Osteoporosis

Learning objectives :
Burden of the disease.
Screening and treatment guidelines.
Bisphosphonates.
Controversial topics : Association of bisphosphonates with
ONJ
Atypical femoral fractures
Atrial fibrillation.
Esophageal cancer.

Burden of Disease
10 million people in US have Osteoporosis
33 million people in US have Osteopenia.
Bone health and osteoporosis: Department of health & human services 2004.

Burden of Disease
> 2 million fractures/year due to either.
300,000 HIP fractures.
547,000 vertebral fractures.
135,000 pelvic factures.
Bone health and osteoporosis: Department of health & human services 2004.

Burden of Disease :
Hip fractures :
50 % Permanent impaired mobility.
25 % Loose skills to live independently.
Increased all cause mortality : first 3 months after hip fracture.
1.2010 position statement of the North American Menopause Society. Menopause 2010.

Annual incidence

Osteoporosis

Risk factors

Who to screen
Women > 65 years.
Men > 70 years.
Postmenopausal women /men >50 years with clinical risk factors.
H/o fracture at age > 50 years.
Chronic steroid use.

Who to treat ? Prior h/o hip/vertebral # or T Score < -2.5 or T Score -1 to -2.5 & 10 yr risk (FRAX) : HIP # > 3 % or major osteoporotic # > 20 % Postmenopausal women /men > 50 yrs with

Calcium and vitamin D

Mainstay of treatment :
Bisphosphonates
Approval in US for osteoporosis
Alendronate : 1995
Risedronate : 2000
Ibandronate : 2005
Zoledronate : 2007.

Bone marrow precursors Osteoblasts Osteoclast Lining cells Stimulators of Bone Formation Fluoride PTH analogs Sr Ranelate (?) Inhibitors of Bone Resorption Estrogen, SERMs Bisphosphonates Calcitonin Inhibitors of RANKL Cathepsin K Therapeutic strategies

THE LANCET Vol 348 • December 7, 1996 Clinical Evidence

Taking Bisphosphonates

Contraindications

Duration of treatment

Cost factor
Alendronate: $4 - $40/month
Risedronate : $60 - $120/month
Ibandronate (oral): $90 - $130/month
IV Ibandronate : $1300/year
IV Zoledronate : $1300/year

Hot topics

Osteonecrosis of jaw

ONJ
Osteoporosis :
Reporting rate 1/100,000 - 1/250.000.
True incidence may be higher.
Malignancy/skeletal metastasis :
Estd. Incidence: btw 1- 10 %

Risk factors

Recommendations

Atypical fractures

Atypical fractures
? Long term over suppression of bone turnover.
Incidence : 1 in 10,000.
Associated median treatment duration : 7 years.
Causality : long term bp/ atypical # unproven.
Further large scale studies needed.

Recommendations
Educate physician/patient about Prodromal pain.
Evaluate with urgent X-Ray.
If negative, may consider MRI.
Stop BP’s if atypical fracture confirmed.
Shane et al. ASBMR task report. J Bone Miner Res. 2010

Atrial fibrillation
FDA recommends physicians to not alter their prescribing patterns while it continues to monitor post marketing reports of AF in such patients.
In v/o above and absence of definitive data : Benefits of treatment outweigh risks.

Esophageal cancer
23 cases reported in last 2 decades. (Wysowski et al)
31 cases from Europe/Japan.
Median time from use to diagnosis : 1-2 yr.
Time from exposure inconsistent w/ causal relation.
Further studies needed.

Renal safety
Safe for creatinine clearance > 30 -35 ml/min.
Lack of experience < 30 ml/min.
No data for use in ESRD.
Exact bone disease unknown unless biopsy.
Expert opinion: half the dose could be used for 3 years in ESRD once bone biopsy confirms osteoporosis.

Take home points
Osteoporosis : significant burden of disease.
Main stay treatment : bisphosphonates.
? Duration of treatment : individualized.
More research needed to confirm association with ONJ, Subtrochanteric fracture.
Benefits of treatment outweigh risks in osteoporosis.

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Osteoporosis

by medicaldump on May 31, 2011

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