Osteoporosis - PowerPoint by 524qW6

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									  Presented by:
  Praharsha R. Menon, MD
  Emory Family Medicine
  10/21/2010

OSTEOPOROSIS:
SCREENING AND TREATMENT
                   DEFINITION:
  A progressive systematic skeletal disease characterized by
  low bone mass and micro-architectural deterioration of
  bone tissue, with a consequent increase in bone fragility
  and susceptibility to fracture



 Thick outer shell and a
  strong inner mesh filled
  with collagen (protein),
  calcium salts and other
  minerals
             A FEW POINTERS…
 Prevalence: 15 million in women and 3 million in men
                   RISK FACTORS
For osteoporosis                   For fragility fractures
 Female gender                   History of falls
 Increased age                   Poor physical condition
 Hypogonadism                    Dementia
 White race                      Impaired vision
 Low body mass index             Environmental hazards
 Family history                  Current use of
 Tobacco use                      benzodiazepines or
 History of fracture              anticonvulsants
 Chronic glucocorticoid or
  anticoagulant use
 Endocrinopathies
 High bone turnover and
  microarchitectural changes
                                             www.aafp.org/afp
             SCREENING GUIDELINES

 USPSTF (United States Preventive Services Task
    Force)

      NOF (National Osteoporosis Foundation)

    ISCD (International Society of Clinical
Densitometry
        USPSTF: SCREENING

 Routine screening:
•  F >/= 65 yo
• F>/= 60 yo if at increased risk for
  osteoporotic fractures             B
 No recommendation for or against routine
  screening in postmenopausal F <60 yo or in F
  < 60-64 yo who are not at increased risk for
  osteoporotic fractures            C
 All men >/= 70 yo    (NOF, ISCD)   C
                DEXA SCAN
 Dual-Energy X-Ray Absorptiometry
 Uses:
      diagnosis of low bone density
      prediction of fracture
      WHO definitions of osteoporosis and
  osteopenia
      Monitoring BMD in patients being treated
  for osteoporosis
 Low radiation, noninvasive, fast
        Which Skeletal Site(s) Should Be
                  Measured?

Every Patient:                       Some Patients:
• Spine : L1- L4                      • Forearm (33% radius,
• Hip                                 1/3 radius)
    – Total Hip                       – If hip or spine cannot
    – Femoral Neck                     be
                                      measured
NOF: uses femoral neck measurement
only                                  – Hyperparathyroidism
ISCD: uses both hip and spine
measurements
                                      – Very obese
The lowest score across sites
determines the diagnosis
 WHO classification with a T-score cannot be
  applied to premenopausal women, men
  under age 50, or children (Z score used)
 Best predictor of osteoporotic fracture: BMD
                   FRAX:
 Measures probability of fracture in the next
  10 years
 WHO task force led by John Kanis used data
 from nine epidemiological studies from the
  US, Europe, Australia, and Asia to determine
  risk factors for osteoporotic fracture
 Independent of BMD
 11 risk factors can be used +/_ BMD by DEXA
        RISK FACTORS BY FRAX
 Age (between 40 and 90 years)
 Sex (female and male)
 Weight in kg
 Height in cm
 Previous fracture while an adult
 Parental fracture (mother or father)
 Smoking (current)
 Alcohol (3 or more drinks daily)
 Systemic steroids (5 or more mg prednisone or more for 3 or
  more months, current or past history)
 Rheumatoid arthritis
 Secondary osteoporosis
    EVALUATION FOR SECONDARY OSTEOPOROSIS
   CMP including ALP, liver fxn, kidney fxn
   Calcium
   CBC
   TSH
   Total testosterone (men)
   25-hydroxyvitamin D (men)

Additional tests (based on level of severity of osteoporosis or
  clinical suspicion of underlying disease):
 Estradiol (pre- or perimenopausal women)
 Intact PTH
 Serum protein electrophoresis
 25-hydroxyvitamin D (women)
                         www.aafp.org
 US TREATMENT THRESHOLD BY FRAX
 10 - year probability of hip fracture > 3 %
                        or
 10 - year probability of major osteoporotic
fracture > 20%
                TREATMENT

 Antiresorptives:
Alendronate, Risedronate, Ibandronate,
Zoledronic acid, Raloxifene, Calcitonin,
Estrogen

 Anabolic (bone forming):
Teriparatide
 TREATMENT INDICATIONS: NOF

 Hip or vertebral fracture
 T-score -2.5 or less at femoral neck (or total
  hip) or spine
 T-score between -1 and -2.5 and a 3% (or
  greater) 10-year probability of hip fracture or
  a 20% (or greater) 10-year probability of
  major osteoporotic fracture, using FRAX
ALSO…

 T - score between -1 and -2.5 and :


  a disease or medication associated with
  osteoporosis

  prior fracture (other than hip or vertebral)
  and T - score between -1 and -2.5
               MEDICATIONS

TREATMENT              PREVENTION
• Alendronate          • Alendronate
• Risedronate          • Risedronate
                       • Ibandronate PO
• Ibandronate
                       • Raloxifene
  PO and IV
                       • Estrogen
• Zoledronic acid
• Raloxifene
• Teriparatide
• Calcitonin
NON-PHARMACOLOGIC TREATMENT
 Fall prevention
 Vitamin D:
 800 to 1,000 IU daily for persons 50 years
  and older (NOF)
 Documented vitamin D deficiency: oral
  vitamin D2 50,000 IU weekly for 8 weeks
  followed by a maintenance dosage of 50,000
  IU every two to four weeks
                         or
  oral cholecalciferol (vitamin D3) 1,000 IU
  once daily
 Calcium: at least 1200 mg daily
PREVENTION
               PREVENTION
 Adequate amounts of calcium


 Adequate amounts of vitamin D


 Regular exercise


 Lifestyle modification


 Screening in appropriate age groups
HEALTHY BONES FOR HEALTHY SOCIETY…
                     REFERENCES

   Diagnosis and Treatment of Osteoporosis: Sweet MG, et al.
    American Family Physician Feb., 2009
   Osteoporosis: Part I. Evaluation and AssessmentL South-Paul
    JE, et al. American Family PhysicianMar. 1, 2001
   www.uspreventiveservicestaskforce.org
   Mayoclinic.com

								
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