Osteoporosis/Osteopenia

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Osteoporosis/Osteopenia

  1. 1. OsteoporosisOsteoporosis Capital Conference 2007Capital Conference 2007 Marc Childress, MDMarc Childress, MD
  2. 2. OsteoporosisOsteoporosis  EpidemiologyEpidemiology  Risk FactorsRisk Factors  PreventionPrevention  ScreeningScreening  DiagnosisDiagnosis  TreatmentTreatment  Osteoporosis in MenOsteoporosis in Men  ManagementManagement  FallsFalls  Acute ComplicationsAcute Complications
  3. 3. OsteoporosisOsteoporosis  Average female bone mineral density peaks at age 35,Average female bone mineral density peaks at age 35, slow decline thereafterslow decline thereafter  Density loss is accelerated post-menopausallyDensity loss is accelerated post-menopausally
  4. 4. EpidemiologyEpidemiology  1.3 million osteoporotic fractures in U.S. every1.3 million osteoporotic fractures in U.S. every yearyear  40% of women over 50 have osteopenia40% of women over 50 have osteopenia  7% of women over 50 have osteoporosis7% of women over 50 have osteoporosis  Presence of osteoporosis carries 4-fold increasePresence of osteoporosis carries 4-fold increase in fracture rate (over 50 years old)in fracture rate (over 50 years old)
  5. 5. EpidemiologyEpidemiology  Among those who live toAmong those who live to 90 years old, 1/3 of90 years old, 1/3 of women and 1/6 of menwomen and 1/6 of men will have sustainedwill have sustained osteoporotic fractureosteoporotic fracture  Hip fracture mortality atHip fracture mortality at 1 year is approaching1 year is approaching 25%25%
  6. 6. Risk FactorsRisk Factors  Female GenderFemale Gender  3X more likely to have hip or vertebral fracture than3X more likely to have hip or vertebral fracture than menmen  6X more likely to have forearm fracture6X more likely to have forearm fracture  Caucasian RaceCaucasian Race  Higher than African-American, Asian raceHigher than African-American, Asian race  SmokingSmoking  Low Body Weight (less than 58 kilos)Low Body Weight (less than 58 kilos)
  7. 7. Risk Factors (cont’d)Risk Factors (cont’d)  Sedentary LifestyleSedentary Lifestyle  Excessive Alcohol IntakeExcessive Alcohol Intake  Ample suggestion that moderate alcohol intake mayAmple suggestion that moderate alcohol intake may be protectivebe protective  No clear thresholdNo clear threshold  Nursing Home ResidentsNursing Home Residents  10X more likely to experience hip fracture than age-10X more likely to experience hip fracture than age- matched non-residentsmatched non-residents
  8. 8. Predisposing Medical ConditionsPredisposing Medical Conditions  Estrogen DeficiencyEstrogen Deficiency  Inflammatory BowelInflammatory Bowel DiseaseDisease  Type 2 Diabetes MellitusType 2 Diabetes Mellitus  Celiac diseaseCeliac disease  Cystic fibrosisCystic fibrosis  HyperthyroidismHyperthyroidism  HyperparathyroidismHyperparathyroidism  HypogonadismHypogonadism  Liver DiseaseLiver Disease  Corticosteroid useCorticosteroid use  Heparin useHeparin use  Cyclosporine useCyclosporine use  Depo-Provera useDepo-Provera use  Vitamin A (systemicVitamin A (systemic retinoid) useretinoid) use
  9. 9. Risk Factors (cont’d)Risk Factors (cont’d)  No clear increase in riskNo clear increase in risk with carbonatedwith carbonated beveragesbeverages  Although unclear riskAlthough unclear risk association with excessiveassociation with excessive caffeinecaffeine
  10. 10. What they want you to know…What they want you to know…  Chronic excess thyroid hormone replacement over aChronic excess thyroid hormone replacement over a number of years in post-menopausal women can lead tonumber of years in post-menopausal women can lead to  diffuse nontoxic goiterdiffuse nontoxic goiter  osteoarthritisosteoarthritis  osteoporosis  hyperparathyroidismhyperparathyroidism
  11. 11. What they want you to know…What they want you to know…  A 31-year-old white female presents with her third stress fractureA 31-year-old white female presents with her third stress fracture of a lower extremity in the past 4 years. Her history andof a lower extremity in the past 4 years. Her history and examination are otherwise unremarkable except for a controlledexamination are otherwise unremarkable except for a controlled seizure disorder.seizure disorder. The most likely cause of her bone problem isThe most likely cause of her bone problem is  Addison’s diseaseAddison’s disease  HypothyroidismHypothyroidism  Osteogenesis imperfectaOsteogenesis imperfecta  Anticonvulsive medicationAnticonvulsive medication
  12. 12. PreventionPrevention  Adequate total dietary calciumAdequate total dietary calcium  1500 mg/day for postmenopausal without HRT1500 mg/day for postmenopausal without HRT  1000-1200 mg/day premen, postmen with HRT1000-1200 mg/day premen, postmen with HRT  Vitamin DVitamin D  800 IU/day for postmenopausal800 IU/day for postmenopausal  400 IU/day premen, postmen with HRT400 IU/day premen, postmen with HRT  Regular weight-bearing exerciseRegular weight-bearing exercise  Additional protective factors: increased BMI, African-Additional protective factors: increased BMI, African- American ethnicity, moderate EtOH intakeAmerican ethnicity, moderate EtOH intake
  13. 13. What they want you to know…What they want you to know…  Which of the following antihypertensives agents may help preserve bone mineral density?Which of the following antihypertensives agents may help preserve bone mineral density?  Atenolol (Tenormin)Atenolol (Tenormin)  Doxazosin (Cardura)Doxazosin (Cardura)  Enalapril (Vasotec)Enalapril (Vasotec)  HydrochlorothiazideHydrochlorothiazide  Nifedipine (Procardia, Adalat)Nifedipine (Procardia, Adalat)  Which one of the following is associated with a reduced risk of post-menopausalWhich one of the following is associated with a reduced risk of post-menopausal osteoporosis?osteoporosis?  Corticosteroid useCorticosteroid use  Cigarette smokingCigarette smoking  Diuretic useDiuretic use  Low BMILow BMI  Asian EthnicityAsian Ethnicity
  14. 14. ScreeningScreening  USPTF/AAFPUSPTF/AAFP— “routine screening” above— “routine screening” above the age of 65, consider between 60-65 forthe age of 65, consider between 60-65 for increased riskincreased risk  National Osteoporosis Foundation—National Osteoporosis Foundation— recommend screening above 65, or in youngerrecommend screening above 65, or in younger with risk factorswith risk factors  Difficulty with recommendationsDifficulty with recommendations  Cost issues  Time interval of screening examination
  15. 15. Screening OptionsScreening Options  Single Photon absorptiometrySingle Photon absorptiometry  -can only be used at radius or calcaneus (unclear attenuation-can only be used at radius or calcaneus (unclear attenuation source)source)  Dual Photon absorptiometryDual Photon absorptiometry  -can be used at deeper sites (spine,hip)-can be used at deeper sites (spine,hip)
  16. 16. Screening OptionsScreening Options  Dual X-ray absorptiometry (DEXA)—MOSTDual X-ray absorptiometry (DEXA)—MOST POPULARPOPULAR  Pros:Pros:  -precise measurements at clinically relevant sites (hip and-precise measurements at clinically relevant sites (hip and spine)spine)  -minimal radiation-minimal radiation  Cons:Cons:  -not portable-not portable  -expensive-expensive
  17. 17. Screening OptionsScreening Options  Quantitative CTQuantitative CT  Pros:Pros:  -similar accuracy to DEXA-similar accuracy to DEXA  -may have slightly better predictive value in risk of-may have slightly better predictive value in risk of vertebral fracturevertebral fracture  Cons:Cons:  -more expensive (than DEXA)-more expensive (than DEXA)  -less reproducible (bigger variance)-less reproducible (bigger variance)  -higher radiation-higher radiation
  18. 18. Screening OptionsScreening Options  UltrasoundUltrasound  Pros:Pros:  -studies thus far have suggested similar predictive ability of fracture to-studies thus far have suggested similar predictive ability of fracture to DEXADEXA  -No radiation-No radiation  -Portable-Portable  Cons:Cons:  -unable to provide true Bone Density Measurements (less applicable-unable to provide true Bone Density Measurements (less applicable to current diagnostic standards and treatment goals based on BMD)to current diagnostic standards and treatment goals based on BMD) *current role in identifying high risk individuals, not in*current role in identifying high risk individuals, not in pervasive screeningpervasive screening
  19. 19. DiagnosisDiagnosis  2 Methods2 Methods  1) Radiographic determination of Bone Mineral1) Radiographic determination of Bone Mineral Density to beDensity to be  -1-1 Standard Deviations below young adult referenceStandard Deviations below young adult reference mean-OSTEOPENIAmean-OSTEOPENIA  -2.5-2.5 Standard Deviations below young adult referenceStandard Deviations below young adult reference mean-OSTEOPOROSISmean-OSTEOPOROSIS  2) Presence of fragility fracture (no signif trauma hx,2) Presence of fragility fracture (no signif trauma hx, and absence of osteomalacia or bone tumor)and absence of osteomalacia or bone tumor)
  20. 20. TreatmentTreatment  BisphosphonatesBisphosphonates- most appropriate initial- most appropriate initial treatment for women with osteoporosistreatment for women with osteoporosis  Alendronate (10 mg/day or 70 mg weekly),Alendronate (10 mg/day or 70 mg weekly),  -best when taken on empty stomach with 8 oz. water,-best when taken on empty stomach with 8 oz. water, standing upright for 30 minutes, risk of esophagitisstanding upright for 30 minutes, risk of esophagitis  - contraindicated in patients with active upper GI disease- contraindicated in patients with active upper GI disease  Risedronate (5 mg/day or 35 mg weekly)Risedronate (5 mg/day or 35 mg weekly)  -less apparent GI risk than alendronate-less apparent GI risk than alendronate
  21. 21. TreatmentTreatment  SERMS (Selective Estrogen ReceptorSERMS (Selective Estrogen Receptor Modulators)-Modulators)-  Raloxifene-best data among 2 in class, approved forRaloxifene-best data among 2 in class, approved for both prevention and treatment of osteoporosisboth prevention and treatment of osteoporosis  Tamoxifen—not FDA approved, but some data toTamoxifen—not FDA approved, but some data to suggest bone benefitsuggest bone benefit
  22. 22. TreatmentTreatment  PTH (Teriparatide)PTH (Teriparatide)-daily injections. Currently limited to-daily injections. Currently limited to those at very high fracture risk or those unresponsive tothose at very high fracture risk or those unresponsive to bisphosponate therapy due to high cost ($20/day) andbisphosponate therapy due to high cost ($20/day) and risk of osteosarcomarisk of osteosarcoma  Calcitonin-Calcitonin- nasal spray. Less effect on bone thannasal spray. Less effect on bone than bisphosphonates, risk of tachyphylaxis. Unique role inbisphosphonates, risk of tachyphylaxis. Unique role in acute treatment of osteoporotic fracture—may beacute treatment of osteoporotic fracture—may be switched to alternate therapy once pain diminished.switched to alternate therapy once pain diminished.
  23. 23. TreatmentTreatment  Estrogen / Progestin therapyEstrogen / Progestin therapy  No longer first line, but still an option in womenNo longer first line, but still an option in women who may be contraindicated from or intolerant towho may be contraindicated from or intolerant to bisphosponates or raloxifene.bisphosponates or raloxifene.  Combination therapyCombination therapy- there are demonstrable- there are demonstrable gains in using bisphosponates in combinationgains in using bisphosponates in combination with SERMs, and estrogen therapy if nowith SERMs, and estrogen therapy if no contraindications and less than desired benefitcontraindications and less than desired benefit on single osteoporosis therapyon single osteoporosis therapy
  24. 24. What they want you to know…What they want you to know…  Raloxifene (Evista) :Raloxifene (Evista) :  is used to manage hot flashesis used to manage hot flashes  increases bone densityincreases bone density  stimulates breast tissuestimulates breast tissue  stimulates endometrial proliferationstimulates endometrial proliferation  raises LDL and total cholesterol levelsraises LDL and total cholesterol levels
  25. 25. Osteoporosis in MenOsteoporosis in Men  --1.5 million men in U.S. with osteoporosis, 3.5 million at risk--1.5 million men in U.S. with osteoporosis, 3.5 million at risk  --1 in 6 men at 90 years of age will experience hip fracture.--1 in 6 men at 90 years of age will experience hip fracture. Mortality with hip fracture higher in men than in women.Mortality with hip fracture higher in men than in women.  --Treatment includes testosterone therapy (unless--Treatment includes testosterone therapy (unless contraindicated—see question) as first line, as well as bisphonatecontraindicated—see question) as first line, as well as bisphonate therapy (works equally well in men—see question). Likely roletherapy (works equally well in men—see question). Likely role for recombinant PTH and possibly SERMs (raloxifene).for recombinant PTH and possibly SERMs (raloxifene).  --Must assure adequate calcium and vitamin D intake, although--Must assure adequate calcium and vitamin D intake, although these are not sufficient for treatment of osteoporosisthese are not sufficient for treatment of osteoporosis  --Diagnosis best made with DEXA, still compared to standard of--Diagnosis best made with DEXA, still compared to standard of young womanyoung woman
  26. 26. What they want you to know…What they want you to know…  A 79-year old white male with a previous history of prostate cancer has a lumbar spine filmA 79-year old white male with a previous history of prostate cancer has a lumbar spine film suggesting osteopenia. Subsequent bone density studies show a T score of -2.7. Which onesuggesting osteopenia. Subsequent bone density studies show a T score of -2.7. Which one of the following is appropriate first line therapy for this patient?of the following is appropriate first line therapy for this patient?  A) TestosteroneA) Testosterone  B) Calcitonin nasal spray (Micalcin)B) Calcitonin nasal spray (Micalcin)  C) Raloxifene (Evista)C) Raloxifene (Evista)  D) Alendronate (Fosamax)D) Alendronate (Fosamax)  Which one of the following is true regarding the use of Alendronate (Fosamax) for theWhich one of the following is true regarding the use of Alendronate (Fosamax) for the treatment of osteoporosis in men?treatment of osteoporosis in men?  A)A) Its effectiveness is similar to that seen in womenIts effectiveness is similar to that seen in women  B) It is ineffective in patients with Paget’s diseaseB) It is ineffective in patients with Paget’s disease  C) It is contraindicated in patients taking NSAIDsC) It is contraindicated in patients taking NSAIDs  D) It causes a decrease in heightD) It causes a decrease in height
  27. 27. Chronic ManagementChronic Management  --No advantage of remeasuring BMD within 1 year--No advantage of remeasuring BMD within 1 year  --Recommendations for remeasurement in 1 or 2 years--Recommendations for remeasurement in 1 or 2 years once therapy has been startedonce therapy has been started  --If evaluated, and no change at one year, not indicative--If evaluated, and no change at one year, not indicative of eventual benefit. Recommend ensuring adequateof eventual benefit. Recommend ensuring adequate calcium Vit D, and additional risk factor reductioncalcium Vit D, and additional risk factor reduction (smoking cessation, deacreased EtOH, etc.)If(smoking cessation, deacreased EtOH, etc.)If significant worsening, likely unresponsive to therapy. Ifsignificant worsening, likely unresponsive to therapy. If improvement, continue regimen and follow long term.improvement, continue regimen and follow long term.
  28. 28. What they want you to know…What they want you to know…  A 70-year-old female had a lumbar vertebral fracture 3 years ago. At thatA 70-year-old female had a lumbar vertebral fracture 3 years ago. At that time she had a dual-energy absorptiometry (DEXA) scan, with a T score oftime she had a dual-energy absorptiometry (DEXA) scan, with a T score of -2.6, and was placed on alendronate (Fosamax), calcium, and vitamin D.-2.6, and was placed on alendronate (Fosamax), calcium, and vitamin D. She recently quit smoking. Her BMI is 21. A DEXA scan today showsShe recently quit smoking. Her BMI is 21. A DEXA scan today shows her bone mineral density to be -2.1.her bone mineral density to be -2.1.  Which one of the following would be most appropriate in the management ofWhich one of the following would be most appropriate in the management of this patient?this patient?  Replace alendronate with raloxifene (Evista)Replace alendronate with raloxifene (Evista)  Stop alendronate, but continue calcium and vitamin DStop alendronate, but continue calcium and vitamin D  Add raloxifene to her regimenAdd raloxifene to her regimen  Add teriparatide (Forteo) to her regimenAdd teriparatide (Forteo) to her regimen  Make no change to her regimenMake no change to her regimen
  29. 29. FallsFalls  --Fracture risk is still significantly linked to risk of fall--Fracture risk is still significantly linked to risk of fall  --Ability to safely transfer is independent risk factor--Ability to safely transfer is independent risk factor  --Vitamin D has been shown in numerous studies to--Vitamin D has been shown in numerous studies to decrease risk of falls independent of the structural bonedecrease risk of falls independent of the structural bone benefitbenefit
  30. 30. What they want you to know…What they want you to know…  Which one of the following has been shown to reduce theWhich one of the following has been shown to reduce the risk of falls in the elderly?risk of falls in the elderly?  Vitamin DVitamin D  Amityriptyline (Elavil)Amityriptyline (Elavil)  Haloperidol (Haldol)Haloperidol (Haldol)  Lorazepam (Ativan)Lorazepam (Ativan)
  31. 31. Acute ComplicationsAcute Complications  Remember that Calcitonin has additional benefit of pain reduction in acuteRemember that Calcitonin has additional benefit of pain reduction in acute course of compression fracturecourse of compression fracture  A 70-year-old white female with osteoporosis sees you forA 70-year-old white female with osteoporosis sees you for follow-up a few days after an emergency room visit for an acute T12 vertebralfollow-up a few days after an emergency room visit for an acute T12 vertebral compression fracturecompression fracture. The fracture was suspected clinically and on plain films; the diagnosis was confirmed with a bone scan. The emergency department physician prescribed oxycontin and NSAIDs, but the. The fracture was suspected clinically and on plain films; the diagnosis was confirmed with a bone scan. The emergency department physician prescribed oxycontin and NSAIDs, but the patient is still experiencing considerable discomfort.patient is still experiencing considerable discomfort.  In addition to increasing the dosage of oxycodone, which one of the following interventions would you suggest now to reduce the patient’s pain?In addition to increasing the dosage of oxycodone, which one of the following interventions would you suggest now to reduce the patient’s pain?  Calcitonin (Miacalcin)Calcitonin (Miacalcin)  Raloxifene (Evista)Raloxifene (Evista)  Alendronate (Fosamax)Alendronate (Fosamax)  Physical therapy, including dexamethasone iontophoresisPhysical therapy, including dexamethasone iontophoresis  VertebroplastyVertebroplasty  A 78-year-old white female presents with a 3-day history of lower thoracic back pain. She denies any antecedent fall or trauma, and first noted pain upon arising. Her description of the pain indicates that it is severe, bilateral,A 78-year-old white female presents with a 3-day history of lower thoracic back pain. She denies any antecedent fall or trauma, and first noted pain upon arising. Her description of the pain indicates that it is severe, bilateral, and without radiation to the arms or legs.and without radiation to the arms or legs.  Her past medical history is positive for hypertension and controlled diabetes milletus. Her meds include HCTZ, enalipril, metformin, and MVI. She is a previous smoker but does not drink alcohol. She underwent menopauseHer past medical history is positive for hypertension and controlled diabetes milletus. Her meds include HCTZ, enalipril, metformin, and MVI. She is a previous smoker but does not drink alcohol. She underwent menopause at age 50 and took estrogen for a few months for hot flashes. Physical exam reveals her to be in moderate pain with a somewhat stooped posture and mild tenderness over T12-L1. She has negative straight leg raising andat age 50 and took estrogen for a few months for hot flashes. Physical exam reveals her to be in moderate pain with a somewhat stooped posture and mild tenderness over T12-L1. She has negative straight leg raising and normal lower extremity sensation, strength, and reflexes.normal lower extremity sensation, strength, and reflexes.  Which of the following is true regarding this patient’s likely condition?Which of the following is true regarding this patient’s likely condition?  An MRI or nuclear medicine bone scan should be performedAn MRI or nuclear medicine bone scan should be performed  Prolonged (approximately 2 weeks) bed rest will increase the chance of complete recoveryProlonged (approximately 2 weeks) bed rest will increase the chance of complete recovery  Investigation for an underlying malignancy is indicatedInvestigation for an underlying malignancy is indicated  Subcutaneous or intranasal calcitonin (Calcimar, Miacalcin) may be verySubcutaneous or intranasal calcitonin (Calcimar, Miacalcin) may be very helpful for pain reliefhelpful for pain relief
  32. 32. Questions?Questions?

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