Osteoporosis Guidelines Review

							Osteoporosis Guidelines
       Review
           Dr. Karen Schultz
               April 2010
http://www.cmaj.ca/cgi/reprint/167/10_s
               uppl/s1.pdf
 The definition of osteoporosis is a
              low BMD
• True
• False
 FALSE…OP is oh so much more
        than BMD!
• Osteoporosis=―a skeletal disorder
  characterized by compromised bone
  strength predisposing a person to an
  increased risk of fracture. Bone strength
  reflects the integration of 2 main features:
  bone density and bone quality.‖
Decreased
Quantity=
            +
                Impaired bone
                   quality
                                =
Low BMD
   Who would you investigate for
         osteoporosis?
1. Someone with rheumatoid arthritis
2. A postmenopausal 56 year old woman
3. Someone whose CXR incidentally noted
   osteopenia
4. Someone complaining that they are 3
   inches shorter than they remembered
5. An alcoholic
How do you assess risk for OP, i.e.
low BMD and/or poor quality bone?
• Risk Factors—those majors and minors
Table 3: Factors that identify people who should be assessed for
osteoporosis
Major risk factors                                     Minor risk factors
• Age > 65 years*                     • Rheumatoid arthritis
• Vertebral compression fracture*            • Past history of clinical
                                                       hyperthyroidism
• Fragility fracture after age 40*           • Chronic anticonvulsant therapy
• Family history of osteoporotic fracture*
(especially maternal hip fracture)
                                             • Low dietary calcium intake
• Systemic glucocorticoid therapy*
of > 3 months duration
                                             • Smoker
                                             • Excessive alcohol intake
• Malabsorption syndrome                     • Excessive caffeine intake
• Primary hyperparathyroidism                • Weight < 57 kg
• Propensity to fall                         • Weight loss > 10% of weight at
                                                       age 25
• Osteopenia apparent on x-ray film          • Chronic heparin therapy
• Hypogonadism
• Early menopause (before age 45)

  *=markers for impaired bone quality
   Who would you investigate for
         osteoporosis?
1. Someone with rheumatoid arthritis (minor)-
   what if they were also on steroids?
2. A postmenopausal 56 year old woman
3. Someone whose CXR incidentally noted
   osteopenia (major)
4. Someone complaining that they are 3 inches
   shorter than they remembered (stay tuned….)
5. An alcoholic (minor…but what if they fell a lot
   in their drunken stupour?....)
   How would you investigate for
         osteoporosis?
1. Calcaneal USS
2. Bone turnover markers (i.e. alk phos,
   osteocalcin, etc)
3. Single photon absorptiometry (SPA)
4. Dual-energy xray absorptiometry (DXA)
5. Lateral thoracic xray
 What is the WHO definition of OP
            on DEXA?
1.   T score of -1.0
2.   Z score of -2.5
3.   Z score of -1.0
4.   T score of -2.5
         A new way of reporting:
              fracture risk
              Table 11.6. Ten-year fracture risk for women
                      Lowest T-Score
              Lumbar spine, total hip, femoral neck, trochanter

Age (years)   Low risk          Moderate risk              High risk
               <10%             10%–20%                    >20%

50            >–2.3             –2.3 to –3.9               <–3.9
55            >–1.9             –1.9 to –3.4               <–3.4
60            >–1.4             –1.4 to –3.0               <– 3.0
65            >–1.0             –1.0 to –2.6               <–2.6
70            >–0.8             –0.8 to –2.2               <–2.2
75            >–0.7             –0.7 to –2.1               <–2.1
80            >–0.6             –0.6 to –2.0               <–2.0
85            >–0.7             –0.7 to –2.2               <–2.2
    Using Fracture Risk to decide
          about treatments
• If also using steroids or fragility fracture
  bump up one risk category
• If both, bump up 2 (i.e. automatically
  highest risk)
• If risk <10% (low risk): healthy lifestyle
• If risk >20% (high risk):HLS + medications
• If risk 10-20% (moderate risk): HLS +
  personalize treatment
          NEWS FLASH:
      The 3C’s, an A and an S
• If you dx OP the following
  Lab tests are recommended in all patients
  to exclude secondary causes:
CBC
Ca
Cr
Alk Phos
SPE
 All patients should have adequate
     calcium and vitamin D. For
    patients over 50 adequate is:
1.   1000 mg elemental calcium and 400 IU Vit D
2.   1000 mg calcium carbonate and 400 IU Vit D
3.   1500 mg elemental calcium and 1000 IU Vit D
4.   1500 mg calcium carbonate and 1000 IU Vit D
5.   1500 mg elemental calcium and 800 IU Vit D
 ….and they should be physically
   active. For OP prevention
  purposes physically active is:
• Weight lifting at least 4 times a week
• Swimming >/= 30 minutes at least 3 times
  a week
• Aerobic activity x 30 minutes most days of
  the week
• Weight bearing exercise >/=30 minutes at
  least 3 times a week
 A 55 year old male has a 23% risk
   of fracture. Best management
              would be:
• Advise about exercise, ca and Vit D and
  redo BMD in 1-3 years
• Calcitonin
• Alendronate
• Risedronate
• Testosterone
    A 55 post menopausal woman with
       a BMD of -2.6 would best be
               treated with:
•   Raloxifene
•   Estrogen and progesterone
•   Etidronate
•   Risedronate
•   Alendronate
     A 55 year old woman with a BMD
    of -1.5 who fractured her wrist after
    tripping over a telephone cord and
     falling would best be treated with:
•   Estrogen and progesterone
•   Calcitonin
•   Alendronate
•   Risedronate
•   Etidronate
•   Raloxifene
 A 67 year old male with a BMD of
 -2.6 in his hip and -1.9 in his spine
     would best be treated with:
1.   Testosterone
2.   Etidronate
3.   Risedronate
4.   Alendronate
5.   Raloxifene
             Good Luck
May they ask you all the right questions