Osteoprosis

1. Fadhila al-Busaidi
Family Medicine Resident

2. 55 yrs old lady with background:
 Osteoprosis on alendronate and since 6
yrs started from KH.
Came for f/u she is asymptomatic.

3. o/e:
Comfertable. BP 135/66. P: 71
Weight: 50kg . Height: 155 . BMI: 20.8
Systemic examination normal.

4. Epidemiology and definition.
Risk factors.
Screening.
Management.

5.  More than 10 million Americans have
osteoporosis.
Roughly 50% of white women and 20% of
white men have a fracture related to
osteoporosis in their lifetime.
National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis.
Washington, DC: National Osteoporosis Foundation; 2014.

6. WHO defined osteoporosis to exist in
postmenopausal women or men when
axial bone density T-score by DXA at the
femoral neck falls 2.5 standard
deviations (SD) or more below the
average value in young healthy women (T-
score ≤ -2.5 SD) at lumbar spine, total hip,
or femoral
neck.
]NICE[

7. Interpreting T score ( WHO )

8. People >50 yrs should
be offered DXA
scanning to evaluate
the need for anti-
osteoporosis therapy
People >50 yrs should
be considered for
fracture-risk
assessment.
Women >50yrs with
h/o previously
untreated early
menopause should be
considered for
fracture-risk
assessment,
particularly in the
presence of other risk
factors
previous
fracture
parental
history of
osteoporosis
history of early
menopause
(< age of 45)
NICE

9. People > 50yrs with BMI
(<20 kg/m2) may be
considered for fracture-
risk assessment,
particularly in the
presence of other risk
factors.
People > 50yrs who
consume more than 3.5
units of alcohol per day
should be considered
for fracture-risk
assessment.
Smokers over the age of
50 should be considered
for fracture-risk
assessment, particularly
in the
presence of other risk
factors.
low BMI (<20
kg/m2)
alcohol intake
smoking
NICE

10. All women 65 years or older.
All postmenopausal women:
 h/o fracture(s) without major trauma after
40 to 45 years of age
 With osteopenia identified radiographically
 systemic glucocorticoid therapy (≥ 3
months)
 Patients at increased risk of secondary
osteoporosis (RA)
AAFP

11. Other perimenopausal or
postmenopausal women with risk
factors:
 Current smoker
 Early menopause
 Family history of osteoporotic fracture
 Excessive consumption of alcohol (> 2
drinks per day for women)
 Low body weight (< 58 kg or BMI < 20 kg
per m2)
 systemic glucocorticoid therapy (≥ 3
months)

14.  The USPSTF found insufficient evidence to
recommend routine screening for osteoporosis in men.
 Men with a minimal trauma fracture at age > 50 years
or those with secondary causes associated with bone
loss could be considered for screening.
 The National Osteoporosis Foundation also
recommends screening all men 70 years and older,
based on the assumption that this group has a similar
osteoporotic fracture risk and treatment effectiveness
as 65-year-old white women.
]AAFP[

15.  Cushing, adrenal insff.
 Hyperparathyroidism
 thyrotoxycosis,
hyperprolactinemia.
 DM, hypogonadism.
 RA or SLE
 IBD and malabsorption
 Leukemia, MM.
 Epilepsy, Parkinson, MS
 Chronic liver/kidney Dis.
 oral glucocorticoids
 Prolong DMPA ( > 2 yrs ).
 Tamoxifine.
 GnRH agonists (in men
with prostate cancer)
 Chemotherapeutics.
 Cyclosporine, MTX.
 PPIs
 Prolong antidepressants
 antiepileptics
 TZDs
Co-existing disease Drugs

16.  Up to 30% of osteoporosis cases in
postmenopausal women are estimated to be from
a secondary cause.
 And up to 50% in men, premenopausal women,
and perimenopausal women.
 For all newly diagnosed patients, recommended
laboratory tests include serum 25-hydroxyvitamin
D, calcium, creatinine, and thyroid-stimulating
hormone levels.
]AAFP[

17. postmenopausal women and men with a
personal history of hip or vertebral fracture,
a T-score of –2.5 or less.
a combination of:
 (T-score between –1 and –2.5) and
 At least 20% FRAX Assessment Tool.
AAFP

19. has potent inhibitory effects on osteoclastic
bone resorption,
high affinity for binding bone mineral.
Alendronic acid, Risedronate, zoledronic
acid, Etidronate & Ibandronic acid.
Bisphosphonate
Examples:

20.  Alendronate and risedronate:
 reduce vertebral and hip fractures.
 Dose: 70mg weekly.
 Ibandronate: reduce spine fractures only.
 Dose: oral (150 mg monthly ) OR ( 3 mg IV
every three months )
 Zoledronic acid: decrease vertebral and hip
fractures
 Dose: 5 mg yearly

21.  The optimal length of oral bisphosphonate therapy
is unknown.
 One study found that women who take alendronate
for 5 yrs followed by 5 yrs of placebo have no
increased incidence of nonvertebral or hip
fractures compared with women who take
alendronate for 10 years. There is, however, an
increase in vertebral fractures.
 Clinicians should consider discontinuing
bisphosphonate therapy after 5 yrs in women
without a personal history of vertebral fractures.

22.  Selective estrogen receptor modulator.
 Prevent: vertebral fractures only.
 The best candidates are:
 postmenopausal unable to tolerate
bisphosphonates,
 have no vasomotor symptoms
 No h/o venous thromboembolism,
 have a high breast cancer risk score

23. Calcium metabolism modifier.
Short-term treatment of painful vertebral
fractures.
Increased risk of cancer with long-term
therapy, marketing authorisation for
calcitonin has been withdrawn for the
treatment of osteoporosis in the UK and
Europe. NICE

24.  A recombinant human parathyroid hormone
with bone anabolic activity.
 vertebral and nonvertebral fractures
 Dose: 20 mcg per day SC for 2 years.
 One study suggests that it is advisable to
follow teriparatide therapy with
bisphosphonate therapy to maintain BMD
gains.

25. human monoclonal antibody that inhibits
the formation and activity of osteoclasts.
Dose: 60 mg SC every six months for
three years.
hip, vertebral, and nonvertebral fractures
Use: not improve with bisphosphonates.
CI: hypocalcemia, CKD stage < III.

26. slightly reduced the risk of hip and
vertebral fractures.
Increased risk of stroke, venous
thromboembolism, coronary heart disease,
and breast cancer.
the lowest effective dose of HRT should be
used for the shortest time. NICE

27. Do not routinely repeat DEXA scans more
often than once every two years.
A decrease in BMD could suggest:
 treatment nonadherence,
 inadequate calcium or vitamin D intake,
 unidentified secondary,
 treatment failure.

28.  All women 65 yrs and older should be screened for
osteoporosis with DEXA of the hip and lumbar
spine.
 Women younger than 65 yrs should be screened
for osteoporosis if the estimated 10-year fracture
risk equals or exceeds that of a 65-year-old white
woman with no risk factors.
 Bisphosphonates should be used as first-line
pharmacologic treatment for osteoporosis along
with lifestyle modifications.

31. AAFP August 2015.
SIGN: Management of osteoporosis and
the prevention of fragility fractures. March
2015. Scottish Intercollegiate Guidelines
Network.
NICE: Osteoporosis overview. Jan 2016