Osteoporosis Shelley B. Bhattacharya, D.O., M.P.H. MS-3 Geriatrics Clerkship University of Kansas  School of Medicine
What is osteoporosis? <ul><li>MOST COMMON METABOLIC BONE DISEASE IN THE ELDERLY!! </li></ul>
Definition <ul><li>Systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone t...
Osteoporotic vs. normal bone <ul><li>Men have about 30% more bone mass than women </li></ul><ul><li>African Americans get ...
WHO Definition <ul><li>Osteopenia: </li></ul><ul><ul><li>BMD 1-2.5 standard deviations below young normal female mean (T s...
National Osteoporosis Foundation Definition <ul><li>Osteopenia:  </li></ul><ul><ul><li>Up to 2 standard deviations below y...
Prevalence 2000 (in millions) 2015 (in millions) Osteoporosis 10 41 Osteopenia 14 80
Epidemiology <ul><li>300,000 new cases per year </li></ul><ul><li>1.7 million in Europe per year </li></ul><ul><li>Men and...
Ten-Year Probability of Fracturing the Hip, Spine, Forearm, or Shoulder in Postmenopausal Women  (Relative Risk Attributab...
What is BMD? <ul><li>Bone Mineral Density </li></ul><ul><li>Accounts for about 70% of bone strength </li></ul><ul><li>Meas...
Bone Densitometer
Beam of densitometer
BMD and Fracture risk <ul><li>How much is fracture risk increased with drop in 1 SD in BMD? </li></ul><ul><li>2.6%!  </li>...
Fracture risk factors <ul><li>1. Fall risk </li></ul><ul><li>2. BMD </li></ul><ul><ul><li>Need maximal peak bone mass </li...
10-Year Probability of Fracture in Women by Age and T-Score Data from Kanis JA, et al.  Osteoporos Int.  2001;12:989-995. ...
Osteoporosis in men <ul><li>Awareness growing </li></ul><ul><li>Risk Factors </li></ul><ul><ul><li>Hypogonadism </li></ul>...
Progression of bone mass <ul><li>Peaks at age 30 </li></ul><ul><li>Loss worsens after menopause </li></ul><ul><li>Estrogen...
                                                                                                                          ...
Vitamin D <ul><li>From NHANES III data of 3444 women 51 and older, over 70% of the women 51-70 years of age did not meet a...
What are the NIH Vitamin D guidelines? <ul><li>Under 70? </li></ul><ul><li>400 IU </li></ul><ul><li>Over 70? </li></ul><ul...
Physical Exam <ul><li>Height, weight </li></ul><ul><li>Gait, mobility </li></ul><ul><li>Kyphosis evaluation </li></ul><ul>...
Labwork <ul><li>Complete Metabolic Panel </li></ul><ul><li>CBC </li></ul><ul><li>UA </li></ul><ul><li>TSH </li></ul><ul><l...
X-ray finding of normal spine <ul><li>Note  </li></ul><ul><li>osteopenic  </li></ul><ul><li>bones </li></ul>Source: school...
X-ray finding of mild deformity Source: schoolscience.co.uk
X-ray findings of classic wedge fracture Source: schoolscience.co.uk
Treatment <ul><li>Calcium  : 800-1200 </li></ul><ul><li>Vitamin D  </li></ul><ul><li>Exercise </li></ul><ul><li>Bisphospho...
Exercise <ul><li>1998 study at Gregg et al </li></ul><ul><li>Expending 750kcal/wk reduced hip fractures by 36% </li></ul><...
Calcium <ul><li>Adolescents: 1200mg/d </li></ul><ul><li>Non pregnant adults: 1200 </li></ul><ul><li>Menopausal women: 1200...
Calcium Supplements <ul><li>Use for osteopenia, osteoporosis and poor Ca intake patients  </li></ul><ul><li>Take 500-600mg...
Vitamin D <ul><li>400-1200 IU/d </li></ul><ul><li>8oz Vit. D fortified milk has how much Vitamin D? </li></ul><ul><li>100I...
Bisphosphonates <ul><li>Use when T score below 2.0 SD from normal </li></ul><ul><li>Poorly absorbed </li></ul><ul><ul><li>...
Bisphosphonate efficacy
Ibandronate (Bonviva) <ul><li>Monthly bisphosphonate </li></ul><ul><ul><li>Just released: q 3 month IV option </li></ul></...
Ibandronate efficacy
Calcitonin <ul><li>32 amino acid peptide </li></ul><ul><li>Nasal spray 200IU/spray </li></ul><ul><li>1 spray per day, q o ...
PTH (Forteo) <ul><li>34 amino acid recombinant PTH SC qd </li></ul><ul><li>Bone formation stimulator </li></ul><ul><li>Lin...
PTH Efficacy
Osteonecrosis of the jaw <ul><li>Clinically presents as a nonhealing tooth extraction or exposed bone in the jaw progressi...
osteoporosis <ul><li>Promising Developments in Osteoporosis Treatment </li></ul><ul><li>Manuel Sosa; Esther González-Padil...
F R A X <ul><li>The WHO developed a computer-generated algorithm, FRAX, which will supply clinicians with a tool to estima...
FRAX <ul><li>. This useful tool provides country- and ethnic-specific 10-year hip and major osteoporotic fracture (hip, di...
FRAX| <ul><li>] The information requested can be easily obtained from simple questioning; it includes age, sex, weight, he...
The information requested can be easily obtained from simple questioning; I includes age, sex, weight, height, personal an...
FRAX <ul><li>Threshold values for the instauration of bone-strengthening medication are established for those individuals ...
The American SOF STUDY OSTEOPOROSIS FRACTURE Research Group has also created another assessment tool for fracture risk. Th...
AGENTES ANABOLICOS <ul><li>TERIPARATIDE  24 meses </li></ul><ul><li>ANALOGO DE USO NASAL (FASE IV) PARA USO INDEFINIDO </l...
CINACALCET <ul><li>Calcium-sensing Receptor </li></ul><ul><li>The calcium-sensing receptor is located in the parathyroid g...
RONACALERET <ul><li>Therefore, small-molecule allosteric modulators can modify the PTH secretion. Thus, positive allosteri...
NUEVOS AGENTES ANTIRESORTIVOS <ul><li>Odanacatib </li></ul><ul><li>Ondanacatib inhibits cathepsin K, causing inactivation ...
GLUCAGON.-LIKE PEPTIDE <ul><li>Glucagon-like peptide (GLP)-2 is an intestinal polypeptide hormone released in response to ...
GLP-2 <ul><li>GLP-2 effects were statistically significant, with the highest dose (3.2 mg/day) at the total hip and trocha...
Osteonecrosis of the jaw <ul><li><1/10,000 patients </li></ul><ul><li>Associated primarily with IV bisphosphonate use in c...
Summary <ul><li>Always think of osteoporosis in a geriatric patient </li></ul><ul><li>Evaluate for risk factors </li></ul>...
 
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  • Kanis and colleagues reported 10-year probabilities of osteoporotic fracture in Swedish women according to age and BMD at the femoral neck. 1 These findings demonstrate that there is no specific point at which intervention is recommended. The green, amber, and red coloration is an arbitrary way of demonstrating the increased risk of fracture as patient age increases and T-score declines. The osteopenic group exhibits a wide range of 10-year fracture rate probabilities. Decisions must be made patient by patient on the basis of individual risk. Because the osteopenic group is a large population with wide variations in fracture risk, it is important to understand which patients in a given BMD range would benefit from therapeutic intervention. 1 Of note, the 10-year probability of fracture is also dependent on the patient’s age: A 50-year-old woman with a T-score of –2.5 has a 10-year probability of fracture of 11.3%. A 60-year-old woman with a T-score of –2.0 has a 10-year probability of fracture of 13%. A 65-year-old woman with a T-score of –1.5 has a 10-year probability of fracture of 12.6%. Reference 1. Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B. Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int . 2001;12:989-995.
  • Osteoporosis%203rd%20yr[1]

    1. 1. Osteoporosis Shelley B. Bhattacharya, D.O., M.P.H. MS-3 Geriatrics Clerkship University of Kansas School of Medicine
    2. 2. What is osteoporosis? <ul><li>MOST COMMON METABOLIC BONE DISEASE IN THE ELDERLY!! </li></ul>
    3. 3. Definition <ul><li>Systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue </li></ul><ul><li>Consequences: </li></ul><ul><ul><li>Bone fragility </li></ul></ul><ul><ul><li>Fracture </li></ul></ul>
    4. 4. Osteoporotic vs. normal bone <ul><li>Men have about 30% more bone mass than women </li></ul><ul><li>African Americans get 10% higher peak bone mass </li></ul>
    5. 5. WHO Definition <ul><li>Osteopenia: </li></ul><ul><ul><li>BMD 1-2.5 standard deviations below young normal female mean (T score) </li></ul></ul><ul><ul><li>What is Z score? </li></ul></ul><ul><li>Osteoporosis: </li></ul><ul><ul><li>BMD over 2.5 standard deviations below young normal female mean </li></ul></ul>
    6. 6. National Osteoporosis Foundation Definition <ul><li>Osteopenia: </li></ul><ul><ul><li>Up to 2 standard deviations below young normal females </li></ul></ul><ul><li>Osteoporosis: </li></ul><ul><ul><li>Below 2 standard deviations </li></ul></ul>
    7. 7. Prevalence 2000 (in millions) 2015 (in millions) Osteoporosis 10 41 Osteopenia 14 80
    8. 8. Epidemiology <ul><li>300,000 new cases per year </li></ul><ul><li>1.7 million in Europe per year </li></ul><ul><li>Men and women </li></ul><ul><li>50% of women over age 50 will sustain a fracture in their lifetime </li></ul>Rosen, Endotext.com, Chap.11
    9. 9. Ten-Year Probability of Fracturing the Hip, Spine, Forearm, or Shoulder in Postmenopausal Women (Relative Risk Attributable to Prior Fracture, 1.74) 3,9 Kanis JA et al. Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int 2001 Dec; 12:989-95 Example Age BMD T-score in Femoral Neck Prior Fragility Fracture 10-year#8232;Fracture Probability A 55 – 1.2 No 7.3% B 65 – 1.5 No 12.6% C 65 – 2.5 No 19.3% D 65 – 1.5 Yes 21.9% E 75 – 1.5 No 15.2% F 75 – 1.5 Yes 26.4% G 75 – 2.4 Yes 40.9%
    10. 10. What is BMD? <ul><li>Bone Mineral Density </li></ul><ul><li>Accounts for about 70% of bone strength </li></ul><ul><li>Measured by DXA Scan </li></ul><ul><ul><li>Measures density in radius, lumbar spine and greater trochanter </li></ul></ul><ul><ul><li>Mass of bone mineral in the path of the beam divided by the cross sectional area of the beam, expressed as g/cm2 </li></ul></ul>
    11. 11. Bone Densitometer
    12. 12. Beam of densitometer
    13. 13. BMD and Fracture risk <ul><li>How much is fracture risk increased with drop in 1 SD in BMD? </li></ul><ul><li>2.6%! </li></ul><ul><li>Not linear. 10% increase fx risk with -2.5 SD in BMD </li></ul><ul><li>Usually fracture in distal forearm, hip or spine </li></ul><ul><ul><li>Distal forearm: MC nonvertebral fx in white women until age 75 </li></ul></ul><ul><ul><li>Spine: Usually from compressive loading, can be painless </li></ul></ul>
    14. 14. Fracture risk factors <ul><li>1. Fall risk </li></ul><ul><li>2. BMD </li></ul><ul><ul><li>Need maximal peak bone mass </li></ul></ul><ul><ul><ul><li>How to increase peak bone mass? </li></ul></ul></ul><ul><ul><li>Need minimal rate of decline with age </li></ul></ul><ul><ul><ul><li>What increases rate of decline? </li></ul></ul></ul><ul><li>3. Architecture and geometry of the bone </li></ul>
    15. 15. 10-Year Probability of Fracture in Women by Age and T-Score Data from Kanis JA, et al. Osteoporos Int. 2001;12:989-995. 30.8 24.5 19.4 15.2 11.8 9.1 7.0 28.4 22.8 18.3 14.6 11.5 9.0 7.1 23.9 19.3 15.6 12.6 10.0 8.0 6.3 20.2 16.2 13.0 10.4 8.2 6.5 5.1 16.8 13.4 10.7 8.5 6.7 5.3 4.1 14.1 11.3 9.2 7.4 5.9 4.7 3.8 75 70 65 60 55 50 T-Score – 3.0 T-Score – 2.5 T-Score – 2.0 T-Score – 1.5 T-Score – 1.0 T-Score – 0.5 T-Score 0 Age (years) 30.8 24.5 19.4 15.2 11.8 9.1 7.0 28.4 22.8 18.3 14.6 11.5 9.0 7.1 23.9 19.3 15.6 12.6 10.0 8.0 6.3 20.2 16.2 13.0 10.4 8.2 6.5 5.1 16.8 13.4 10.7 8.5 6.7 5.3 4.1 14.1 11.3 9.2 7.4 5.9 4.7 3.8 75 70 65 60 55 50 T-Score – 3.0 T-Score – 2.5 T-Score – 2.0 T-Score – 1.5 T-Score – 1.0 T-Score – 0.5 T-Score 0 Age (years) 30.8 24.5 19.4 15.2 11.8 9.1 7.0 28.4 22.8 18.3 14.6 11.5 9.0 7.1 23.9 19.3 15.6 10.0 8.0 6.3 20.2 16.2 10.4 8.2 6.5 5.1 16.8 13.4 10.7 8.5 6.7 5.3 4.1 14.1 9.2 7.4 5.9 4.7 3.8 75 70 65 60 55 50 T-Score – 3.0 T-Score – 2.5 T-Score – 2.0 T-Score – 1.5 T-Score – 1.0 T-Score – 0.5 T-Score 0 Age (years) 12.6 13.0 11.3
    16. 16. Osteoporosis in men <ul><li>Awareness growing </li></ul><ul><li>Risk Factors </li></ul><ul><ul><li>Hypogonadism </li></ul></ul><ul><ul><li>Alcoholism </li></ul></ul><ul><ul><li>Glucocorticoid use </li></ul></ul><ul><ul><li>Sedentarism </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><li>Look for Hypercalciuria – why? What syndrome? </li></ul><ul><li>August 2007 article in Clinical Endocrinology News found lower quality of life amongst men with osteoporosis </li></ul>Palkhivala, A. Vertebral Fractures Underdiagnosed in Men , Clinical Endocrinology News, Aug. 2007, p.21
    17. 17. Progression of bone mass <ul><li>Peaks at age 30 </li></ul><ul><li>Loss worsens after menopause </li></ul><ul><li>Estrogen protects against osteoclastic activity </li></ul><ul><li>Resorption exceeds reabsorption </li></ul>
    18. 18.                                                                                                                                                                                                                      
    19. 19. Vitamin D <ul><li>From NHANES III data of 3444 women 51 and older, over 70% of the women 51-70 years of age did not meet adequate Vitamin D intake guidelines </li></ul><ul><li>90% of women over 70 did not meet guidelines </li></ul>Moore et al, J of Amer Diab Assn. 2004; 104:980-83
    20. 20. What are the NIH Vitamin D guidelines? <ul><li>Under 70? </li></ul><ul><li>400 IU </li></ul><ul><li>Over 70? </li></ul><ul><li>600IU </li></ul><ul><li>NOF guidelines: 400-800 IU/d </li></ul>
    21. 21. Physical Exam <ul><li>Height, weight </li></ul><ul><li>Gait, mobility </li></ul><ul><li>Kyphosis evaluation </li></ul><ul><li>Percussion of spine—why? </li></ul><ul><li>Signs of steroid use </li></ul>
    22. 22. Labwork <ul><li>Complete Metabolic Panel </li></ul><ul><li>CBC </li></ul><ul><li>UA </li></ul><ul><li>TSH </li></ul><ul><li>Vit D </li></ul><ul><li>If hi calcium, do PTH </li></ul><ul><li>If male, do free testosterone </li></ul><ul><li>If suspect Multiple Myeloma: SPEP/UPEP </li></ul>
    23. 23. X-ray finding of normal spine <ul><li>Note </li></ul><ul><li>osteopenic </li></ul><ul><li>bones </li></ul>Source: schoolscience.co.uk
    24. 24. X-ray finding of mild deformity Source: schoolscience.co.uk
    25. 25. X-ray findings of classic wedge fracture Source: schoolscience.co.uk
    26. 26. Treatment <ul><li>Calcium : 800-1200 </li></ul><ul><li>Vitamin D </li></ul><ul><li>Exercise </li></ul><ul><li>Bisphosphonates </li></ul><ul><li>Calcitonin </li></ul><ul><li>PTH </li></ul><ul><li>Estrogen </li></ul><ul><li>Aclasta (Zolendronic acid) </li></ul>
    27. 27. Exercise <ul><li>1998 study at Gregg et al </li></ul><ul><li>Expending 750kcal/wk reduced hip fractures by 36% </li></ul><ul><li>Weight bearing, 30-60 min., 3-4x/wk </li></ul><ul><li>Strength training 2x/wk </li></ul>Gregg, Ann Int Med 1998; 129:81-88
    28. 28. Calcium <ul><li>Adolescents: 1200mg/d </li></ul><ul><li>Non pregnant adults: 1200 </li></ul><ul><li>Menopausal women: 1200 </li></ul><ul><li>Women and men over 65: 1500 mg/d </li></ul><ul><li>Usually given as CaCo3 600 bid with dietary intake or 500 tid without dietary intake </li></ul>
    29. 29. Calcium Supplements <ul><li>Use for osteopenia, osteoporosis and poor Ca intake patients </li></ul><ul><li>Take 500-600mg at a time </li></ul><ul><li>CaCo3 with meals </li></ul><ul><ul><li>Can be constipating </li></ul></ul><ul><li>Ca Citrate with or without meals </li></ul><ul><li>Take with Vitamin D </li></ul>
    30. 30. Vitamin D <ul><li>400-1200 IU/d </li></ul><ul><li>8oz Vit. D fortified milk has how much Vitamin D? </li></ul><ul><li>100IU </li></ul><ul><li>Other sources </li></ul><ul><ul><li>Cereals, egg yolk, seaweed, liver </li></ul></ul>
    31. 31. Bisphosphonates <ul><li>Use when T score below 2.0 SD from normal </li></ul><ul><li>Poorly absorbed </li></ul><ul><ul><li>Take in AM </li></ul></ul><ul><ul><li>30 minutes before PO </li></ul></ul><ul><ul><li>Standing up or upright in bed </li></ul></ul><ul><ul><li>With 8oz plain water (no juice, no other meds) </li></ul></ul><ul><li>Daily, weekly or monthly </li></ul><ul><li>Use with Calcium/Vitamin D </li></ul><ul><ul><li>Fosamax plus 5600 IU Vit. D released June 2007 </li></ul></ul>
    32. 32. Bisphosphonate efficacy
    33. 33. Ibandronate (Bonviva) <ul><li>Monthly bisphosphonate </li></ul><ul><ul><li>Just released: q 3 month IV option </li></ul></ul><ul><li>Same administration routine </li></ul><ul><li>Comparable results (50%) in vertebral fracture reduction in those with and without hx fx </li></ul>
    34. 34. Ibandronate efficacy
    35. 35. Calcitonin <ul><li>32 amino acid peptide </li></ul><ul><li>Nasal spray 200IU/spray </li></ul><ul><li>1 spray per day, q o nostril </li></ul><ul><li>Used for analgesia </li></ul><ul><li>Not very effective as monotherapy for future fracture reduction </li></ul>
    36. 36. PTH (Forteo) <ul><li>34 amino acid recombinant PTH SC qd </li></ul><ul><li>Bone formation stimulator </li></ul><ul><li>Linear BMD effect </li></ul><ul><li>Cost $500/mo—2 nd line </li></ul>
    37. 37. PTH Efficacy
    38. 38. Osteonecrosis of the jaw <ul><li>Clinically presents as a nonhealing tooth extraction or exposed bone in the jaw progressing to bone infection </li></ul><ul><li>Cancer patients have 4X higher risk of getting this due to concomitant radiation, chemo, steroids </li></ul><ul><li>To May 2004, FDA Adverse Event Reporting Database found 152 cases associated with all bisphosphonates </li></ul>
    39. 39. osteoporosis <ul><li>Promising Developments in Osteoporosis Treatment </li></ul><ul><li>Manuel Sosa; Esther González-Padilla </li></ul><ul><li>New Assessment Tools for Fracture Risks & Treatment Decisions </li></ul><ul><li>Anabolic Agents </li></ul><ul><li>New Resorption Inhibitors </li></ul>
    40. 40. F R A X <ul><li>The WHO developed a computer-generated algorithm, FRAX, which will supply clinicians with a tool to estimate absolute, time-specific fracture risk quantitatively </li></ul>
    41. 41. FRAX <ul><li>. This useful tool provides country- and ethnic-specific 10-year hip and major osteoporotic fracture (hip, distal forearm, shoulder, vertebral body) risks, based on information entered into the calculator, which is available for free online </li></ul>
    42. 42. FRAX| <ul><li>] The information requested can be easily obtained from simple questioning; it includes age, sex, weight, height, personal and family history of fracture, current tobacco and alcohol consumption, corticosteroid usage, previous conditions associated with secondary osteoporosis, and history of rheumatoid arthritis </li></ul>
    43. 43. The information requested can be easily obtained from simple questioning; I includes age, sex, weight, height, personal and family history of fracture, current tobacco and alcohol consumption, corticosteroid usage, previous conditions associated with secondary osteoporosis, and history of rheumatoid arthritis FRAX
    44. 44. FRAX <ul><li>Threshold values for the instauration of bone-strengthening medication are established for those individuals who have a 3% or more risk of a hip fracture and/or 20% risk or more of a major osteoporotic fracture </li></ul><ul><li>. The FRAX calculator is particularly useful for younger, healthy, postmenopausal females with osteopenia, a group of people with a relatively low 10-year fracture risk. </li></ul>
    45. 45. The American SOF STUDY OSTEOPOROSIS FRACTURE Research Group has also created another assessment tool for fracture risk. The SOF model, unlike FRAX. And QFRAX. Is based only on BMD and age. However, it predicts the 10-year risk of hip and major osteoporotic fracture as well as the FRAX tool in a group of postmenopausal females, 65 years and old. These findings highlight the importance of age as a risk factor for fragility fractures .
    46. 46. AGENTES ANABOLICOS <ul><li>TERIPARATIDE 24 meses </li></ul><ul><li>ANALOGO DE USO NASAL (FASE IV) PARA USO INDEFINIDO </li></ul>
    47. 47. CINACALCET <ul><li>Calcium-sensing Receptor </li></ul><ul><li>The calcium-sensing receptor is located in the parathyroid gland and the kidney. It is a G-protein-coupled, seven-pass transmembrane molecule whose main function is to coordinate calcium homeostasis by regulating the release of PTH. </li></ul>
    48. 48. RONACALERET <ul><li>Therefore, small-molecule allosteric modulators can modify the PTH secretion. Thus, positive allosteric modulators or calcium-sensing receptor agonists, named calcimimetics, such as cinacalcet, decrease PTH secretion in patients with renal disease and hyperparathyroidism; while negative allosteric modulators or calcium-sensing receptor antagonists, named calcilytics, such as ronacaleret, can inhibit the receptor, releasing </li></ul>
    49. 49. NUEVOS AGENTES ANTIRESORTIVOS <ul><li>Odanacatib </li></ul><ul><li>Ondanacatib inhibits cathepsin K, causing inactivation of its preoteolytic activity in osteoclasts. The presence of the 4-fluoroleucine side chain at the P2 position interacting within the S2 pocket is what gives ondanactib its potency and selectivity.[38] This is responsible for the lack of accumulation of undesirable collagen in cutaneous fibroblasts </li></ul>
    50. 50. GLUCAGON.-LIKE PEPTIDE <ul><li>Glucagon-like peptide (GLP)-2 is an intestinal polypeptide hormone released in response to food intake. Bone remodeling occurs according to a circadian rhythm[46] that is affected by rates of food intake and increases overnight with nocturnal fasting. </li></ul><ul><li>Bone resorption activity peaks overnight; therefore, treatment with GLP-2 at bedtime will achieve a substantial reduction in the bone resorption. However, GLP-2 does not appear to reduce bone formation, as evidenced by stable osteocalcin levels during treatment </li></ul>
    51. 51. GLP-2 <ul><li>GLP-2 effects were statistically significant, with the highest dose (3.2 mg/day) at the total hip and trochanter. These results suggest that GLP-2 may dissociate bone resorption from bone formation.[48] If this pattern could be sustained, GLP-2 would have a great advantage over other available antiresorptive agents that decrease bone formation and hold promise in the treatment of osteoporosis. </li></ul>
    52. 52. Osteonecrosis of the jaw <ul><li><1/10,000 patients </li></ul><ul><li>Associated primarily with IV bisphosphonate use in cancer patients undergoing dental procedures </li></ul><ul><li>ONJ precaution labeling has been added to all bisphosponates </li></ul><ul><li>Risk factors: CA with chemo, radiation, anemia, infection </li></ul><ul><li>1 case so far of ONJ without cancer hx </li></ul>
    53. 53. Summary <ul><li>Always think of osteoporosis in a geriatric patient </li></ul><ul><li>Evaluate for risk factors </li></ul><ul><li>Don’t forget the men! </li></ul><ul><li>Order DXA at baseline and every 2 years </li></ul><ul><li>Treat based on DXA findings </li></ul><ul><li>Encourage nicotine cessation, steroid wean, exercise </li></ul>

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