Osteoporosis 2010

7/31/2019 Osteoporosis 2010

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WHO OWNS THE BONES?

Patchwork Quilt of Womens HealthWho screens?Who treats?Who teaches/ to whom?

Whose job it it?RheumatologyEndocrinologyPrimary CareGynecologyGerontology

OrthopedicsOrganizations

NOFNAMSISCD


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Overview

Prevention and Treatment of Osteoporosis

Demographics

Screening

Prevention/Lifestyle

Risk Factors

Pharmaceuticals

Nutriceuticals


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Definition

Osteoporosis is a skeletal disordercharacterized by compromised bonestrength predisposing to an increased

fracture risk.

BONE DENSITY=BONE DENSITY (70%) + BONE STRENGTH (30%)

BONE DENSITY: grams of mineral per area

BONE QUALITY: architecture, turnover, damage accumulation,and mineralization

NIH Consensus DevelopmentConference on Osteoporosis, 2000


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Demographics

10 Million People have Osteoporosis

34 Million People have Osteopenia1:2 Women will have an osteoporoticfracture in their lifetime

1.5 Million Fractures Annually 20% die within one year

$18B Annually

www.nof.org


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Screening

DEXA is most cost-effective screen today All women at least 65 yo

Perimenopausal, if risk factors

Any adult > 50 yo with a fracture Adults with a condition or on a medication associated

with bone loss

Patients considering or currently on a medication for

osteoporosis Postmenopausal women considering discontinuation

of HRT

NOF Clinicians Guide to Prevention andTreatment of Osteoporosis


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Unrecognized Vertebral Fracturesin Hospitalized Patients

0

5

10

15

20

25

30

35

40

45

50

Fx

Present

In Report In

DCSum

In

Record

On Rx


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Undertreatment of Hip Fracture inHospitalized Patients

0

5

10

15

20

25

30

35

40

DXA Ca + Vit D Rx BP Rx

Hosp A

Hosp B

Hosp C

Hosp D


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Densitometry

How often? Not more than every 2 years

Which bones? Spine, Hip, Femoral Neck

When to treat? Osteoporosis

Osteopenia with another risk factor

Lifestyle

Exercise, Calcium, Vitamin D, Smoking, AlcoholRisk Factors Age, activity, diet, meds (steroids>3 months), stability, previous

fracture, BMI


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Bone Densitometry Values

T Score: Standard Deviation comparison of a patients

bone density to a normal 25 yo.

We now have comparison tables by sex and ethnic group.Normal

T score >-1.0

Osteoporosis

T score < -2.5Osteopenia

T score -1.0 to -2.5


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National Osteoporosis RiskAssessment (NORA)

Bone Density RR 95% CI

Normal BMD 1

Osteopenia 1.8 1.49-2.18

Osteoporosis 4.03 3.59-4.53


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FRAX SCORE

WHO Fracture Risk Assessment Tool

Uses calculations based on patient data todetermine a 10-year risk of hip and majorosteoporosis-related fracture

http://www.shef.ac.uk/FRAX/index.htm


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NAMS Recommendations

Use lowest T-score to define diagnosisPrevention and nutritional measures firstDrug Treatment:

Any Vertebral FractureAll T-scores < -2.5Anyone on steroids >3 monthsT-scores of -2 to -2.5 if one risk factor

BMI


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Medical Workup

25-OH Vitamin D Levels

FSH

TSH

Parathyroid Hormone

Creatinine Clearance

Alkaline Phosphatase

Liver Enzymes

Celiac Antibodies

Protein Electrophoresis

24-hr. Urine Calcium, Creatine, Sodium, Free Cortisol


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Risk Factors used in FRAX

Geographic Region

Race

Sex

Height/Weight

Previous FragilityFracture

Family History ofOsteoporosis

Current Smoking

Steroid Use (5 mg/dafor over 3 months)

Rheumatoid Arthritis

SecondaryOsteoporosis

Alcohol (3 or more

units daily)BMD (T score atfemoral neck)


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So Whom Do We Treat?

Patients with previous hip or vertebralfracture

T score of -2.5 or less at femoral neck,total hip, or spine

T score of -1.0 to -2.5 (Osteopenia) AND: Other prior fracture

Secondary cause associated with high fracture risk

FRAX risk of 3% or more at hip

FRAX risk of 20% or more for major osteoporosisrelated fracture at any site


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Trends in TreatmentRecommendations

2003Patients with previous hipor vertebral fracture

T-score of -2 at hipT-score of -1.5 to -2 at hipPLUS additional riskfactor.

2008Patients with previous hipor vertebral fracture

T-score of -2.5 at femoralneck, total hip, or spine

T-score of -1 to -2.5 atfemoral neck, total hip, or

spine AND: Other fracture

Other risk factors

FRAX of 3% or more at hip

FRAX of 20% for other site


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Treatment Options

Nutrition and Supplements

Exercise

Fall Prevention

Alcohol and Nicotine AvoidancePharmaceuticals Bisphosphanates

SERMs

PTH HRT

Calcitonin


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Bisphosphanates

Generic

Alendronate

Risendronate

IbandronateZoledronic Acid

Pamidronate

Etidronate

Tiludronate

Brand Name

Fosamax

Actonel

BonivaReclast

Aredia

Didronel

Skelid


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BisphosphanatesPrevention Treatment Comments

Alendronate(Fosamax)

5 mg/da35 mg/wk

10 mg/da70 mg/wk

Must take on emptystomach, early am,with 8 oz. water, nofood for 30 min.

Risendronate(Actonel)

5 mg/da35 mg/wk75 mg 2 days/wk150 mg/mo

5 mg/da35 mg/wk75 mg 2 days/wk150 mg/mo

Same directions asfor Alendronate

Ibandronate(Boniva)

2.5 mg/da150 mg/mo3mg/3mo IVPCheck creatinine

before injection.

Same directions asfor Alendronate, butno food for 1hr.

Zoledronic Acid(Reclast)

5 mg. annually IVP Acute phasereaction muscleachesSome concern foratrial fibrillation


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Bisphosphanates

All are indicated for prevention and/ortreatment of postmenopausal osteoporosis

Bind permanently to bone to decreaseosteoclastic activity and increase bonemass

Concerns about bone quality (frozen

bone)

Implications for fertility contraindicated inwomen planning pregnancy


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Bisphosphanates

Similar efficacy

Adverse effects: Esophageal erosion,hypocalcemia, bone pain

Contraindications: esophageal dysmotility,significant renal dysfunction, hypocalcemia

Osteonecrosis of Jaw (ONJ):


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Estrogen Agonist/Antagonist(Formerly called SERMS)

Raloxifene (Evista)

Bind to ER, activating some/ blockingothers

Decrease vertebral fractures, but nosignificant effect on hip fractures

One 60 mg tab daily

Adverse Effects: hot flashes, VTE, legcramps

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


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Pharmacologic Treatment Options

Anabolics

Teriparatide (Forteo)

Antiresorptives

Calcitonin

Estrogens

SERMS (Raloxifene/Evista)

BisphosphanatesAlendronate

Risendronate

Ibandronate

Zoledronic Acid


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Recombinant Parathyroid Hormone(r-PTH:Teriparatide (Forteo)

Stimulates new bone formation

New fractures are significantly decreased

Vertebral decreased by 65%

Non vertebral decreased by 55%

Concern about malignancies in mice

Dosage 20 mcg SQ daily for 2 years

Cost - $20. per day

Neer, RM, et al. NEJM2001;344:1434-41


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Calcitonin (Miacalcin, Fortical)

Naturally occuring hormone whichantagonizes the effects of PTH

Reduces osteoclastic bone resorption

200 IU intranasal spray achieves 33%reduction in vertebral fractures inpostmenopausal women with prior

vertebral fractures (PROOF study)

Chestnut et al. Am J. Med.2000;109:267-276.


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Compliance FACT

After being prescribed a pharmaceutical forosteoporosis or osteopenia, less than 50%of patients have continued therapy at 6 mo

Cost issues

Side effect issues

Silent Disease issues

How can we affect this statistic???


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Lifestyle Issues

ExerciseCalcium

Vitamin D

Medications


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Poor Consumption of Vitamin DNHANES III DATA

National Health and Nutrition Evaluation

SurveyJ.Amer Diet Assn. 2004:104:980-983


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Bone Health

Calcium:35 RCTs document that calcium prevents orreduces bone loss in adultsDose Premenopausal (or on HRT): 1000 mg daily Postmenopausal: 1500 mg daily

Vitamin D:Oral Vitamin D between 700-800 IU/d

significantly reduces the risk of fractures400 IU/d is not sufficient for prevention


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Working Smarter, not Harder

Shared MedicalAppointments (SMA)

Basics Number served

Confidentiality statement Charges (99214)

25-40. 50% Counseling

Dexa SMA Data reviewed and

distributed Diagnoses established

Lifestyle measures

Therapies discussed


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FINISH

Thank you


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Prescription Nutritionals

3 Primary Concerns for Womens Health:Bone HealthCardiovascular HealthMental Well-Being

Primary Nutrients with Supporting Evidence:CalciumVitamin D

Omega-3 Fatty AcidsFolic AcidVitamin B 6


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Cardiovascular Health

Omega-3 Fatty Acids:Eskimo observational studiesNurses Health StudyPhysicians Health Study RR 0.77 decreased mortality 850 mg can be expected to save 20 lives per 1000 patients with CHD over 3.5 yrs.

Folic AcidLowers homocysteineImproves endothelial function

B VitaminsNurses Health Study RR 0.55 of MI in groups with highest levels of Folate and B 6

SHEEP Study

RR 0.66 of MI in women taking B vitamin supplementsCalciumSignificantly increases HDL:LDL RatioSuggests 30% reduction in CV events


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Mental Well-Being

Omega-3 Fatty AcidsReverses inflammation from Omega-6 anddysmenorrheaSignificant reduction in menstrual symptoms inadolescents

Calcium48% fewer PMS symptoms than placebo groupOsteoporosis risk much greater in women with history ofPMS

Folic AcidLow folate has been linked to depressionDepressed patients have increased homocysteine levels


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Prescribing Nutriceuticals

Write out above recommendations and sendthe patient to a pharmacy, healthfoodstore, Nutritionist, or Sams Club,

Or . . . .

Prescribe Nutriceuticals

ENCORA

METAGENICS


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Ideal Dosing of NutritionalSupplements for Women

Calcium1200 mg for women >51 (IOM)Doses >500 mg should be dividedBetter utilized if larger dose is at HS

Vitamin D400 IU (IOM) wrongNew evidence suggests 700-800 IUNeeded to absorb calcium and prevent hyperparathyroidism

Omega-3 Fatty Acids500/d in those at risk for CHD1000 mg/d if documented CHD (AHA)

Folic Acid400 mcg/d (IOM)0.8-5 mg being studied for CV benefitLarger dose in AM (prime time for MI)

Osteoporosis 2010

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