Rami Mortada, MDAssistant Professor
Division of EndocrinologyKansas University – Wichita
OsteoporosisThe silent disease
Outline
• What is osteoporosis ??• Why should you care ??• Who is at risk ??• How/who needs to be checked ??• Treatment
– Ca and Vit D– Medication
Osteoporosis: The silent disease
Fracture might be the initial presentation
What is osteoporosis ?
Definition of Osteoporosis
Thin and brittle bone which make them more fragile with increased risk of fractures
.
Normal Bone Osteoporotic Bone
NIH Consensus Development Panel on Osteoporosis. JAMA. 2001;285:785-795.
Bone is a living organ
Bone remodeling
Remodeling
Bone Remodeling Unit: 1. ActivationAverage time to complete: 2. Resorption
~ 6 months 3. Reversal 4. Formation
Peak bone mass
Why do we get osteoporosis ??
X
X
+++ Resorption + Formation
Why do we get osteoporosis ??
How does osteoporosis happen ??
• FAILURE TO ACHIEVE PEAK BONE MASS
• DISORDER OF BONE REMODELING– BONE LOSS > BONE FORMATION
Why should you care ??
SITE INCREASE IN MORTALITY RISK
Vertebrae 8.6
Hip 6.7
Any Clinical Fracture 2.2
Fracture and risk of death
Who is at risk ??
Risk Factors: female sex
VS
Women have four times risk of osteoporosis compared to men
Risk factors: smoking
Smoking is a major risk factor for osteoporosis
Risk factors: Low body weight
Risk factor: Aging
Risk factor: Menopause
20% bone loss in the 5 years after menopause
Risk factor: fragility factor
• History of fragility fracture• 1st degree relative with Osteoporosis or fragility
fracture
24
Other Risk Factors
• Absence of menstrual cycles • Diet low in calcium, low Vitamin D • Certain medications • Hormone disorder: thyroid, parathyroid, prolactin…
How do you check for osteoporosis ??
Bone density
Bone density: DEXA scan
Bone density images
Who needs a bone density ??
• Age 65 or older• Previous fracture with little trauma or vertebral fracture • Family history of osteoporosis• Long term use of glucocorticoids (like prednisone)• Early Menopause (before age 45)• Alcohol• Smoking
T-score
A SCORE COMPARING BONE DENSITY TO PEAK BONE DENSITY OF AN ADULT OF THE
SAME SEX
Status T-score
Normal +2.5 to −1.0, inclusive
Osteopenia Between −1.0 and −2.5
Osteoporosis ≤−2.5
Severe osteoporosis ≤−2.5 + fragility fracture
T score result
T score is not enough…
0
5
10
15
20
-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1
BMD T-score
Hip
frac
ture
ris
k (%
per
10
Yea
rs)
The relationship between BMD and fracture risk varies with age.
Kanis et al, Osteopor Int 2001
50
60
70
80
AGE
AGE T-Score = -1.0
T-Score= -2.5
50 6 % 11 %
60 8 % 16 %
70 12 % 23 %
80 13 % 26 %
Risk of Fractures Over 10 Years in Women
Who needs to get treated ??
Who needs to be treated ??
• Osteoporosis ( T score > -2.5)
• Osteopenia with increased risk of fracture
Sample FRAX Calculation:
What are the treatment options ??
Universal measurement for osteoporosis prevention and treatment : Risk factor reduction
Universal measurement for osteoporosis prevention and treatment : Risk factor reduction
Stop Moderate Limit GC
Fall prevention: weight bearing exercise
Weightbearing exercise
Universal measurement for osteoporosis prevention and treatment : Fall prevention
1. Make an appointment with your doctor2. Keep moving3. Wear sensible shoes4. Avoid home hazard5. Light up your living space6. Use assistive devices
Treatment
Calcium 1200 mg / day is recommended
Treatment: Vitamin D
Vit D
Vit D
Vit D
Ca ++
Ca ++ Ca ++
Ca ++Ca ++
Ca ++
Ca ++
1000- 2000 U Daily
Medication for osteoporosis
• Anti resorptive-agents: Stop bone loss
• Anabolic agent: Increase bone formation
Bisphosphonates• Fosamax, Actonel, Boniva, Reclast• The big gun in osteoporosis treatment
Effects• Significantly stop bone loss – anti-resorptive• Reduce vertebral fractures 60%-70% at 3 years• Reduce hip fractures 40%-50% at 3 years• Pills: daily, monthly and weekly • Intravenous: once yearly
BMD
Subjects: Postmenopausal women with low BMD
Response to Long-term Alendronate
Adapted with permission from Bone HG, et al. N Engl J Med. 2004;350:1189-1199.
Urinary N-telopeptide
Placebo
Alendronate 10 mg
Alendronate 10 mg
0
4
8
12
16
% c
hang
e fr
om b
asel
ine
-100
-80
-60
-40
-20
0
% C
hang
e fr
om b
asel
ine
0 2 4 6 8 10
Years0 2 4 6 8 10
Years
Lumbar spine
Femoral Neck
Safety of bisphosphonate
• Reflux disease and ulcer• Worsening of kidney disease
Osteonecrosis of the jaw Atypical femur fracture
How about a holiday ???
Bisphosphonate holiday after 5 years
Raloxifene: Estrogen Agonist/Antagonists
Effects• Anti-resorptive: Stop bone loss• Reduces spine fracture and increases BMD• No hip fracture protection• Breast cancer risk reduction• No endometrial proliferation or cancer
Side effects• Blood clots • May increase hot flashes
Evista [package insert]. Indianapolis, IN: Eli Lilly and Company; 2007.
Estrogen
• Anti-resorptive: stop bone loss– Risk reduction of 34% for vertebral and hip fractures after
5 years
• Indications– Prevention of postmenopausal osteoporosis– Long-term treatment not recommended
• Contraindications– Thromboembolic disease, breast cancer, CVD, stroke,
abnormal genital bleeding, estrogen-dependent cancer
Denosumab
• Skeletal Effects – Anti-resorptive– Risk reduction vertebral fracture 38%,
hip fracture 58% after 5 years– Injection,
• Indications– Severe osteoporosis– Intolerance to bisphosphonate
• Side effects– Decreasing Calcium level, increasing
infection ( maybe)– No long term data about safety profile
Teriparatide
• Skeletal Effects –Anabolic – Decrease vertebral fracture 68%,
hip fracture 40%– Daily injection x 3 years
• Indications– Severe osteoporosis ( T -2.5-4)
• Best treatment available, must be followed by a course of anti resorptive therapy
Word of wisdom
The most important prevention and treatment of osteoporosis is likely to remain the same: diet and exercise
Conclusion
• Osteoporosis is a serious but silent disease • Due to decreased bone formation or increased bone loss • Early prevention is the key element to prevent fracture • Diet and exercise is the cornerstone for osteoporosis
prevention and treatment • Screen with bone density at age 65, sooner if any risk factor • Treatment is effective in decreasing fracture risks
Thank you
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