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Osteoporosis community talk

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Osteoporosis Presentation intended for community outreach

Osteoporosis Presentation intended for community outreach

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  • 1. FRAGILITY FRACTURES & OSTEOPOROSIS:A HEALTH CARE CRISIS KENNETH J EDWARDS,M.D,F.A.C.S
  • 2. OSTEOPOROSIS  MAJOR HEALTH CRISIS  DECREASED BONE MASS  MICROARCHITECTURAL DETERIORATION  ALTERED QUALITY
  • 3. OSTEOPOROSIS  AFFECTS 50% OF WOMEN OVER 50  LIFETIME RISK OF FRACTURE OF HIP,WRIST, AND SPINE IS 40%
  • 4. Osteoporosis - Types  Postmenopausal osteoporosis (type I)  Caused by lack of estrogen  Causes PTH to overstimulate osteoclasts  Excessive loss of trabecular bone  Age-associated osteoporosis (type II)  Bone loss due to increased bone turnover  Malabsorption  Mineral and vitamin deficiency
  • 5. FRAGILITY FRACTURE  FRACTURE OCCURING IN FALL FROM STANDING HEIGHT OR LESS  LOW TRAUMA RESULTING IN BIG FRACTURES
  • 6. Fragility fractures are common  1 in 2 women and 1 in 5 men over age 50 will suffer a fracture in their remaining life time1  55% of persons over age 50 are at increased risk of fracture due to low bone mass  At age 50, a woman’s lifetime risk of fracture exceeds combined risk of breast, ovarian & uterine cancer  At age 50, a man’s lifetime risk of fracture exceeds risk of prostate cancer 1. Johnell et al. Osteoporos Int. 2005; 16: S3-7
  • 7. Fractures will be more common  Fracture incidence projected to increase 2- to 4-fold in the next decades due to aging of the population  In Europe  12% to 17% of population >65 in 2002  20% to 25% of population >65 in 2025 Aged 70+ Men Women 1990 2030 Men Wome n
  • 8. Bone mass Bone structure Bone quality Fall Risk Impact of fall Skeletal strength Fracture risk Type of fall Energy reduction External protection Neuromuscular function Environmental risks Age Pathogenesis of fragility fractures
  • 9. NORMAL VS OSTEOPOROTIC BONE
  • 10. Costs of Osteoporosis  Affects 1 in 2 women and 1 in 8 men > 50 years old  Causes 1.5 million fractures/year - 700,000 spine, 300,000 hip and 300,000 wrist, 25,000 deaths from complications  Menopause is the biggest risk factor for disease  Disease often not diagnosed until after 1 or more fractures have occurred  Prevalence could rise to 41 million by 2015 from 28 million today  Cost to health care estimated at $14 billion ($38M/day)  Psychological and social effects of disease are immense
  • 11. Projected to reach 3.250 million in Asia by 2050 Adapted from Cooper et al, Osteoporos Int. 1992; 2:285-9 Estimated number of hip fractures: (1000s) 1950 2050 600 3250 1950 2050 668 400 1950 2050 742 378 1950 2050 100 629 Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million Projected number of osteoporotic hip fractures worldwide
  • 12. All fractures are associated with morbidity Cooper. Am J Med. 1997; 103(2A):12s-19s 40% Unable to walk independentl y 30% Permanent disability 20% Death within one year 80% Unable to carry out at least one independent activity of daily living
  • 13. Vertebral fractures restrict daily activities 2.8 7.8 21.7 2.1 4.2 8.6 3.6 12.6 44.7 2.2 4.6 9.9 0 5 10 15 20 25 30 35 40 45 Oddsratio Back pain Difficulty with >3 daily activities >3 activities affected due to back pain Medical consultation 1 # 2 # 3 # Adapted from Ross PD et al. No vertebral fractures over the last four years People with vertebral fractures have greater pain, disability and healthcare utilisation, on average, than those without fracture
  • 14. 1.91.81.92.0Minor fracture 2.43.31.71.9Forearm 1.81.44.42.3Spine 1.91.42.52.3Hip Minor fractureForear m SpineHipSite of prior fracture Risk of subsequent fracture Prior fracture increases the risk of subsequent fracture Klotzbuecher et al. J Bone Miner Res 2000; 15:721-727 A prior fracture increases the risk of new fracture 2- to 5-fold
  • 15. Cost of osteoporosis in the United States Ray et al. J Bone Miner Res 1997; 12:24-35 Total annual cost $13.8 Billion $3.9 (28%) $1.3 (10%) $8.6 (62%) Hospitalization Outpatient Nursing Home
  • 16. Economic impact of osteoporosis Annual direct cost Disease Prevalence including hospitalization (millions) (US$ billion) Cardiovascular 4.6 20.3 disease Asthma 15 7.5 Osteoporosis 10 13.8 Information supplied by National Heart, Lung & Blood Institute, National Osteoporosis Foundation, American Heart Association Annual economic cost of treating fractures in the USA is similar to that of treating cardiovascular disease and asthma
  • 17. Osteoporotic fractures: comparison with other diseases 1996 new cases, all ages 184 300 750 000 vertebra l 250 000 other sites 250 000 forear m 250 000 hip 0 500 1000 1500 2000 Osteoporotic fractures Heart attack Stroke Breast cancer Annualincidencex1000 1 500 000 annual incidence all ages 513 000 annual estimate women 29+ 228 000 annual estimate women 30+ American Heart Association, 1996 American Cancer Society, 1996 Riggs & Melton Bone, 1995; 17:505S-511S
  • 18. ETHNIC DIFFERENCES
  • 19. OSTEOPOROTIC FRACTURES POSE A LIFETIME RISK OF DEATH COMPARABLE TO BREAST CANCER
  • 20. BIOLOGY OF BONE
  • 21. Two Components of the Bone  Cortical Bone  Dense and compact  Runs the length of the long bones, forming a hollow cylinder  Trabecular bone  Has a light, honeycomb structure  Trabeculae are arranged in the directions of tension and compression  Occurs in the heads of the long bones  Also makes up most of the bone in the vertebrae
  • 22. Cancellous or Trabecular Bone
  • 23. Bone Cells  Osteocytes - derived from osteoprogenitor cells  Osteoblasts  Osteoclasts
  • 24. Osteocytes  Trapped osteoblasts  In lacunae  Keep bone matrix in good condition and can release calcium ions from bone matrix when calcium demands increase  Osteocytic osteolysis
  • 25. Osteoclasts  Resorb bone matrix from sites where it is deteriorating or not needed  Digest bone matrix components  Focal decalcification and extracellular digestion by acid hydrolases and uptake of digested material  Disappear after resorption  Assist with mineral homeostasis
  • 26. Osteoblasts  Make collagen  Activate nucleation of hydroxyapatite crystallization onto the collagen matrix, forming new bone  As they become enveloped by the collagenous matrix they produce, they transform into osteocytes  Stimulate osteoclast resorptive activity
  • 27. Bone Remodeling Process
  • 28. Bone Remodeling Process  Proceeds in cycles – first resorption than bone formation  The calcium content of bone turns over with a half-life of 1-5 years
  • 29. Why Remodel Bone ????  Allows bone to respond to loads (stresses)  Maintain materials properties  Allows repair of microdamage  Participates in serum Ca2+ regulation
  • 30. Hormonal Influence  Vitamin D  Parathyroid Hormone  Calcitonin  Estrogen  Androgen
  • 31. Vitamin D  Osteoblast have receptors for (1,25-(OH)2-D)  Increases activity of both osteoblasts and osteoclasts  Increases osteocytic osteolysis (remodeling)  Increases mineralization through increased intestinal calcium absorption  Possibly linked to CLL,Heart Disease
  • 32. VITAMIN D  35-50% AMERICANS DEFICIENT  INSTITUTE OF MEDICINE: 600 IU/DAY < 70 800 IU/DAY >70  5-10 MIN/SUN 3000 IU VIT D  NEED 3-4 DAYS/WEEK
  • 33. PARATHYROID HORMONE  Accelerates removal of calcium from bone to increase Ca levels in blood  PTH receptors present on both osteoblasts and osteoclasts  Osteoblasts respond to PTH by  Change of shape and cytoskeletal arrangement  Inhibition of collagen synthesis  Stimulation of IL-6, macrophage colony-stimulating factor secretion  Chronic stimulation of the PTH causes hypocalcemia and leads to resorptive effects of PTH on bone
  • 34. Calcitonin  C cells of thyroid gland secrete calcitonin  Straight chain peptide - 32 aa  Synthesized from a large preprohormone  Rise in plasma calcium is major stimulus of calcitonin secretion  Plasma concentration is 10-20 pg/ml and half life is 5 min
  • 35. Actions of Calcitonin  Osteoclasts are target cells for calcitonin  Major effect of clacitonin is rapid fall of plasma calcium concentration caused by inhibition of bone resorption  Magnitude of decrease is proportional to the baseline rate of bone turnover
  • 36. Other Systemic Hormones  Estrogens  Increase bone remodeling  Androgens  Increase bone formation
  • 37. BIOLOGY OF OSTEOPOROSIS
  • 38. ESTROGEN LOSS  Estrogen loss triggers increases in IL-1, IL-6, and TNF due to:  Reduced suppression of gene transcription of IL-6 and TNF  Increased number of monocytes  Increased cytokines lead to increased osteoclast development and lifespan
  • 39. BONE DENSITY & FRACTURE RISK
  • 40. Whole bone strength declines dramatically with age 0 2000 4000 6000 8000 10000 Femoral neck (sideways fall) young old Courtney et al. J Bone Joint Surg Am. 1995; 77:387-95 Mosekilde. Technology and Health Care 1998; 6:287-97 Lumbar vertebrae (compression) Wholebonestrength (Newtons) 0 2000 4000 6000 8000 10000 young old
  • 41. Cortical porosity increases with age (41 iliac biopsies, age 19-90) Age (years) 0 3 6 9 12 15 0 20 40 60 80 r = 0.78 P < 0.001 (%) Brockstedt et al. Bone 1993; 14:681-91 4-fold increase in cortical porosity from age 20 to 80 Increased heterogeneity with age
  • 42. 20-year-old80-year-old Age-related changes in femoral neck cortex and association with hip fracture Those with hip fractures have: • Preferential thinning of the inferior anterior cortex • Increased cortical porosity Bell et al. Osteoporos Int 1999; 10:248-57 Jordan et al. Bone, 2000; 6:305-13 Mayhew et al, Lancet 2005
  • 43. High Bone Turnover Resorption > Formation Decreased Bone Strength Disrupts Trabecular Architecture Decreases Bone Mass Increases Cortical Porosity Decreases Cortical Thickness Alters Bone Matrix Composition L. Mosekilde Tech and Health Care, 1998 Bouxsein. Best Practice in Clin Rheum. 2005; 19:897-911 Seeman & Delmas, New England J Med, 2006; 354:2250-61
  • 44. Common Osteoporotic Fractures Hip Shoulder Knee Elbow
  • 45. POST- OP 2 MONTHS 6 MONTHS F 83yrs Standard Screw: Complications
  • 46. Vertebroplasty and kyphoplasty  Filling void in crushed vertebral body with PMMA  Patient prone – transpedicular injection of cement  Vertebroplasty – high pressure injection – good pain relief  Kyphoplasty – pre-insertion of balloon to create a void for low pressure injection – aiming for height restoration
  • 47. Balloon kyphoplasty : Can you uncrush a bone?
  • 48. APPROACH TO OSTEOPOROTIC PATIENT  PHYSICAL EXAM  LABS/STUDIES  TREATMENT
  • 49. Fragility fracture patient assessment * In addition to routine pre-op or fracture evaluation  Family history of OP  Menarche / Menopause  Nutrition  Medications  (past and present)  Level of activity  Fracture history  Fall history & risk factors for falls  Smoking, alcohol intake  Risk factors for secondary OP  Prior level of function History should include:
  • 50. DRUGS THAT DECREASE CALCIUM RETENTION  CORTICOSTEROIDS  HEPARIN  LASIX  NICOTINE  CAFFEINE  ANTACIDS
  • 51. • SR / CRP • Blood count • Calcium • Phosphate • Alkaline Phosphatase (AP) • Renal function studies • Basal TSH • Intact PTH • Protein-immunoelectrophoresis • Vit D (25 and 1.25) Laboratory tests* NOTES: - * These are in addition to routine pre-op labs such as coagulation studies - These are screening labs, more may be indicated based on these results
  • 52. Assessment of bone mineral density by DXA Current gold standard for diagnosis of osteoporosis BMD (g/cm2) = Bone mineral content (g) / area (cm2) Diagnosis based on comparing patient’s BMD to that of young, healthy individuals of same sex
  • 53. WHO GUIDELINES FOR OSTEOPOROSIS  Normal: Not less than 1 SD below the avg. for young adults  Osteopenia: -1 to -2.5 SD below the mean  Osteoporosis: More than 2.5 SD below the young adult average  70% of women over 80 with no estrogen replacement therapy qualify  Severe osteoporosis  More than 2.5 SD below with fractures
  • 54. When to Measure BMD in Postmenopausal Women  All women 65 years and older  Postmenopausal women <65 years of age:  If result might influence decisions about intervention  One or more risk factors  History of fracture
  • 55. When Measurement of BMD Is Not Appropriate  Healthy premenopausal women  Healthy children and adolescents  Women initiating ET/HT for menopausal symptom relief (other osteoporosis therapies should not be initiated without BMD measurement)
  • 56. DAILY CALCIUM REQUIREMENTS  CHILD 700 MG  TEEN/YOUNG ADULT 1300 MG  ADULT 800 MG  PREGNANCY 1500 MG  LACTATION 2000 MG  POST MENOPAUSAL 1500 MG  MAJOR FRACTURE 1500 MG
  • 57. CALCIUM SUPPLEMENTS  CALCIUM CARBONATE NEEDS ACIDITY(NO PPI’S)  CALCIUM CITRATE BETTER DISSOLUTION MORE BIOAVAILABILITY
  • 58. Pharmacological agents shown to reduce fracture risk Bisphosphonates  Alendronate (FOSAMAX®)  Risedronate (ACTONEL®)  Ibandronate (BONVIVA®)  Zolendronate (ACLASTA®) SERMs • Raloxifene (EVISTA®) Stimulators of bone formation • rh-PTH (FORTEO®) Mixed mode of action • Strontium ranelate (PROTELOS®) Hormone therapy • Estrogen / progestin
  • 59. BIPHOSPHONATES  ALENDRONATE(FOSAMAX)  IBANDRONATE(BONIVA)  RESIDRONATE(ACTONEL)  ZOLENDRONIC ACID(RECLAST)
  • 60. BIPHOSPHONATES  INHIBITS OSTEOCLASTIC ACTIVITY  DECREASE BONE TURNOVER  REDUCE HIP FRACTURE INCIDENCE  REDUCE VERTEBRAL FRACTURE INCIDENCE  GI SYMPTOMS  NEED FOR PULSE DOSING DUE TO FRACTURES  DOES IT CREATE BRITTLE BONE?
  • 61. CALCITONIN  MIACALCIN/FORTICAL  DAILY NASAL SPRAY  REDUCES SPINAL FX 37%  REDUCES OSTEOPOROTIC BONE PAIN  INHIBITS OSTEOCLASTIC ACTIVITY  NO DATA ON HIP FRACTURES
  • 62. ESTROGEN HORMONE THERAPY  INCREASES BONE MASS  REDUCES HIP FRACTURES  REDUCES SPINE FRACTURES  BREAST CANCER UP 40% AFTER 10 YRS  UTERINE CANCER INCREASE  INCREASED DVT
  • 63. ESTROGEN AGONIST/ANTAGONIST  RALOXIFINE(EVISTA)  SELECTIVE ESTROGEN RECEPTOR MODULATOR(SERM)  INDICATED FOR REDUCTION IN BREAST CA IN OSTEOPOROTIC WOMEN  REDUCES VERTEBRAL FRACTURES  LITTLE EFFECT ON HIP FRACTURES  INCREASED DVT
  • 64. PARATHYROID HORMONE(FORTEO)  PTS WITH PROLONGED STEROID USE  DAILY INJECTION  2 YEAR MAXIMUM USE  MEANT FOR SEVERE OSTEOPOROSIS  GOOD FOR BIPHOSPHONATE FRACTURES  T SCORE<3.5  STIMULATES OSTEOBLAST>OSTEOCLASTS
  • 65. Effects of Exercise on Bone  Two types of studies conducted  Compare trained athletes with sedentary people  Athletes and chronic exercisers have higher BMD  Competitive runners in 60s have ~40% greater BMD than controls  Weight lifters have 10-35% greater spine BMD  Tennis players have 30% greater thickness of dominant humerus  Early life experience is important (Peak BMD)  Women who get hip fractures have lower levels of occupational or leisure activity from 15-45 years old  Significant associations between hip BMD and early-life exercise both men and women
  • 66. Interaction of Age with Exercise  Increasing age causes deficits in response (I.e., gain of system goes down)  Probably caused by multiple factors  Women from 60-80 show BMD increase of only 5-8% with exercise  Increases in BMD with exercise reverts to normal within a few months of terminating training  Exercise clearly helps maintain bone as system gain or setpoint is reduced
  • 67. Tai Qi reduces fall risk Quin et al. Arch Phys Med Rehabil. 2002; 83:1355-9 Wolff et al. J Am Geriatr Soc. 1996; 44:489-97
  • 68. LAKELAND GERIATRIC FRACTURE PROGRAM  DESIGNED TO IMPROVE CARE OF GERIATRIC FRACTURE PATIENT  MULTIDISCIPLINARY APPROACH  PARTNERSHIP WITH SYNTHES  EVIDENCE BASED
  • 69. LAKELAND GERIATRIC FRACTURE PROGRAM  EXPEDITE TIME TO SURGERY AND MOBILIZATION  PAIN MANAGEMENT STANDARDIZATION  DELERIUM PREVENTION  POST –OP DISPOSITION  HIP FRACTURE NAVIGATOR
  • 70. LAKELAND GERIATRIC FRACTURE PROGRAM  BETTER IDEA OF OUTCOMES  CONTINUOUS PROCESS IMPROVEMENT AS GOAL  UNIQUE PROGRAM IN MICHIGAN
  • 71. BOTTOM LINE  TAKE CALCIUM AND VITAMIN D  EXERCISE FOR IMPROVED BALANCE AND STRENGTH
  • 72. Thank You