Post on 31-Jan-2016
description
Osteoporosis Case Studies
March 2012
Ronald C. Hamdy, MD, FRCP, FACP
Professor of Medicine
Director, Osteoporosis Center
Professor/Chair, Geriatric Medicine
East Tennessee State University
Editor-in-Chief, Journal of Clinical Densitometry
Osteoporosis Case Studies
March 2012
Ronald C. Hamdy, MD, FRCP, FACP
Professor of Medicine
Director, Osteoporosis Center
Professor/Chair, Geriatric Medicine
East Tennessee State University
Editor-in-Chief, Journal of Clinical Densitometry
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Asymptomatic Natural menopause 2 years ago Exercises regularly – strenuous routine Good dietary calcium and vitamin D intake Family history: negative for osteoporosis No prescribed medications OsCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 121 pounds; height 64”
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Asymptomatic Natural menopause 2 years ago Exercises regularly – strenuous routine Good dietary calcium and vitamin D intake Family history: negative for osteoporosis No prescribed medications OsCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 121 pounds; height 64”
Area BMD T-score
L1 9.9 1.419 + 2.4
L2 11.4 1.445 + 2.9
L3 13.9 1.483 + 2.4
L4 14.1 1.494 + 1.7
L1-4 48.8 1.463 + 2.6
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Area BMD T-score
L1 9.9 1.419 + 2.4
L2 11.4 1.445 + 2.9
L3 13.9 1.483 + 2.4
L4 14.1 1.494 + 1.7
L1-4 48.8 1.463 + 2.6
RIGHT HIP BMD T-score Femoral Neck 1.081 + 0.8Trochanter 0.773 - 0.2Total Hip 1.047 + 0.4LEFT HIPFemoral Neck 1.016 + 0.3Trochanter 0.818 + 0.3Total Hip 1.047 + 0.4
RIGHT HIP BMD T-score Femoral Neck 1.081 + 0.8Trochanter 0.773 - 0.2Total Hip 1.047 + 0.4LEFT HIPFemoral Neck 1.016 + 0.3Trochanter 0.818 + 0.3Total Hip 1.047 + 0.4
Lunar, ProdigyLunar, Prodigy
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Diagnosis: Normal bone density (WHO criteria)Diagnosis: Normal bone density (WHO criteria)
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Diagnosis: Normal bone density (WHO criteria)Diagnosis: Normal bone density (WHO criteria) Management recommendations: Management recommendations:
Maintain Bone Mass – Healthy lifestyleMaintain Bone Mass – Healthy lifestyle
Repeat DXA scan 2 yearsRepeat DXA scan 2 years
Mrs. MB, 51 years old WW, Concerned about Osteoporosis
Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSCRIGHTFem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.4 0.078 0.050
LEFTFem Neck 1.016 + 0.3 0.945 - 0.3 - 7.0 0.071 0.031Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.3 0.068 0.042Total Hip 1.0471.047 + 0.4+ 0.4 0.966 - 0.3 0.966 - 0.3 - 7.7 0.0810.081 0.022
L1-L4 1.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028
Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis
Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSCRIGHTFem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.4 0.078 0.050
LEFTFem Neck 1.016 + 0.3 0.945 - 0.3 - 7.0 0.071 0.031Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.3 0.068 0.042Total Hip 1.0471.047 + 0.4+ 0.4 0.966 - 0.3 0.966 - 0.3 - 7.7 0.0810.081 0.022
L1-L4 1.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028
Laboratory investigations: Blood Chemistry profile, Vit. D, PTH: Within normal limits.Laboratory investigations: Blood Chemistry profile, Vit. D, PTH: Within normal limits.
Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis
Normal BMDNormal BMD
Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis
Normal BMDNormal BMD
Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis
Bone loss sustained: Expected Post-menopausal loss
Management recommendation: Maintain Bone massRepeat DXA scan 1 year
Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis
Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis
VERY VERY
VERYVERY
Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis
Base 2-yrs % 1-yr BMD change 04-05
Region BMD BMD Diff. BMD T-score % Abs LSC
RIGHT
Fem Neck 1.081 0.985 - 8.9 0.977 - 0.1 - 0.8 0.008 0.034
Trochanter 0.773 0.732 - 5.3 0.713 - 0.5 - 0.3 0.019 0.053
Total Hip 1.047 0.969 - 7.4 0.958 - 0.3 - 0.8 0.011 0.050
LEFT
Fem Neck 1.016 0.945 - 7.0 0.938 - 0.3 - 0.7 0.007 0.031
Trochanter 0.818 0.750 - 8.3 0.739 - 0.1 - 1.5 0.011 0.042
Total Hip 1.0471.047 0.966 0.966 - 7.7 0.9480.948 - 0.3- 0.3 - 1.8- 1.8 0.0180.018 0.022
L1-L4 1.463 1.394 - 5.0 1.374 + 1.7 - 1.4 0.020 0.028
Bo
ne
Mas
sB
on
e M
ass
ActiveGrowt
h
SlowLoss
RapidLoss
ContinuingLoss
Age in YearsAge in Years
50501010 2020 4040 6060 7070 8080 90903030
MENOPAUS
E
Peak Bone MassPeak Bone Mass
1- 5% annually1- 5% annually
Age-associated Changes in Bone Mass
1- 2% annually1- 2% annually
Low back pain , gradually worsening
Episode of very severe pain, incapacitating, 3 weeks ago
Positive family history;
Sister 85 yrs, died after hip fracture
Daily calcium intake: about 1500 mg
CBC, CMP, TSH; within normal limits
Meds: NSAID, calcium supplements
Weight 130 pounds, height 64”
X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
Low back pain , gradually worsening
Episode of very severe pain, incapacitating, 3 weeks ago
Positive family history;
Sister 85 yrs, died after hip fracture
Daily calcium intake: about 1500 mg
CBC, CMP, TSH; within normal limits
Meds: NSAID, calcium supplements
Weight 130 pounds, height 64”
X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
Low back pain , gradually worsening
Episode of very severe pain, incapacitating, 3 weeks ago
Positive family history;
Sister 85 yrs, died after hip fracture
Daily calcium intake: about 1500 mg
CBC, CMP, TSH; within normal limits
Meds: NSAID, calcium supplements
Weight 130 pounds, height 64”
X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
Mrs. MRW, 76 years WW
Area BMD T-score
L1 12.65 0.849 - 0.69
L2 11.80 1.012 - 0.15
L3 15.55 0.920 - 1.49
L4 11.61 1.123 + 0.06
L1-4 51.61 0.969 - 0.71
Mrs. MRW, 76 years WW
Area BMD T-score
L1 12.65 0.849 - 0.69
L2 11.80 1.012 - 0.15
L3 15.55 0.920 - 1.49
L4 11.61 1.123 + 0.06
L1-4 51.61 0.969 - 0.71
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Vertebral compression fracturesVertebral compression fractures
Mrs. MRW, 76 years WW
Area BMD T-score
L1 12.65 0.849 - 0.69
L2 11.80 1.012 - 0.15
L3 15.55 0.920 - 1.49
L4 11.61 1.123 + 0.06
L1-4 51.61 0.969 - 0.71
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Vertebral compression fracturesVertebral compression fractures
Diagnosis: Osteoporosis
10-years % # probability:
Hip # 33
Other # 50
Diagnosis: Osteoporosis
10-years % # probability:
Hip # 33
Other # 50
Mrs. MRW, 76 years WW
Area BMD T-score
L1 12.65 0.849 - 0.69
L2 11.80 1.012 - 0.15
L3 15.55 0.920 - 1.49
L4 11.61 1.123 + 0.06
L1-4 51.61 0.969 - 0.71
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip
Vertebral compression fracturesVertebral compression fractures
Diagnosis: OsteoporosisDiagnosis: Osteoporosis
Mrs. MRW, 76 years WW
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Vertebral compression fracturesVertebral compression fractures
Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip
Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, Prolia
Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, Prolia
Risk for hip fractures relative to placebo for participants who are at high risk for fracture, by agent
MacLean, C. et. al. Ann Intern Med 2008;148:197-213
FDA Approved Medication –Hip Fractures
StudyStudy NumbersNumbers Duration Duration yearsyears
risk risk reductionreduction
AlendronateAlendronate FITFIT 2,0272,027 33 YesYes
RisedronateRisedronate HIPHIP 5,4455,445 33 YesYes
IbandronateIbandronate BONEBONE 2,9462,946 33 NoNo
ZoledronateZoledronate HORIZONHORIZON 7,7367,736 33 YesYes
RaloxifeneRaloxifene MOREMORE 7,7057,705 33 NoNo
CalcitoninCalcitonin PROOFPROOF 1,2551,255 55 NoNo
DenosumabDenosumab FREEDOMFREEDOM 7,7367,736 33 YesYes
TeriparatideTeriparatide 1,6371,637 1.51.5 **
* Study aborted 18 months
Mrs. MRW, 76 years WW
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Vertebral compression fracturesVertebral compression fractures Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, Prolia
Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, Prolia
Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip
Diagnosis: OsteoporosisDiagnosis: Osteoporosis
Mrs. MRW, 76 years WW
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8
Vertebral compression fracturesVertebral compression fractures
Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip
Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, Prolia
Bisphosphonates:
Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast
Raloxifene, Evista
Calcitonin, Miacalcin
Teriparatide, Forteo
Denosumab, ProliaDiagnosis: OsteoporosisDiagnosis: Osteoporosis
Mrs. MRW, 76 years WW
CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES
Mrs. MRW, 76 years WW
CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES
Probability:
1:10,000 to 1:100,000
Probability:
1:10,000 to 1:100,000
Probability #:
Hip # 33 % 1:3
Other # 50 % 1:2
Probability #:
Hip # 33 % 1:3
Other # 50 % 1:2
Mrs. MRW, 76 years WW
CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW (ONJ)• ATYPICAL FEMORAL SHAFT FRACTURES (AFSF)
Probability:
1:10,000 to 1:100,000
Probability:
1:10,000 to 1:100,000
Atypical femoral shaft fracturesAtypical femoral shaft fracturesProdromal symptoms/signsProdromal symptoms/signs
Clinical:Clinical:
Pain, localised tendernessPain, localised tenderness Imaging:Imaging:
X-rays, technetium scan, MRI, CT-scans, MRIX-rays, technetium scan, MRI, CT-scans, MRI Laboratory:Laboratory:
Bone turnover markers: N-TX, C-TXBone turnover markers: N-TX, C-TX
0.00
0.02
0.04
0.06
0.08
0.10
0.12
0 6 12 18 24
Control Group67 hip fractures
Hip Protectors13 hip fractures
CumulativeHazard of
Hip Fractures
Months
54%*
Kannus P, et al. N Engl J Med 2000; 343:1506-1513
Prevention of Hip fracture with Hip Prevention of Hip fracture with Hip ProtectorsProtectors
*P=0.008
1801 elderly men and women in long stay or supported home care
Bisphosphonates:
alendronate, risedronate,
ibandronate zoledronate
Raloxifene
Calcitonin
Teriparatide
Denosumab
Bisphosphonates:
alendronate, risedronate,
ibandronate zoledronate
Raloxifene
Calcitonin
Teriparatide
Denosumab
? Kyphoplasty
?? Vertebroplasty
? Kyphoplasty
?? Vertebroplasty
Mrs. MRW, 76 years WW
Bisphosphonates:
alendronate, risedronate,
ibandronate zoledronate
Raloxifene
Calcitonin
Teriparatide
Denosumab
Bisphosphonates:
alendronate, risedronate,
ibandronate zoledronate
Raloxifene
Calcitonin
Teriparatide
Denosumab
? Kyphoplasty
?? Vertebroplasty
? Kyphoplasty
?? Vertebroplasty
Mrs. MRW, 76 years WW
Calcium/vitamin DCalcium/vitamin D
DAILY CALCIUM INTAKE Elemental Calcium (mg)
Postmenopausal:Postmenopausal: 1,5001,500 Premenopausal:Premenopausal: 1,0001,000 Pregnant/nursing:Pregnant/nursing: 1,200 - 1,5001,200 - 1,500 Men < 65 years:Men < 65 years: 1,0001,000 Men Men >> 65 years: 65 years: 1,5001,500
Mrs. IB, WW, 56 years
Asymptomatic Surgical menopause when 41 years Exercises regularly Good dietary calcium and vitamin D intake Family history: positive for osteoporosis No prescribed medications CitraCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 175 pounds; height 64” – No height loss
Mrs. IB, WW, 56 years
Asymptomatic Surgical menopause when 41 years Exercises regularly Good dietary calcium and vitamin D intake Family history: positive for osteoporosis No prescribed medications CitraCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 175 pounds; height 64” – No height loss
Mrs. IB, WW, 56 years
Area BMD T-score
L1 11.1 0.910 - 1.8
L2 11.3 0.914 - 1.8
L3 11.5 0.922 - 2.3
L4 12.3 0.927 - 2.6
L1-4 46.2 0.925 - 2.1
RIGHT HIP BMD T-score Femoral Neck 0.887 - 1.2Trochanter 0.713 - 0.9Total Hip 0.925 - 0.9LEFT HIPFemoral Neck 0.910 - 1.1Trochanter 0.755 - 0.7Total Hip 0.961 - 0.8
RIGHT HIP BMD T-score Femoral Neck 0.887 - 1.2Trochanter 0.713 - 0.9Total Hip 0.925 - 0.9LEFT HIPFemoral Neck 0.910 - 1.1Trochanter 0.755 - 0.7Total Hip 0.961 - 0.8
Diagnosis: OsteopeniaDiagnosis: Osteopenia
WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –
• AgeAge
• WeightWeight
• HeightHeight
• AgeAge
• WeightWeight
• HeightHeight
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –
• AgeAge
• WeightWeight
• HeightHeight
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
Femoral neck
T-score
or
Z-score
Femoral neck
T-score
or
Z-score
WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –
• AgeAge
• WeightWeight
• HeightHeight
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
Femoral neck
T-score
or
Z-score
Femoral neck
T-score
or
Z-score
10-year probability of fracture (%)
Hip
Others
10-year probability of fracture (%)
Hip
Others
WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –
• AgeAge
• WeightWeight
• HeightHeight
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
Femoral neck
T-score
or
Z-score
Femoral neck
T-score
or
Z-score
10-year probability of fracture (%)
Hip
Others
10-year probability of fracture (%)
Hip
Others
NOF Guidelines
Hip > 3%
Others > 20%
NOF Guidelines
Hip > 3%
Others > 20%
WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –
• Diagnosis: Osteopenia (WHO criteria)Diagnosis: Osteopenia (WHO criteria)
• 10-year % fracture probability10-year % fracture probability• HipHip 1 1
• OthersOthers 2626
Mrs. IB, WW, 56 years
NOF Guidelines
Hip > 3%
Others > 20%
NOF Guidelines
Hip > 3%
Others > 20%
Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?
What is the goal of treatment ?What is the goal of treatment ?
Mrs. IB, WW, 56 years
Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?
What is the goal of treatment ?What is the goal of treatment ?
Fracture Risk Reduction Fracture Risk Reduction
Mrs. IB, WW, 56 years
Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?
What is the goal of treatment ?What is the goal of treatment ?
Fracture Risk Reduction Fracture Risk Reduction
Mrs. IB, WW, 56 years
10-year probability Hip # 1
Other # 26
10-year probability Hip # 1
Other # 26
Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?
What is the goal of treatment ?What is the goal of treatment ?
Fracture Risk Reduction Fracture Risk Reduction
Mrs. IB, WW, 56 years
10-year probability Hip # 1
Other # 26
10-year probability Hip # 1
Other # 26
FDA Approved Medication – Vertebral Fractures
StudyStudy NumbersNumbers Duration Duration yearsyears
risk risk reductionreduction
AlendronateAlendronate FITFIT 2,0272,027 33 YesYes
RisedronateRisedronate VERTVERT 2,458 2,458 1,1161,116
33 YesYes
IbandronateIbandronate BONEBONE 2,9462,946 33 YesYes
ZoledronateZoledronate HORIZONHORIZON 7,7367,736 33 YesYes
RaloxifeneRaloxifene MOREMORE 7,7057,705 33 YesYes
CalcitoninCalcitonin PROOFPROOF 1,2551,255 55 YesYes
DenosumabDenosumab FREEDOMFREEDOM 7,7367,736 33 YesYes
TeriparatideTeriparatide 1,6371,637 1.51.5 YesYes
Hormonal Replacement Therapy - WHI
Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel, Atelvia) Risedronate (Actonel, Atelvia) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? Hormonal Replacement Therapy ? ?? ? Hormonal Replacement Therapy ? ?
Mrs. IB, WW, 56 years
Calcium
Vitamin D
Calcium
Vitamin D
Diagnosed with osteoporosis about 9 years agoDiagnosed with osteoporosis about 9 years ago
Based on fragility fracture T10: moderate wedgeBased on fragility fracture T10: moderate wedge Secondary causes excluded.Secondary causes excluded. Started risedronate (Actonel) 35 mg weekly, then Started risedronate (Actonel) 35 mg weekly, then
converted to 150 mg once a monthconverted to 150 mg once a month No adverse effects, taking it as directed, own routineNo adverse effects, taking it as directed, own routine Good complianceGood compliance Good daily calcium/vitamin D intakeGood daily calcium/vitamin D intake
Mrs. PRP, WW, 82 years
Scan Date
Age BMD T-scores % BMD Change
Baseline Previous
2001 73 0.700 - 2.0
2003 75 0.721 - 1.8 + 3.0 + 3.0
2004 76 0.724 -1.8 + 1.8 + 1.3
2006 78 0.757 - 1.5 + 6.1 + 4.3
2007 79 0.747 -1.6 + 6.3 - 0.2
2010 82 0.771 - 1.4 + 9.2 + 2.9
Mrs. PRP, WW, 82 yearsRight Total Hip
Scan Date
Age BMD T-scores % BMD Change
Baseline Previous
2001 73 0.700 - 2.0
2003 75 0.721 - 1.8 + 3.0 + 3.0
2004 76 0.724 -1.8 + 1.8 + 1.3
2006 78 0.757 - 1.5 + 6.1 + 4.3
2007 79 0.747 -1.6 + 6.3 - 0.2
2010 82 0.771 - 1.4 + 9.2 + 2.9Should risedronate (Actonel) be continued ?
Mrs. PRP, WW, 82 yearsRight Total Hip
Atypical femoral shaft #
Delayed # healing
Bisphosphonate therapy
Oversuppressed bone turnover
Fracture Risk Reduction
Osteo-necrosis Jaw
Bisphosphonate therapy & Bone Turnover
Suppress, but not
Over-suppress !
COLLAGEN CROSS LINKSCOLLAGEN CROSS LINKS
CTxNTx
N-TELOPEPTIDEREGION
HELICAL REGION C-TELOPEPTIDEREGION
PyrDpd
C-Telopeptide or C-Tx C-Telopeptide or C-Tx
C-Telopeptide or C-Telopeptide or C-Tx C-Tx
1000 pg/mL
100 pg/mL
200 pg/mL
Mrs. PRP, WW, 82 yearsRight Total Hip
Scan Date
Age BMD T-scores % BMD Change
Baseline Previous
2001 73 0.700 - 2.0
2003 75 0.721 - 1.8 + 3.0 + 3.0
2004 76 0.724 -1.8 + 1.8 + 1.3
2006 78 0.757 - 1.5 + 6.1 + 4.5
2007 79 0.747 -1.6 + 6.4 - 0.3
2010 82 0.771 - 1.4 + 9.2 + 3.0Continue risedronate (Actonel)C-Tx 320 pg/mL
Mrs. RV, 60 years, WW, Second visit
2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3
LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2
L1-L4 Cannot be interpreted: scoliosis and artifacts
2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3
LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2
L1-L4 Cannot be interpreted: scoliosis and artifacts
Prescribed alendronate in 2008
Mrs. RV, 60 years, WW, Second visit
Did not refill her second prescription
of Alendronate
2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3
LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2
L1-L4 Cannot be interpreted: scoliosis and artifacts
2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3
LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2
L1-L4 Cannot be interpreted: scoliosis and artifacts
Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in
Known to have osteoporosis
CBC, Blood Chem. Profile, TSH: within normal limits.
Prescribed a bisphosphonate.
Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in
Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in
DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD
Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2
Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8
Lumbar Vertebrae Multiple vertebral compression fractures
DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD
Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2
Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8
Lumbar Vertebrae Multiple vertebral compression fractures
Complete blood picture
Blood chemistry profile Normal
Thyroid stimulating hormone
Complete blood picture
Blood chemistry profile Normal
Thyroid stimulating hormone
Bisphosphonates, good complianceBisphosphonates, good compliance
Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in
Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in
DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD
Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2
Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8
Lumbar Vertebrae Multiple vertebral compression fractures
DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD
Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2
Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8
Lumbar Vertebrae Multiple vertebral compression fractures
Complete blood picture
Blood chemistry profile Normal
Thyroid stimulating hormone
Complete blood picture
Blood chemistry profile Normal
Thyroid stimulating hormone
Bisphosphonates, good complianceBisphosphonates, good compliance
25(OH) Vitamin D 12 ng/mL
25(OH) Vitamin D 12 ng/mL
Non-response to oral bisphosphonatesNon-response to oral bisphosphonates
• ComplianceCompliance
• Inadequate Calcium/vitamin DInadequate Calcium/vitamin D
• Secondary osteoporosis Secondary osteoporosis
OsteoporosisOsteoporosis
Diagnosis:Diagnosis:
Fragility fracturesFragility fractures
DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis < - 1.0 to – 2.5: Osteopenia< - 1.0 to – 2.5: Osteopenia >> - 1.0: Normal - 1.0: Normal
OsteoporosisOsteoporosisDiagnosis:Diagnosis:
Fragility fracturesFragility fractures
DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis < - 1.0 to – 2.5: Osteopenia< - 1.0 to – 2.5: Osteopenia >> - 1.0: Normal - 1.0: Normal
Management strategy:
WHO FRAX 10 year # probability %
NOF guidelines: Hip # > 3.0
Other # >20
Management strategy:
WHO FRAX 10 year # probability %
NOF guidelines: Hip # > 3.0
Other # >20
OsteoporosisOsteoporosis
Diagnosis:Diagnosis:
Fragility fracturesFragility fractures
DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis OsteopeniaOsteopenia >> - 1.0: Normal - 1.0: Normal
Medications:
Alendronate (Fosamax, generics)
Risedronate (Actonel, Atelvia)
Ibandronate (Boniva)
Zoledronate (Reclast)
Raloxifene (Evista)
Calcitonin (Miacalcin)
Teriparatide (Forteo)
Denosumab (Prolia)
HRT ??
Medications:
Alendronate (Fosamax, generics)
Risedronate (Actonel, Atelvia)
Ibandronate (Boniva)
Zoledronate (Reclast)
Raloxifene (Evista)
Calcitonin (Miacalcin)
Teriparatide (Forteo)
Denosumab (Prolia)
HRT ??
Management strategy:
WHO FRAX 10 year # probability %
NOF guidelines: Hip # > 3.0
Other # >20
Management strategy:
WHO FRAX 10 year # probability %
NOF guidelines: Hip # > 3.0
Other # >20
FDA Approved Medication for Osteoporosis# Risk Reduction# Risk Reduction
Calcium
Vitamin D
Diet
Exercise
No smoking
Calcium
Vitamin D
Diet
Exercise
No smoking
VertebraeVertebrae HipsHips
AlendronateAlendronate YesYes YesYes
RisedronateRisedronate YesYes YesYes
IbandronateIbandronate YesYes NoNo
ZoledronateZoledronate YesYes YesYes
RaloxifeneRaloxifene YesYes NoNo
CalcitoninCalcitonin YesYes NoNo
TeriparatideTeriparatide YesYes
Denosumab YesYes YesYes
WHO – FRAX
NOF – Guidelines
Hip > 3% Others > 20%
WHO – FRAX
NOF – Guidelines
Hip > 3% Others > 20%
Management Of
Osteoporosis
Management Of
Osteoporosis
MedicationsMedications
Lifestyle changesLifestyle changes
Calcium & Vitamin DCalcium & Vitamin D
Fall PreventionFall Prevention
DiseasesDiseases
Medications causing bone loss
Medications causing bone loss
Reduce impact of fallsReduce impact of falls
Early diagnosis Prevention
Early diagnosis Prevention
OsteoporosisOsteoporosis
It is never too early or too late to prevent or treat
osteoporosis !