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OSTEOPOROSIS Powered By Docstoc
					The Management and Treatment
      of Osteoporosis

     Michele Vaca Hossack, MD
• To reinforce the US Preventive Services
  Task Force Recommendations for
  Osteoporosis screening
• The management of Osteoporosis in
  females, males and elderly patients s/p
• The teach the interpretation of Dexa Scans
• To present Evidence Based Medicine in
  comparing the efficacy of the treatment
  options for osteoporosis
• Osteoporosis- state of severe bone loss and
  microarchitectural disturbance that renders
  bone susceptible to fracture with minimal

• Osteopenia- Any state in which bone mass
  is reduced below normal
     Osteoporosis vs. Osteopenia
T -score                Degree of      Risk of
(No of SD below         bone loss      Fracture
mean of young adults)
0 to -1                 Normal         None

-1 to -2.5              Osteopenia     Small to
Below 2.5               Osteoporosis   Moderate to
Why is Osteoporosis important?
• Of women who survive to age 80 40% will
  sustain one major osteoporotic fracture
• 13% of men over 50 will have osteoporotic
• 1 in 3 men aged > 60 will have an
  osteoporotic fracture
• fractures decrease quality of life
• The annual cost of osteoporotic fractures
  exceeds 10 billion dollars
      Serious Consequences of
         vertebral fractures
• Compression fractures cause chronic back
• Compression fractures are disabling
• fecal incontinence
• can lead to isolation and depression
• increased risk for additional vertebral
  fractures within 12 months (The mortality
  rate for multiple fractures is 20%)
• cause of nursing home placement
   Serious Consequences of hip
• Hip fractures 20% of women die within one
  year of fracture
• only 40% regain baseline level of function
• frequent cause of nursing home placement
• if an ORIF of hip is not done in 24-48 hrs a
  step off walking deformity is common
              Clinical Case
• 66 y/o female c chronic back pain x 2yrs.
  Pt c back pain increasing in intensity over
  the past week. Pt. recalls falling down on
  the pavement and landing on her rear end
  several months ago, but no recent trauma.
  PMHX sig for osteoarthritis, HTN, and
  hypercholesterolemia PSHX none

• Meds HCTZ, naprosyn, ranitidine
          What would you do?
•   Lumbar x-ray
•   rest
•   ice
•   Naprosyn
•   Ultram (tramadol) for breakthrough pain
•   Dexa Scan
• The patient returns in 4 weeks with some
  improvement with pain medications, but
  continues to experience pain 5/10 3x’s a
• lumbar xray-
• Dexa Scan-
       Representative Scheme for
        Interpreting DEXA Scan
• T-score               Degree of     Risk of
(No. of SD below        bone loss     fracture
mean of young adults)

 0 to -1                none          none
-1 to -2                moderate      small
-2 to -3                severe        moderate
Below -3                Very severe   Severe
     Osteoporosis vs. Osteopenia
T -score                Degree of      Risk of
(No of SD below         bone loss      Fracture
mean of young adults)
0 to -1                 Normal         None

-1 to -2.5              Osteopenia     Small to
Below 2.5               Osteoporosis   Moderate to
                 Who to treat?
• Patients c fractures of hip and spine
• Dexa Score >2.5
• Dexa Score 1.5 to 2.5 if risk factors are
  –   postmenopausal women
  –   women > 65, men > 70
  –   glucocorticoids
  –   history of fracture
  –   High fall risk
  –   family history of osteoporosis
      How would you manage this
• Inquire about             •Narcotics if needed
  medication’s side         to get patient mobile
  effects                   •Limit bed rest and
• Insure adherence with     inactivity
  medication plan           •Physical therapy to prevent
• Tailor medication         immobility
  regimen to the patient    •heat
• Use non-narcotics first   •nasal calcitonin
  (Naprosyn, Tylenol)       •orthopaedic referral
     Rule out secondary causes of
•   CBC
•   Chem 10 (calcium, phosphorus, albumin)
•   25-OH Vitamin D
•   24-hr urine calcium
•   tsh if on thyroxine
•   spep if cbc is abnormal
•   PTH if serum or urine calcium abnormal
• Calcium intake (1200-1500mg/day)
• Vitamin D (800 IU/day)
• Weight Bearing Exercise (Walking, Biking)
• Life-style modification (moderate alcohol,
  no smoking)
• Fall Risk Prevention
• avoid sedatives, narcotics, anticholinergics
•   Alendronate (FDA approved)
•   Risedronate (FDA approved)
•   Raloxifene (FDA approved)
•   Nasal Calcitonin (FDA approved)
•   Parenteral Calcitonin (FDA approved)

• Teriparatide (FDA approved)
    – anabolic effect on Bone
• Wehren et. al, Putting evidence-based medicine into
  clinical practice: Comparing anti-resorptive agents for the
  treatment of osteoporosis. Current Medical Resident
  Opinion. 2004 Jul;20(7): 1161-2
• A Meta-analyses study at the University of
  Maryland School of Medicine which
  utilized published data by the Osteoporosis
  Research Advisory Group, and the
  Osteoporosis Methodology Group
• Alendronate was 34% more effective than
  calcitonin (confidence interval .48-.90) on
  vertebral fracture incidence
• Alendronate was significantly more
  effective than risedronate, calcitonin,
  estrogen, etidronate, raloxifene (Relative
  Risk: .70, .64, .59, .52) on the incidence of
  non-vertebral fractures

• Luckey et. al, Once-weekly alendronate 70
  mg and raloxifene 60 mg daily in the
  tretment of postmenopausal osteoporosis.
  Menopause. 2004; Jul-Aug; 11(4):405-15.
   Alendronate 70mg qweek vs
      Raloxifene 60 mg qd
• 12 month randomized , double-blind study
• 456 women with osteoporosis at 52 sites in
  the United States
• Endpoint: percent change from baseline
  after 1 year
• Alendronate significant increase in LS
  BMD 4.4%, p<.001) than raloxifene 1.9%,
• Alendronate significant increase in hip
  BMD , p<.001) than raloxifene
• Bisphosphonates
  – proven effective to prevent hip, vertebral, and
    Colle’s fractures.
  – Side effect GI upset
• Raloxifene
  – Proven effective in patients with low BMD in
    the vertebrae
  – Not proven effective in patients with low BMD
    in the appendicular skeleton
  – patients who can not tolerate GI side effects of
• Teriparatide (1-34 Fragment of Parathyroid
  –   administered parenteral
  –   expensive
  –   oriented for severe osteoporosis
  –   prevalent vertebral fractures

• Stronium (not FDA approved)
  – anti-fracture efficacy at all sites
  – good tolerance
  – may play a role in the future
    Women’s Health Initiative
• Estrogen-progestin does not reduce the risk
  of coronary heart disease
• increases the risk of breast cancer
• increases the risk of stroke
• increases the risk of venous
  thromboembolic events
• decreases vertebral compression and hip
       Surveillance Screening
• In this patient, when would you repeat a
  Dexa Scan?
• Repeat scan after 1 year of treatment
              Clinical Case
• 120 lb , 130/80
• 60 y/o f c migraine headaches that occur
  once a month presents to the office.
  PMHX: HTN             PSHX: none
• After addressing her chief complaint, Do
  you screen this patient for osteoporosis?
• If this patient was 65 would you screen for
   U.S.Preventive Services Task
     Force Recommendations
• Women aged 65 and        • No recommendation
  older be screened          for or against routine
  routinely for              screening for women
  osteoporosis               who are younger than
• Women aged 60 and          60 or in women aged
  older c increased risk     60-64 who are not at
  for osteoporotic           increased risk for
  fractures                  osteoporotic fractures.
• Rating of                • Rating of
  Recommendation B           Recommendation C
     ORAI-Osteoporosis Risk
      Assessment Instrument
• Lower body weight (weight < 70 kg)
• no use of estrogen therapy
• age
  – women
     • greater than 65
     • greater than 60 c risk factors
  – men
     • greater than 70
 Identifying High Risk Patients
• Ask about fractures   • early menopause
  (low trauma >40)      • s/p oopherectomy at
• Ask about family        an early age
  history               • Disease and
• Measure Height          medications that
• check weight            increase risk
• check smoking,        • caffeine
  alcohol               • low calcium and
• check for               vitamin D intake
  glucorcorticoid use   • decreased physical
             Clinical Case
• 135 lbs, 130/80
• 65 y/o male s c/o.
• PMHX: HTN , Hypercholesterolemia,
  DM,Prostate Cancer
• Meds: atenolol, lipitor, glucophage, lupron
• For Health Care Maintenance, Would you
  screen this patient for osteoporosis?
     US Preventive Task Force
     Recommendation for Men
• Men greater than or   • Men greater than or
  equal 70 y/o should     equal 65 y/o c risk
  have DEXA screening     factor should have
                          DEXA screening
         Osteoporosis in Men
• one in three men aged > 60 will have an
  osteoporotic fracture
• Spinal fractures occur in 5% of men >50
• hip fractures occur in 6% of men >50
• life expectancy for men 76.8 years

• Diamond, T. Pharmacotherapy of osteoporosis in
  men. Expert Opinion Pharmacotherapy. 2005
  Jan; 6(1):45-58.
  Diseases that cause Bone loss
• Glucocorticoids
• Hypogonadism (GNRH agonist Rx for
  prostate cancer)
• alcoholism
• Hyperparathyroidism
• Gastrectomy
• Glucocorticoids
• Anticonvulsants
• Organ Transplantation
   Definition of Osteoporosis in
• Who criteria based on bone density in
  wormen only
• ISCD recommends the use of a male
  database as a reference population
• for the prevalence of osteoporosis is then
  similar to the prevalence of fractures in men

• NHANES data
    What would be your work up to
      rule out secondary causes
•   Cbc
•   chemistry 10
•   Phosphorus
•   24-hour urine calcium
•   25 hydroxyvitamin D
•   Testosterone
•   TFTs (if on thyroxine)
•   PTH (if 24-hour unrine calcium is
•   Calcium intake (1200-1500mg/day)
•   Vitamin D (800 IU/day)
•   Exercise
•   Life-style modification (moderate alcohol,
    no smoking)
•   Alendronate (FDA approved)
•   Risedronate (FDA approved)
•   Raloxifene (FDA approved)
•   Teriparatide (FDA Approved)

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