Managing Your Osteoporosis - Springfield Clinic


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Managing Your Osteoporosis, presented by Michael Pick MD, Plastic and Rheumatology, Springfield Clinic.

Originally presented at Springfield Clinic Me 1st Women's Health Event, May 2010 - All information and images provided by presenter.

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  • 05/07/10 19:12
  • 05/07/10 19:12 Postmenopausal osteoporosis (PMO) is a major health issue in the United States. Currently, 10 million Americans have osteoporosis. Another 34 million are at risk for developing the disease. Forty percent of women aged 50 years or older are at risk for developing an osteoporosis-related fracture during their lifetime. Many find it surprising that each year, the risk of suffering a fracture from osteoporosis is greater than the risk of suffering a heart attack, stroke, or breast cancer.
  • 05/07/10 19:12
  • 05/07/10 19:12
  • 05/07/10 19:12 Osteoporosis is a word that is often used, but not always fully understood. Osteoporosis affects the entire skeleton. It is a disease – not a natural part of getting older that causes bones to lose bone mass or bone density. This causes bones to become weak and more likely to fracture. Most osteoporotic fractures occur in the spine, hip, and wrist. You often hear about hip fractures, but actually spinal fractures are the most common fractures. These fractures can lead to disability and deformity. We’ll talk more about this in a bit.
  • 05/07/10 19:12
  • 05/07/10 19:12 Here are some facts about your bones: Women build bone from birth until age 30-35 when they achieve peak bone mass. This means that things like your calcium intake as a young adult do affect your level of bone mass as an older adult. Most women maintain peak bone mass until menopause. After menopause, the lack of estrogen in the body often causes women to not be able to create new bone as fast as it is naturally broken down in the body. They lose bone most rapidly in the first several years after menopause. In the first 5 years after menopause, women can lose up to 25% of their bone. We have the potential to live much longer than our grandparents. This increased life expectancy means we live many more postmenopausal years… that’s many more years of potential bone loss.
  • 05/07/10 19:12
  • 05/07/10 19:12 This slide illustrates how your bones operate as living tissue at the cellular level. That’s right, your bones are living! They go through a continual process of “remodeling” throughout life. Some cells called “osteoclasts” (pronounced os -tee-oh-clasts) break down bone (called “bone resorption”) while others, called “osteoblasts” (pronounced os -tee-oh-blasts) build up bone (bone formation). In normal healthy adults, this process is usually in balance. However, there are a number of things that can upset this balance: Diminished estrogen levels with the onset of menopause and Chronic use of certain medications are two examples. When more bone is being broken down than is being formed, osteoporosis can result.
  • 05/07/10 19:12 These figures illustrate the changes in bone architecture at the microscopic level that are characteristic of osteoporosis. Osteoporotic bone, on the left, shows clear loss of bone, with large spaces and breaks in the microscopic architecture in your bone. These breaks throughout the infrastructure of your bone lead to overall weakened bones, and ultimately to fractures. Normal bone, shown on the right, appears as a thick, dense network with small spaces.
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  • 05/07/10 19:12 So what can you do about it? First you need to understand your risk. The risk factors are divided into two categories: 1) those that are unchangeable, because they are likely inherited and 2) those that are changeable by modifying what you do every day. Here are the unchangeable risk factors that increase your risk for osteoporosis: If you are a female If you are past menopause, because that’s when you start losing bone Family history of fracture – if a mother or grandmother had it, you are at increased risk Those with Caucasian or Asian ancestry are at greater risk because they often have a small or thin frame. If you have fractured yourself, you may not have thought it was due to osteoporosis, but it may have been a first sign.
  • 05/07/10 19:12 There are things that put you at risk that you can change Weight bearing exercise, such as walking, encourages your body to build more bone and strengthens the muscles that support your bones Most people know that calcium is needed to maintain healthy bones, but many do not get enough. An adult women should have a daily intake of about 1200 mg of calcium. You should look for a calcium that has vitamin D. Your body can’t absorb calcium without vitamin D. Smoking or alcohol use also affect your bones.
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  • 05/07/10 19:12 Understanding your risk factors is important, but having a bone mineral density test (BMD Test) is the most effective way to understand if you actually have osteoporosis. There are different types of BMD testing. Bone density can be measured at one or more sites on your body, such as your spine, hip, foot, or wrist. Your BMD test score, called a T-Score, can help your doctor understand whether you have osteoporosis.
  • 05/07/10 19:12 The gold standard in BMD testing is called a DEXA (pronounced decks – ah) which stands for dual energy x-ray absorptiometry. It can measure at the hip and spine, and compares bone density to that of a young, healthy adult. This result is called a T-score. Other BMD tests use peripheral measures such as at the ankle, hand, or finger. This is best used as a screening tool to indicate possible risk of future fracture.
  • 05/07/10 19:12
  • 05/07/10 19:12 Who should get a baseline bone density test? A baseline BMD tests is needed to determine the health of your bones relative to a young, healthy adult of the same gender and form a basis from which to compare your future scores to understand your bone health over time. According to the National Osteoporosis Foundation (NOF), you should get a baseline if: You are a women 65 or older You are a women with a history of fracture, because this is a key risk factor If you are past menopause with at least one risk factor If you are an adult who has taken high doses of medications such as steroids for long periods of time that can cause bone loss.
  • 05/07/10 19:12
  • 05/07/10 19:12 Recall the T-score compares your bone density to that of a young, healthy adult of the same gender. The number can be positive or negative and is a calculation of how far above or below this “norm” your bone mineral density is. Both the NOF and the World Health Organization (WHO) have developed a definition of osteoporosis using T-scores to help guide diagnosis and treatment. By these criteria, patients with BMD higher than –1 (so that would be numbers like zero or +1) are considered to have normal BMD. Patients with BMD T-scores between –1 and –2.5 are considered to have low bone mass. Patients with this level of low bone mass are considered “osteopenic” (pronounced os -tee-oh- pee -nick). And finally, patients with BMD T-scores of –2.5 or lower (-3 or –3.5, etc.) have osteoporosis.
  • Bone mineral density (BMD) peaks during the third decade, with the rate of bone acquisition being greatest during puberty. In menopausal women, BMD declines rapidly. It continues to decrease after menopause for a cumulative average loss of one-third to one-half of peak BMD over a lifetime. (Meunier et al, 1999) As a result, without treatment, postmenopausal women commonly develop osteoporosis and fractures later in life. (Meunier et al, 1999) Meunier JP et al. Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther . 1999;6:1025–1044.
  • 05/07/10 19:12 The ultimate goal of preventing osteoporosis is to prevent fractures. To help prevent fractures, you need to maintain bone mass. Essential to maintaining bone mass is good nutrition, which includes a diet rich in calcium and vitamin D. In addition, you need to manage other aspects of your lifestyle that can inhibit the development and maintenance of healthy bones. By routinely doing things like weight-bearing exercise and avoiding smoking, you can also help prevent bone loss.
  • The major form of exercise that you need to start with is weight bearing exercises. Weight bearing exercises (exercises that forces your body to support your full weight) work to increase skeletal muscle mass Weight bearing exercise is most preventive when started early in life (in adolescence). However, starting this exercise at any time during life can still have a beneficial effect This type of exercise includes walking, jogging, dancing, climbing stairs or playing tennis , is easily obtained, and you only need to do this 20-30 minutes 3 times weekly. Persons with osteoporosis should have their doctors approval before starting any exercise program and they need to avoid exercises that involve spinal flexion.
  • The second type of exercise that you need is exercise that helps you strengthen your muscles and helps with your balance. This type of exercise has not been proven to have any direct affect on bone mass. The goal of this type of exercise is to decrease the risk of falling by: Strengthening muscles Improving posture Improving balance This type of exercise includes swimming, bike riding, and rowing, is easily obtained and you only need to do this 20-30 minutes 3 times weekly. Weight lifting is another example of this type of exercise—however, is not to be done if you have osteoporosis unless under very strict supervision and approval by your physician.
  • 05/07/10 19:12 If you are at risk for osteoporosis, you are at greater risk for breaking a bone, especially if a fall occurs. It is, therefore, very important that falls be prevented. You can learn ways to help prevent these falls. The majority of these issues have to do with rearranging household objects and making sure that the things in the house will not increase the chance that you will fall. This slide reviews only some of the things that you can do to help prevent a fall including maintaining good lighting, removing clutter from floors and stairs, getting rid of loose rugs, and wearing non-slip or skid soled shoes with low heels. Other issues include keeping things in locations where they are easily accessable and don’t require you to have to move around the house a lot to use them. This includes keeping the phone close-by, and eye-glasses kept around neck or on a close-by sturdy side table.
  • 05/07/10 19:12 We all know how important calcium is to healthy bones, but we may not know just how much we need to take daily to be successful. The NOF recommends everyone get a minimum of 1200 mg every day after age 50. You can try to get this entirely from your diet, or from a supplement. More likely, you’ll use a combination of the two to reach this level. Some good sources of calcium are shown here. Note how many servings of each it would take to get your daily recommended allowance if that were your only source of calcium. A great tip I use to boost calcium in my diet – one teaspoon of non-fat powdered milk has 52 mg. of calcium. You can add it to recipes for soup, pancakes, or other foods, and increase the calcium in them.
  • 05/07/10 19:12 Vitamin D is needed to help your body absorb calcium. It is recommended that you get 400-800 international units of vitamin D. This is the way that the level of vitamin D is reported – international units. You can get vitamin D from foods fortified with vitamin D or from vitamin D supplements. Milk is a great source of vitamin D, but if you want a convenient way to get it daily, most calcium supplements include vitamin D, so you can kill two birds with one stone. Just be sure to check the label to ensure your calcium has the vitamin D you need.
  • 05/07/10 19:12 If your doctor says that you have or are at risk for osteoporosis, here are the most common medications he or she may prescribe. Today, I’m going to talk about Actonel. Note: Evista (raloxifene HCI) is a registered trademark of Eli Lilly Company. (Pronounced eee-vis-ta) Miacalcin (calcitonin salmon) Nasal Spray is a registered trademark of Novartis Pharmaceuticals Corporation. (Pronounced me-a-cal-sin) Fosamax (alendronate sodium tablets) is a registered trademark of Merck & Company, Inc. (Pronounced foss-a-max) FOR ADDITIONAL INFORMATION ON ACTONEL AND OSTEOPOROSIS, PLEASE READ ACTONEL PATIENT INFORMATION.
  • 05/07/10 19:12 In closing, there is good news about osteoporosis. You can help prevent osteoporosis by taking care of your body before and after menopause. Helpful lifestyle measures are doing weight-bearing exercise regularly, following a healthy diet, including getting the recommended daily allowance of calcium and vitamin D, and avoiding smoking and too much alcohol. Keep in mind though that unfortunately, these measures may not be enough. And since you can’t see bone loss, to truly know whether you have or are at risk for fractures from osteoporosis, there is BMD testing that measures the density of your bones. The T-score from your BMD test enables your doctor to diagnose osteoporosis, hopefully before a fracture occurs. If your doctor diagnoses osteoporosis, there are things you can do. If your doctor recommends a prescription medication to help prevent or treat your osteoporosis, ask if Actonel is right for you. You need to fight to maintain healthy bones for life.
  • Managing Your Osteoporosis - Springfield Clinic

    1. 1. Osteoporosis Important information about what it is and what you can do Michael A. Pick, M.D. Rheumatologist Springfield Clinic May 5, 2010
    2. 2. The Impact of Osteoporosis <ul><li>10 million people have osteoporosis. </li></ul><ul><li>34 million people have low bone mass. </li></ul><ul><li>40% of women over 50 will suffer an osteoporosis-related fracture in their lifetimes. </li></ul><ul><li>Each year, the risk of suffering a fracture from osteoporosis is greater than the combined risk of suffering a heart attack, stroke, or breast cancer in women. </li></ul>
    3. 3. Incidence of Disease in US Women 05/07/10 <ul><ul><li></li></ul></ul>Derived from data received from the NOF, AHA, and the ACA
    4. 4. Impact of Osteoporosis <ul><li>In 2005, osteoporosis-related fractures were responsible for an estimated $19 billion in costs. </li></ul><ul><li>By 2025, experts predict that these costs will rise to approximately $25.3 billion </li></ul><ul><li>Osteoporosis is a major public health threat for an estimated 44 million Americans, or 55 percent of the people 50 years of age and older </li></ul>
    5. 5. What is Osteoporosis? <ul><li>Osteoporosis affects the entire skeleton. </li></ul><ul><li>Osteoporosis causes bones to lose density, become weak, and fracture easily. </li></ul><ul><li>Most osteoporotic fractures occur in the spine, hip, and wrist. </li></ul><ul><li>2/3 of spine fractures occur without any symptoms </li></ul><ul><li>Fractures can lead to disability and deformity. </li></ul>
    6. 6. Consequences of Fractures <ul><li>24 percent of hip fracture patients aged 50 and over die in the year following their fracture. </li></ul><ul><li>One in five of those who were ambulatory before their hip fracture requires long-term care afterward. </li></ul><ul><li>At six months after a hip fracture, only 15 percent of hip fracture patients can walk across a room unaided. </li></ul><ul><li>In addition to hip fractures, vertebral fractures are also linked to an increased risk of death. </li></ul><ul><li>Caucasian women aged 65 or older have twice the incidence of fractures as African-American women. </li></ul>
    7. 7. Bone Facts <ul><li>Women build bone from birth until age 30-35 when they achieve peak bone mass </li></ul><ul><li>Most women maintain peak bone mass until menopause </li></ul><ul><li>Bone loss occurs most rapidly in the first three years after menopause </li></ul><ul><li>Increased life expectancy means we live many more postmenopausal years… that’s many more years of potential bone loss </li></ul>
    8. 8. What is the natural progression of osteoporosis?
    9. 9. Bone Remodeling Reversal Formation Bone Bone Osteoblast s Osteoid Mineralization Bone Resting Activation Resorption Bone Osteoclast s
    10. 10. Bone Resorption
    11. 11. Bone Formation
    12. 12. Osteoporotic Bone Loss Normal Osteoporosis Dempster DW, et al. J Bone Min Res . 1986;1:15 - 21 . Reprinted with permission from the American Society for Bone and Mineral Research.
    13. 13. National Osteoporosis Foundation Risk Factors <ul><li>Increasing age </li></ul><ul><li>Female </li></ul><ul><li>Family history and/or personal history of fractures as an adult </li></ul><ul><li>Caucasian or Asian </li></ul><ul><li>Normal or early menopause </li></ul><ul><li>Inactive lifestyle </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Inadequate calcium intake </li></ul><ul><li>Certain medications, such as glucocorticoids </li></ul>
    14. 14. What Osteoporosis Risk Factors Are Unchangeable? <ul><li>Gender (female) </li></ul><ul><li>Menopausal status </li></ul><ul><li>Family history of Osteoporosis </li></ul><ul><li>Caucasian or Asian ancestry </li></ul><ul><li>Small and/or thin frame </li></ul><ul><li>History of fracture </li></ul><ul><li>Illnesses, e.g. RA, IBD, Anorexia </li></ul>
    15. 15. What Osteoporosis Risk Factors Are Changeable? <ul><li>Well balanced diet </li></ul><ul><li>Lack of exercise </li></ul><ul><li>Lack of calcium and vitamin D </li></ul><ul><li>Smoking </li></ul><ul><li>Excessive alcohol use </li></ul>
    16. 16. Risk Factors <ul><li>The long-term use of glucocorticoids (such as prednisone) can cause osteoporosis in both men and women. </li></ul><ul><li>Recommendations exist for the prevention and treatment of glucocorticoid-induced osteoporosis </li></ul><ul><li>Talk to you doctor if you are taking glucocorticoids. </li></ul>
    17. 17. How do I know if I have osteoporosis? <ul><li>Bone Mineral Density Test (BMD Test) </li></ul><ul><li>Measures bone density at various sites </li></ul><ul><li>Determines risk for fractures </li></ul>
    18. 18. What kinds of BMD tests are there? <ul><li>DEXA (dual energy x-ray absorptiometry) </li></ul><ul><ul><li>Gold standard </li></ul></ul><ul><ul><li>Measures hip and/or spine </li></ul></ul><ul><ul><li>Compares bone density to that of a young adult (T-score) </li></ul></ul><ul><li>Peripheral measures (heel, finger, wrist) </li></ul><ul><ul><li>A screening tool </li></ul></ul><ul><ul><li>Indicates possible risk of future fracture </li></ul></ul>
    19. 19. What kinds of BMD tests are there?
    20. 20. Who Should Get a Baseline Bone Density Test? <ul><li>National Osteoporosis Foundation Recommendation : </li></ul><ul><li>All women 65 years old or older </li></ul><ul><li>All women with a history of fragility fractures </li></ul><ul><li>All postmenopausal women with at least one risk factor </li></ul><ul><li>Adults with a disease or medication history associated with bone loss </li></ul>
    21. 21. Medicare Guidelines for Bone Density Test Coverage <ul><li>An estrogen deficient woman at clinical risk for osteoporosis </li></ul><ul><li>An individual with vertebral abnormalities as demonstrated by X-ray to be indicative of osteoporosis, low bone mass or vertebral fracture </li></ul><ul><li>An individual receiving long-term glucocorticoid therapy </li></ul><ul><li>An individual with primary hyperparathyroidism </li></ul><ul><li>An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy </li></ul>
    22. 22. What does a T-Score measure? T-score Normal Greater than –1.0 Low Bone Mass Between – 1.0 to – 2.5 (Osteopenia) Osteoporosis Less than or equal to – 2.5 World Health Organization (WHO) National Osteoporosis Foundation (NOF) Physicians Guide to Prevention & Treatment of Osteoporosis , 1998 Bone mass T-score: The standard deviation in a patient’s bone mineral density (BMD) compared with the peak bone mass in a young adult of the same gender
    23. 23. Pattern of Decline in Bone Mineral Density 05/07/10 <ul><ul><li></li></ul></ul>Meunier JP et al. Clin Ther. 1999;6:1025–1044. T-Score Osteoporosis < -2.5 Low Bone Mass -1.0 to -2.5 Normal >1.0 T-Score Age Normal
    24. 24. Bone Density Report - Lumbar Spine
    25. 25. Help Prevent Osteoporosis <ul><li>Prevent fractures </li></ul><ul><li>Maintain bone mass </li></ul><ul><ul><li>Good nutrition </li></ul></ul><ul><ul><li>Adequate calcium and Vitamin D </li></ul></ul><ul><ul><li>Encourage weight bearing exercise </li></ul></ul><ul><ul><li>Avoid smoking </li></ul></ul><ul><li>Even though you do all these, you can still develop osteoporosis </li></ul>
    26. 26. Weight Bearing Exercise <ul><li>Exercise that forces your body to support your full weight. </li></ul><ul><li>20-30 minutes at least </li></ul><ul><ul><li>five times a week </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>- Walking - Dancing </li></ul></ul><ul><ul><li>- Climbing stairs - Jogging </li></ul></ul><ul><ul><li>- Tennis - Climbing stairs </li></ul></ul><ul><li>Before starting any exercise you should consult with your physician. </li></ul>
    27. 27. Exercise for Strength and Balance <ul><li>Goal: decrease the risk of falling </li></ul><ul><li>No proven effect on bone mass </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Swimming </li></ul></ul><ul><ul><li>Bike riding </li></ul></ul><ul><ul><li>Rowing </li></ul></ul><ul><ul><li>Weight lifting </li></ul></ul><ul><li>Before starting any exercise you should consult with your physician. </li></ul>
    28. 28. Prevent Falls <ul><li>Maintain good lighting </li></ul><ul><li>Have vision checked </li></ul><ul><li>Use sturdy step-stools </li></ul><ul><li>Do not carry heavy things </li></ul><ul><li>Keep clutter off stairs and floors </li></ul><ul><li>Get rid of loose rugs and furniture </li></ul><ul><li>Wear shoes with low heels and non-skid soles </li></ul><ul><li>Rise slowly from sitting to standing </li></ul><ul><li>Use walking help if needed (cane, walker) </li></ul>
    29. 29. How Much Calcium is Enough? <ul><li>Varies for age </li></ul><ul><ul><li>1,200 mg every day after age 50 </li></ul></ul><ul><li>From diet or supplement or both </li></ul><ul><li>Good Sources of Calcium </li></ul><ul><li>Milk-300 mg/glass (4 glasses per day) </li></ul><ul><li>Yogurt-400 mg/cup (3 cups per day) </li></ul><ul><li>Broccoli-172 mg/cup (7+ cups per day) </li></ul>
    30. 30. How Much Vitamin D Should I Get? <ul><li>800 IU every day </li></ul><ul><li>From fortified foods or supplements or both </li></ul><ul><li>Good sources of Vitamin D </li></ul><ul><li>Milk (100 IU per glass) </li></ul><ul><li>Supplements with calcium (most have 800 IU) </li></ul>
    31. 31. Medications Available for Post-Menopausal Osteoporosis <ul><li>Estrogen </li></ul><ul><li>Evista ® (raloxifene HCl) </li></ul><ul><li>Miacalcin ® (calcitonin salmon) Nasal Spray </li></ul><ul><li>Fosamax ® (alendronate sodium tablets) </li></ul><ul><li>Actonel ® (risedronate sodium tablets) </li></ul><ul><li>Boniva® (ibandronate sodium tablets) </li></ul><ul><li>Reclast® (zoledronic acid) </li></ul><ul><li>Forteo® ( teriparatide </li></ul><ul><li>Consult with your physician to determine what medication may be appropriate for you. </li></ul>
    32. 32. Side Effects Of OP Medications <ul><li>Heartburn </li></ul><ul><li>Osteonecrosis of the Jaw </li></ul><ul><li>Atypical Fractures </li></ul><ul><li>Joint Pain </li></ul><ul><li>Flu-like Symptoms </li></ul><ul><li>Blood Clots </li></ul><ul><li>Muscle Cramps </li></ul><ul><li>Hot Flashes </li></ul>All medications have potential side effects .
    33. 33. The Good News <ul><li>Osteoporosis can be prevented </li></ul><ul><li>Osteoporosis can be diagnosed </li></ul><ul><li>Osteoporosis can be treated </li></ul><ul><li>Fight to maintain healthy bones for life! </li></ul><ul><li>Talk to your doctor about your risk! </li></ul>