Management of Osteoporosis by uMYwGu

VIEWS: 5 PAGES: 45

									Managing Osteoporosis in the
      New Millennium


     Elena Barengolts, MD

       Associate Professor of
              Medicine
   University of Illinois at Chicago
        College of Medicine
            Osteoporosis



A disease of women,
 occasionally men,
  and rarely men
who dress like women
               Case #1

Mrs. White is an 82 year old female,
nursing home resident who has just
returned to the nursing home following
repair of a hip fracture she sustained
during a fall. She has mild dementia
(follows instructions) and a history of
breast cancer.
  Osteoporosis Epidemiology


• 1.3 million fractures per year
• Osteoporosis is 3 times more common
      than breast cancer
• Cost
      - $10 - 12 billion in 1990
      - $50 billion in 2040
             Case #2

Miss Scarlett is a 92 year old woman
who has recently suffered a painful
vertebral fracture. She is in a
wheelchair due to a stroke she
suffered 4 years ago. Her creatinine
is 2.4. She is frail with significant
kyphosis.
     Osteoporosis: More Common
     than Heart Attack in Women

    Annual Incidence of Common Disease
Osteoporotic Fracture                   > 1,000,000*
Heart Attack                                513,000**
Stroke                                      228,000^
Breast Cancer                               182,000^^
Uterine Cancer                               32,800^^
Ovarian Cancer                               26,600^^
Cervical Cancer                              15,800^^
*1993 estimated all ages       ^1991 estimated, women 30+
** 1991 estimated, women 29+   ^^1995 new cases, all women
             Case #3


Colonel Mustard who has suffered
with symptomatic GERD for the last
10 years, falls and breaks a hip. He
is 65 years old and has no apparent
risk for osteoporosis.
           Hip Fracture Outcomes

• 24% mortality within first year1
• 50% of hip fracture sufferers unable
     to walk without assistance2
• ~ 33% totally dependent3
• 7.8% need long-term nursing home
     care for an average of 7.6 years4
   1   Ray, NF et al. J Bone Miner Res 1997; 12:24-35
   2   Riggs, BL, Melton LJ III. Bone 1995; 17 (Suppl): 505S-511S
   3   Kannus, P et al. Bone 1996;18 (Suppl): 57S-63S
   4   Chrischilles EA et al. Arch Intern Med 1991; 151: 2026-32
                Case #4
 Professor Plum who is an expert on
osteoporosis, is worried about his 50 yo
daughter. Her mother, the professor’s
wife, recently had a hip fracture due to
severe osteoporosis. Ms. Plum is of small
build, smokes cigarettes 1 ppd x 25 y,
drinks lots of coffee and is a self-admitted
couch potato. She refuses HRT but
agrees to a DEXA. Her T-score is -1.7 at
the L spine and -1.8 at the hip.
Modifiable Risk Factors

• Behavioral
     Inactivity
     Alcohol abuse
     Cigarette smoking
• Nutritional
     Low calcium intake
     Low vitamin D intake
     Caffeine excess
• Drugs
• Low BMD
            Case #5


Mr. Green is a 70 year old man
with a recent history of prednisone
use to manage temporal arteritis.
He recently sustained a fracture of
the left wrist after falling down his
stairs. A DEXA scan reveals a T-
score of -2.6 at the hip and -2.0 at
the lumbar spine.
       Drugs


• Glucocorticoids
• Thyroid hormone excess
• Anticonvulsants
• Heparin, warfarin
• Cyclosporin A
• Methotrexate
• GnRH analogs
              Case #7


Sorry, no chance to help Mr. Body.
He was found dead, in the hall, after
tripping over the candlestick, falling
down the stairs and breaking both
hips! If only his doctor had identified
his advanced osteoporosis.
    Osteoporosis: Evaluation

• Bone mass measurement devices

    • Central

    • Peripheral

• Bone turnover
          Osteoporosis:
     Diagnosis and Evaluation

• Central DXA
  (Dual Energy X-ray
  Absorptiometry)
  remains the state-of-
  the-art diagnostic
  standard
• Bone density is the
  most important
  predictor of
  fracture risk
  World Health Organization
(WHO) Osteoporosis Guidelines




                                T - Score
 WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.
 Osteoporosis prevention and
         screening

• Increased dietary calcium & Vit. D

• Exercise - weight bearing
    (walking, dancing, some
    exercise classes)

• Recommend a BMD test
              Calcium absorption
• Adult average 30% (20-70%)
  • Most efficient-Duodenum, proximal jejunum
  • Largest amount- distal jejunum, ileum
• Mechanism:
  • Cellular=active: in vesicles & and bound to calbindin
  • Paracellular=passive: diffusion
• Vitamin D: increased synthesis of calbindin
• Other factors
  • Estrogen: via increased vit D synthesis
  • Glucocort: via reduced paracellular diffusion
  • Thyrotoxicosis & acidosis: via decreased vit D syn Alcohol:
    direct toxic effect on enterocytes
            Endocrinology Ed. L. DeGroot Saunders Co 2001, pp.1030-1033
               Calcium bioavailability
              RDA for Ca 1000 mg/day
• Increased: growth spurt, pregnancy
  • intestinal pH 4-6 – after a meal
  • bile salts
  • lactose: milk
• Decreased:
  • Aging
  • dietary high fiber: impair bile reabsorption
  • Phytates/ cellulose: wheat bran cereal
  • oxalate: spinach, rhubarb, tea
• Neutral or negligible effect:
  • Protein, fat, magnesium, phosporus, caffeine
               Heaney RP et al, Consensus Opinion, Menopause 2001;8:84-95
               Endocrinology Ed. L. DeGroot Saunders Co 2001, pp.1030-1033
    Normal response to varying Ca intake
           Endocrinology Ed. L. DeGroot Saunders Co 2001, pp.1030-1033


•   Calcium                                       mg/day
•   Dietary intake Ca                            220 850 2100
•   Absorbed Ca*                                 150 340 490
•   Efficiency,%                                 68 4    23
•   Renal Ca excretion                           150 210 260
•   Skeletal Ca uptake**                         420 420 420
•   Skeletal Ca release**                        530 420 350
•   Total Ca balance                             -110 0 +70
* diet-fecal calcium correcrted for endgns fecal Ca
**values calculated with compartmental model
       Calcium intake- the best
        source of Ca is food

• Total calcium intake – most important
  • With higher intake % absrbed dcrs but total
    amount absorbed increased
• Absorptive efficiency – individualized
  • Is not completely understood
  • Relates to nutrition, hormonal status, physical
    activity, drugs, alcohol
         Calcium absorption

• From milk 30%
• From vegetables and grains same as
  milk or slightly better
• Less than milk:
  • high phytic acid: wheat bran cereal, soy bean
  • High oxalate: spinach (5% vs 30% milk)
          RP Heaney J Int Med 1992:231:169-180 RP
       Heaney, CM Weaver Am J Clin Nutr 1991;53:745-47;
 Practical Approach to Dietary Ca
        Dietary intake estimation
Product                     Calcium (mg)
Milk, whole/skim (8 oz.)               300
Yogurt - lowfat (8 oz.)                400
Cheese (1 oz.)                         200
Ice cream, ½ cup                       100
OJ - Ca fortified, (8 oz.)             300
Sardines w. bones (3 oz)               370
Salmon w. bones (3 oz)                 200
Total = dairy Ca + 250 for all nondairy
                  Heaney RP et al, Consensus Opinion, Menopause 2001;8:84-95
Dietary Changes for Vegetarians

    FOOD                        CA, mg
Baked beans, 1/2 c. cooked     154
Almonds, 1/4 cup               100
Sesame seeds, Tbsp              33
Broccoli, fresh, cooked, 1 c   150
Bok choy, 1 c cooked/raw       150/200
Collards, fresh, cooked, 1 c   350
Turnip greens, 1 c             200
Figs, dried, 10 figs           270
Soybean curd (tofu), 4 oz      150
  Practical Approach to Dietary Ca


  Fortified foods                              CA, mg
Soy milk, 1c                            100-300
Milk, 1c                                500
Cereal, w/o milk, 1c                    100-1000
Fruit juice, 1c                         300
Breakfast bars, 1 bar                   200-500
    Heaney RP et al, Consensus Opinion, Menopause 2001;8:84-95
       Practical Approach to Ca
              supplement

•   Which is the best?
•   When to take?
•   With or between meal, bed time
•   Once a day or divided doses?
            Calcium absorption
• Coingestion with food - 20-25%
  improved absorbtion of both food and
  supplented Ca compared to empty
  stomach
• Improved absorbtion: Chewable,
  effervescent
• Divided doses but worse compliance
• Bed time - prevents PTH-mediated
        resorption during the fasting at
  bone RP Heaney et al. Am J Clin Nutr 1989;49;372-6 RP Heaney
  night               J Int Med 1992;231:169-80
   Ca supplement - absorption

• Preparation       Fractional absorption
• Hydroxyapatite         0.203 ± 0.110
• Tricalcium phosphate 0.252 ± 0.13
• Carbonate              0.296 ± 0.054
• Citrate                0.296 ± 0.060
• Bone meal/oyster shell 0.333 ± 0.113
• Bisglycinocalcium*     0.440 ± 0.104
 *Chelated to amino acids
         Carr CJ, Shangraw RF Am pharm 1987:NS27:49-57
       Ca absorption from food

•   Food             Fractional absorption
•   Milk                   0.339 ± 0.095
•   Spinach                0.012 ± 0.007
•   Low phytate soybeans 0.306 ± 0.054
•   Kale                   0.405 ± 0.101
•   Mean value ± SD measured under
    standard meal conditions

              RP Heaney J Int Med 1992;231:169-80
     Risk Factors for vitamin D
            deficiency
•   Lack of sunlight exposure
•   Dietary lack
•   Malabsorption
•   Liver disease
•   Renal disease
•   Anticonvulsants
     Vitamin D Considerations


• Casual exposure to sunlight provides
      most of our Vitamin D requirements
• At latitude 42º N (Chicago), ultraviolet
      exposure is inadequate for
      producing sufficient Vit D in the skin
      between November and February
        Lifestyle Approach to Vit D

• Vitamin D fortified milk (8 oz = 50 IU)
• Egg yolk
• Liver of salt water fish = cod liver
• Fortified cereal (“Total” 1 cup 40 IU)
• 15 min. of daily sun exposure
     provides about 400 IU of Vit D
         Practical Approach to Vit D
• Most multivitamins (200 - 400 IU)
• Cholecalciferol (D3) 400 IU in
    combination with Calcium (OTC)
• Ergocalciferol (D2) 50,000 IU or 8,000 IU/ml
  drops (Calciferol)
• Calcifediol (25 OH D3) 20, 50 mcg (Calderol)
• Calcitriol 1,25 (OH)2 D 0.25 - 0.5 mcg
  (Rocaltrol)
              Chinese Vegetable Stir-Fry

Thickener:1/4 cup water,2 Tbsp light soy sauce, 1/8 tsp pepper, 1
tsp olive oil. Tofu Mixture:1 packet firm tofu, cut into 1/2 inch
cubes and drained, 3/4 cup onion, cubed, 2 large cloves garlic,
minced. Veggie: Chopped:1/2 bunch broccoli, 1 small zucchini, 1
cup green/red bell pepper, 1 cup collard, kale or bok choy, 2 large
tomatoes, 1/2 cup vegetable broth.
Method: In wok add oil & Tofu Mixture, stir-fry for 3-4 min. Onion
and tofu should begin to brown. Add broth &Veggie and simmer
for 10 min. Add tomatoes, cover and cook for 5 min. Add thickener
and cook, stirring for 3 min. Serve over rice or noodles.


Yield: 8 servings, per serving: cal 126 Kcal, carb 12 gm, protein:
10 gm, fat: 4 gm, calcium 200 mg
• 2 cups 1% milk
• 2 cups cereal “Total”
• Mix in a bowl, stir for 30 sec
• Yield: 2 serving, per serving:
calories 150, fat 8 g,
carb 12 g, protein 8 g,
calcium 800 mg

								
To top