation clinical recommendations 2008
National Osteoporosis Foundation Clinical Recommendations 2008
  • National Osteoporosis Foundation Clinical Recommendations February 2008 are based on the newly developed WHO 10-year fracture risk model (FRAX®) adapted to different population groups
  • The FRAX algorithm
    • Estimates the likelihood of a person breaking a bone due to osteoporosis during the next 10 years
    • Provides a useful way to ensure that people at risk of fracture receive treatment
    • Takes into account 9 clinical risk factors in addition to bone mineral density
    • Available online at http://www.shef.ac.uk/FRAX

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

risk factors used to calculate who 10 year fracture risk
Risk Factors Used to Calculate WHO 10-Year Fracture Risk

Femoral neck T-score

Age

Sex

Secondary osteoporosis

Previous low-trauma fracture

*1 unit = 8 g alcohol ~ ½ pt beer ~ 1 glass wine.

BMI = body mass index.

Kanis JA, et al. Bone. 2002;30:251-258; Kanis JA, et al. Osteoporos Int. 2005;16:581-589; National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

Low BMI

Steroid exposure

Family history of hip fracture

Current cigarette smoking

Alcohol intake >2 units/day*

10 year fracture risk age and bmd
10-Year Fracture Risk: Age and BMD
  • For a given BMD, risk increases with age

Age

20

80

15

70

Hip Fracture Risk (% /10 Years)

10

60

5

50

0

-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

BMD T-Score

Kanis JA, et al. Osteoporos Int. 2001;12:989-995.

clinical evaluation of risk factors for osteoporosis
Clinical Evaluation of Risk Factors for Osteoporosis
  • Medical history
    • Risk factors
    • Signs and symptoms
  • Physical examination
    • Height assessment (with stadiometer)
  • BMD testing
  • Laboratory tests
central dual energy x ray absorptiometry dexa test of choice for diagnosing osteoporosis
Central Dual Energy X-Ray Absorptiometry (DEXA): Test of Choice for Diagnosing Osteoporosis
  • Benefits
    • Highly accurate and precise
    • Profiles all skeletal areas
    • Requires little time
    • Emits low dose of radiation
  • Limitations
    • AP spine measurement affected by vascular calcifications and spinal osteoarthritis
    • Trabecular and cortical bone measured together
  • AP = anteroposterior.
who should have a bone density test
Who Should Have a Bone Density Test?

Patient Category

USPSTF

NOF

AACE

ISCD

Women  65 years of age

Yes

Yes

Yes

Yes

Women 60 – 64 with risk factor

Yes

Yes

Yes

Yes

All women  65 with risk factor

Yes

Yes

Yes

All women with a fragility fracture

Yes

Yes

Yes

Diseases/conditions/drugs causing osteoporosis

Yes

Yes

Yes

Anyone receiving treatment for osteoporosis

Yes

Yes

Anyone considering therapy for osteoporosis

Yes

Yes

Men aged  70 years

Yes

All men with a fragility fracture

Yes

USPTF. Ann Intern Med 2002 137:526-8; Leib, E. S., et al. J Clin Densitom 1998 7:1-6; Endocr Pract 7:293-312

t score
T-Score
  • Number of SDs above or below sex-matched mean reference value of young adults
    • T-score = (BMD patient – BMD young normal reference) SD young normal reference
    • Comparison to peak bone mass
    • Peak adult bone mass follows a normal distribution (bell curve). Low bone mass on initial DEXA does not necessarily mean bone loss. Person may be at low end of bell curve
  • Used for adult diagnosis
  • Each SD decrease = doubling of fracture risk

NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Treatment. JAMA. 2000;285:785-795.

which of the following applies to the who nof criteria for diagnosis of osteoporosis

0

Which of the following applies to the WHO/NOF criteria for diagnosis of osteoporosis?
  • T-score > -1.0
  • T-score between -1 and -2.3
  • T-score is not a WHO/NOF criterion for diagnosing osteoporosis
  • T-score ≤ -2.5

Use your keypad to vote now!

who nof criteria for diagnosis of bone status
WHO/NOF Criteria for Diagnosis of Bone Status

*Measured in T-scores. T-score indicates the number of standard deviations below or above the average peak bone mass in young adults.

Ebeling PR. N Engl J Med. 2008;358:1474-1482; National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm.

Accessed April 22, 2008.

fracture rates correlate with t scores national osteoporosis risk assessment nora study
Fracture Rates Correlate With T-Scores: National Osteoporosis Risk Assessment (NORA) Study

Data From More Than 163,000 Women

Fracture Rate/100 Person-Years

Siris ES, et al. JAMA. 2001;286:2815-2822.

national osteoporosis foundation treatment recommendations
National Osteoporosis Foundation:Treatment Recommendations
  • Postmenopausal women and men aged >50 years with either of the following
    • Low bone mass (T-score -1 to -2.5, osteopenia) at femoral neck, total hip, or spine and 10-year hip fracture risk >3%
    • 10-year all major osteoporosis-related fracture risk >20% based on US-adapted WHO FRAX model

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

acr recommendations bisphosphonate use in gio
ACR Recommendations: Bisphosphonate Use in GIO
  • Prevention of bone loss in patients initiating long-term (3 months) glucocorticoid therapy
  • Patients with low BMD (T-score ≤1) receiving long-term glucocorticoid therapy
  • Patients receiving long-term glucocorticoid therapy who cannot tolerate HRT or had fractures during HRT

ACR = American College of Rheumatology; GIO = glucocorticoid-induced osteoporosis;

HRT = hormone replacement therapy.

American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis.Arthritis Rheum. 2001;44:1496-1503.

slide33

0

Randomized, controlled trials with the bisphosphonate alendronate demonstrated reductions in risk of hip fracture at month 18 by:
  • <10%
  • 15%-25%
  • 30%-40%
  • >60%

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slide34
Effects of Alendronate on Cumulative Incidence of Symptomatic Vertebral and Hip Fractures (FIT 1 and 2 Trials)

Vertebral

Hip

3

5

-59%

-63%

4

PBO

PBO

2

P

<.014

3

P

<.001

Cumulative Incidence

Cumulative Incidence

ALN

2

ALN

1

*

*

*

*

*

*

1

*

*

*

0

0

0

6

12

18

24

30

36

0

6

12

18

24

30

36

Months

Months

*P <.05

ALN = alendronate; FIT = Fracture Intervention Trial; PBO = placebo.

Black DM, et al. J Clin Endocrinol Metab. 2000;85:4118-4124.

risedronate reduces risk of vertebral fracture in high risk subjects in 1 year
Risedronate Reduces Risk of VertebralFracture in High-Risk Subjects in 1 Year

Placebo

68%

(51%, 80%)

P <.001

Risedronate 5 mg

60%

(33%, 77%)

P <.001

14

62%

(36%, 77%)

P <.001

12

62%

(44%, 75%)

P <.001

10

48%

(7%, 71%)

P = .029

8

Percent of Subjects With New Vertebral Fractures

6

4

2

0

Aged

70 Years

2 Prevalent

Fractures

Low

FN BMD

Low

LS BMD

Overall

FN = femoral neck; LS = lumbar spine.

Watts NB, et al. J Clin Endocrinol Metab. 2003;88:542-549.

zoledronic acid
Zoledronic Acid
  • HORIZON study
    • 3-year study to decrease fracture risk in postmenopausal women with osteoporosis
  • Pivotal Fracture Trial (PFT)
    • 3-year study to decrease fracture risk in postmenopausal women with osteoporosis
  • Efficacy 70% ↓vertebral fractures, 40% ↓hip fractures, 25% ↓nonvertebral fractures

Black DM, et al. N Engl J Med. 2007;356:1809-1822.

zoledronic acid reduced cumulative 3 year risk of hip fractures strata i ii

Placebo (n = 3861) Zoledronic acid (n = 3875)

Zoledronic Acid Reduced Cumulative 3-Year Risk of Hip Fractures (Strata I + II)

3

41%*

2

Cumulative Incidence (%)

1

0

0

3

6

9

12

15

18

21

24

27

30

33

36

Time to First Hip Fracture (months)

*P = .0024, relative risk reduction vs placebo (95% CI)

CI = confidence interval.

Adapted from Black DM, et al. N Engl J Med. 2007;356:1809-1822.

women s health initiative effects of hrt in women aged 50 79
Women’s Health Initiative: Effects of HRT in Women Aged 50-79

6700 Women With 5.2 Years of Follow-up

Disadvantages

Vertebral fracture

Intestinal cancer

Hip fracture

Difference (%) vs Placebo

Stroke

Cardiovasculardiseases

Breast cancer

Thromb. venous

Advantages

Manson JE, at al. N Engl J Med. 2003;349:523-534.

more increase in bmd with long term raloxifene treatment
MORE: Increase in BMD With Long-term Raloxifene Treatment

BMD Lumbar Spine

BMD Femoral Neck

Placebo (n = 1512)

Raloxifene 60 mg (n = 1490)

3

3

2

2

1

1

Mean % Change From Baseline

0

0

-1

-1

-2

-2

0

12

24

36

0

12

24

36

Months

Months

P <.001 for all comparisons.

MORE = Multiple Outcomes of Raloxifene Evaluation.

Ettinger B, et al. JAMA. 1999;282:637-645.

more reduction in new vertebral fractures among women who completed the study
MORE: Reduction in New Vertebral Fractures Among Women Who Completed the Study

Placebo

Raloxifene hydrochloride 60 mg/d

Raloxifene hydrochloride 120 mg/d

25

RR 0.5 (95% CI, 0.4-0.6)

RR 0.5 (95% CI, 0.6-0.9)

20

% of Patients With Incident Vertebral Fracture

15

10

5

0

N = 6828

RR = relative risk.Ettinger B, et al. JAMA. 1999;282:637-645.

calcitonin nasal spray proof study analysis at 5 years
Calcitonin Nasal Spray: PROOF Study (Analysis at 5 Years)

Reduction in % of New Vertebral Fractures vs Placebo

No. of Hip Fractures Per Group

25

0

10

20

20

100 IU

18%

(NS)

30

400 IU

23%

(NS)

15

40

200 IU

33%

(P = .03)

50

7

(NS)

10

8

60

4

(NS)

70

2

(NS)

5

80

90

0

100

Placebo

100 IU

200 IU

400 IU

N = 511

NS = nonsignificant

IU = international units; PROOF = Prevent Recurrence of Osteoporotic Fractures.

Chesnut CH III, et al. Am J Med. 2000;109:267-276.

effect of parathyroid hormone on bmd over 18 months
Effect of Parathyroid Hormone on BMD Over 18 Months

1637 Postmenopausal Women With Prior Vertebral Fracture

14

Lumbar spine

12

Femoral neck

10

8

Change From Baseline

in BMD (%)

6

4

2

0

-2

PTH 20 µg

Placebo

PTH = parathyroid hormone.

Neer RM, et al. N Engl J Med. 2001;344:1434-1441.

summary fda approved osteoporosis therapies
Summary: FDA-Approved Osteoporosis Therapies

PMO = postmenopausal.

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

what percent of patients will stop their medications within 6 12 months of initiation

0

What percent of patients will stop their medications within 6-12 months of initiation?
  • <10%
  • 10%-15%
  • 20%-30%
  • 40%-50%

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adherence and persistence
Adherence and Persistence
  • 20%-30% of patients taking oral osteoporosis medications suspend their medications within 6-12 months of initiation due to
    • Side effects
    • Lack of knowledge
    • Reluctance to take regular medications

Papaioannou A. Drugs Aging. 2007;24:37-55.

flex study persistence
FLEX Study: Persistence
  • FLEX
    • Compared effects of discontinuing alendronate treatment after 5 years vs continuing treatment for 10 years
    • Women who discontinued treatment after 5 years experienced a moderate decline in BMD, increase in biochemical markers, no higher fracture risk except clinical vertebral fractures

FLEX = Fracture Intervention Trial Long-Term Extension.

Black DM, et al. JAMA. 2006;296:2927-2938.

osteonecrosis of jaw
Osteonecrosis of Jaw
  • Osteonecrosis of jaw
  • Potential complication of bisphosphonate
  • Rare
    • 60% occur after dental extraction
    • Most cases occur in cancer patients
  • Most cases associated with high-dose IV bisphosphonate treatment in metastatic cancer patients
postmenopausal asian woman with possible osteoporosis
Postmenopausal Asian Woman With Possible Osteoporosis
  • At annual physical examination for 57-year-old Asian woman
    • Height: 5 ft 2 in; weight: 101 lb; BMI: 18.5 kg/m2
    • Postmenopausal for 5 years
    • No HRT
    • Medications: mesalamine for ulcerative colitis
    • No known drug allergies
    • Family history: mother had a hip fracture at age 76 years
postmenopausal asian woman with possible osteoporosis50
Postmenopausal Asian Woman With Possible Osteoporosis
  • Medical history: GERD, used PPIs daily for 5 years; ulcerative colitis, uses mesalamine; has used systemic steroids orally 3 or 4 times for limited periods of time
  • Diet: balanced, except does not include dairy (lactose intolerant)
  • Exercise: walks 20 minutes a day
  • Smokes ½ pack a day

GERD = gastroesophageal reflux disease.

should this patient have a dexa scan

0

Should this patient have a DEXA scan?
  • No, she is <65 years of age
  • Yes, she is 5 years postmenopausal
  • Yes, she has multiple risk factors for osteoporosis

Use your keypad to vote now!

risk factors for osteoporotic fracture

Moderate (RR 1-2)

Major (RR ≥2)

Risk Factors for Osteoporotic Fracture
  • Aged >70 years
  • Menopause aged <45 years
  • Hypogonadism
  • Fragility fracture
  • Hip fracture in parents
  • Glucocorticoids
  • Malabsorption
  • High bone turnover
  • Anorexia nervosa
  • BMI <18 kg/m2
  • Immobilization
  • Chronic renal failure
  • Transplantation
  • Estrogen deficiency
  • Calcium intake <500 mg/d
  • Primary hyperparathyroidism
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Anticonvulsants
  • Hyperthyroidism
  • Diabetes mellitus
  • Smoking
  • Alcohol in excess

Brown JP, et al. CMAJ. 2002;167(10 suppl):S1-S34.

slide53

0

DEXA scan indicates T-score -1.9 lumbar spine; T-score -.9 femoral neck. Does this patient have osteoporosis?
  • Yes
  • No
  • Not enough information

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who nof criteria for classification of bone status
WHO/NOF Criteria for Classification of Bone Status

Diagnostic criteria*

  • T-score > -1
  • T-score between -1 and -2.5
  • T-score ≤ -2.5
  • T-score ≤ -2.5 + fragility fracture(s)

Classification

  • Normal
  • Osteopenia
  • Osteoporosis
  • Severe or established osteoporosis

*T-score = number of standard deviations below or above the average peak bone mass in young adults.

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis.

Available at: www.nof.org/professionals/Clinicians_Guide.htm. Accessed April 22, 2008.

what treatment should be recommended for this patient

0

What treatment should be recommended for this patient?
  • Ca+ 1200-1500 mg/d
  • Ca+ 1200-1500 mg/d + 800 IU vitamin D
  • All of the above plus smoking cessationand consider adding a bisphosphonate

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national institutes of health recommendations for calcium intake
National Institutes of Health Recommendations for Calcium Intake

NIH. Dietary Supplement Fact Sheet: Calcium. 2005. Available at:http://ods.od.nih.gov/factsheets/calcium.asp.

Accessed April 17, 2008.

nonpharmacologic approaches to postmenopausal osteoporosis
Nonpharmacologic Approaches to Postmenopausal Osteoporosis
  • Adequate intake of dietary calcium, vitamin D, and protein
  • Regular physical activity
  • Minimize alcohol intake
  • Stop smoking
  • Minimize risk of falls
  • Recommend hip protectors for those prone to falls
antiresorptive therapy with alendronate in osteoporosis
Antiresorptive Therapy With Alendronate in Osteoporosis
  • Clinical trials indicate increased bone mass over 3 to 4 years
  • Reduces incidence of fractures in spine, hip, and wrist by 47%-51%
    • Prevention or treatment PMO
    • Approved treatment men
    • Approved treatment GIO
  • Fracture efficacy (FIT and FOSIT trials)
    • Year 1 nonvertebral fracture reduction: 47%
    • Year 3 vertebral fracture reduction: 47%
    • Year 3 hip fracture reduction: 51%

FOSIT = Fossa Intervention Trial.

Black DM, et al. J Clin Endocrinol Metab. 2000;85:4118-4124; Pols HA, et al. Osteoporos Int. 1999;9:461-468.

antiresorptive therapy with risedronate in osteoporosis
Antiresorptive Therapy With Risedronate in Osteoporosis
  • Increased bone mass spine, hip; reduced risk fractures 40%-65% in a 3- to 5-year period
    • Prevention or treatment of PMO
    • Approved prevention or treatment of GIO
    • Approved in treatment for men
  • Dose: 5 mg/d or 35 mg every week or 75 mg 2 consecutive days a month
  • Fracture efficacy (VERT and HIP trials)
    • Year 3 vertebral fracture reduction: 41%-49%
    • Year 1 vertebral fracture reduction: 65%
    • Year 3 hip fracture reduction: 40%-60%

HIP = Hip Intervention Program; VERT = Vertebral Efficacy With Risedronate Therapy.

Deal CL. Cleve Clin J Med. 2002;69:964,968-970,973-976; Harris ST, et al. JAMA. 1999;282:1344-1352; Reginster J, et al. Osteoporos Int. 2000;11:83-91.

antiresorptive therapy with ibandronate in osteoporosis
Antiresorptive Therapy With Ibandronate in Osteoporosis
  • BONE study
    • Efficacy: ~50% reduction in vertebral fractures by year 3
    • Bisphosphonate for PMO
  • Dosing
    • 150 mg once a month, MOBILE study
    • 3 mg IV once every 3 months, DIVA study

BONE = Bone, Osteogenesis, Nonsteroidal Anti-Inflammatory Drug ; DIVA = Dosing IntraVenous Administration; MOBILE = Monthly Oral iBandronate In LadiEs.

Miller PJ. J Bone Miner Res. 2005;1315.

pce takeaways63
PCE Takeaways
  • Osteoporosis is a preventable disease—not a condition of aging
  • Technology for accurate bone density measurement is available
  • Women and men at risk can be identified
  • Safe and effective pharmacologic treatments are available
  • Patient education is critical to encourage persistence with medication in the management of osteoporosis
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radisson hotel at opryland nashville tennessee may 31 200865
Radisson Hotel at Opryland

Nashville, Tennessee

May 31, 2008

2008

Symposia Series 2

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