Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue. It increases bone fragility and risk of fracture. While not a natural part of aging, risk is higher for post-menopausal women over 65 and all races and sexes can be affected. Bone density testing is recommended for women over 65, men over 70, and younger adults with clinical risk factors to diagnose osteoporosis. Dual energy x-ray absorptiometry (DEXA) is the gold standard test which measures bone mineral density at the hip and spine.
Know everything about Osteoporosis- prevention and management.
Did You Know?
The incidence of hip fracture is 1 woman to 1 man in India
Know more such facts and useful information on prevention of Osteoporosis.
Hinduja hospital conducts regular webinars and tweetinars for online users where they can seek advice from expert doctors of hinduja hospital for free. Above is the webinar conducted by hinduja hospital on Osteoporosis where issues like osteoporosis symptoms, osteoporosis prevention, osteoporosis treatment were discussed successfully by Spine Consultant, Dr. Uday Pawar.
To know more about such upcoming webinars and tweetinars from hinduja hospital, visit http://www.hindujahospital.com/communityportal/
Know everything about Osteoporosis- prevention and management.
Did You Know?
The incidence of hip fracture is 1 woman to 1 man in India
Know more such facts and useful information on prevention of Osteoporosis.
Hinduja hospital conducts regular webinars and tweetinars for online users where they can seek advice from expert doctors of hinduja hospital for free. Above is the webinar conducted by hinduja hospital on Osteoporosis where issues like osteoporosis symptoms, osteoporosis prevention, osteoporosis treatment were discussed successfully by Spine Consultant, Dr. Uday Pawar.
To know more about such upcoming webinars and tweetinars from hinduja hospital, visit http://www.hindujahospital.com/communityportal/
Osteoporosis is a disease in which bones become fragile and can easily break. It has no symptoms in its early stages and is a public health threat to more than 44 million Americans. In this community lecture given live on our Berkeley Heights, NJ campus, Dr. Toscano-Zukor, explains how to identify your risk factors for osteoporosis as well as prevent and treat this disease.
Osteoporosis is a progressive systemic skeletal disease characterized by low bone mass and microarchitecture deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.
Osteoporosis is a disease in which bones become fragile and can easily break. It has no symptoms in its early stages and is a public health threat to more than 44 million Americans. In this community lecture given live on our Berkeley Heights, NJ campus, Dr. Toscano-Zukor, explains how to identify your risk factors for osteoporosis as well as prevent and treat this disease.
Osteoporosis is a progressive systemic skeletal disease characterized by low bone mass and microarchitecture deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.
How do we diagnose osteoporosis and making a treatment decission using BMD as a diagnostic tool. It also covers how do we assess clinical risk factors to make an intervention and to minimize fracture
Dr Steve Cummings presentation from Osteoporosis 2016: Patients receiving bisphosphonates should not take holidays from treatment.
Find out more at: https://nos.org.uk/conference
Prof. Jon Tobias's presentation from Osteoporosis 2016: What are the properties of the perfect therapy?
Find out more at: https://nos.org.uk/conference
Kate Ward's presentation from Osteoporosis 2016: Relationships between muscle function and bone microarchitecture in the Hertfordshire cohort study.
Find out more at: https://nos.org.uk/conference
Prof. Richard Eastell's presentation from Osteoporosis 2016: Patients receiving bisphosphonates should take holidays from treatment. The case for holidays.
Find out more at: https://nos.org.uk/conference
Prof. Nicholas Harvey's presentation from Osteoporosis 2016: Calcium, with or without vitamin D supplementation, is not associated with ischaemic heart disease or cardiac death: the UK Biobank cohort.
Find out more at: https://nos.org.uk/conference
Prof. Richard Keen's presentation from Osteoporosis 2016: Teaching old dogs new tricks? Combination therapy in osteoporosis.
Find out more at: https://nos.org.uk/conference
Everything you should know about Osteoporosis?
What is Osteoporosis?
Osteoporosis is a disorder of bones characterized by low bone density and a deterioration of bone micro- architecture that enhances bone fragility and increases the risk of fracture
Osteoporosis becomes a serious health threat for aging men & postmenopausal women by predisposing them to an increased risk of fracture
Do you know that?
Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures per year
Spine, hip, and wrist fractures are most common.
Oss pro (Asma Saleem product Manager Neutro Pharma)Asma Saleem
A bone mineral density (BMD) test measures the density of minerals (such as calcium) in your bones using a special X-ray or scan. Bone (BMD) is related to bone strength
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
2. Osteo = bone
Porosis = full of holes
Osteoporosis = means
bones that are full of
holes
3. OsteoporosisOsteoporosis
• The most common metabolic bone disorderThe most common metabolic bone disorder
• Systemic skeletal disease characterized by:Systemic skeletal disease characterized by:
– Low bone massLow bone mass
– Microarchitectural deterioration of bone tissueMicroarchitectural deterioration of bone tissue
– Increased bone fragility and susceptibility to fractureIncreased bone fragility and susceptibility to fracture
Not a natural part of aging
Increased risk for women, post-menopausal, over age 65
All races, sexes, and ages are susceptible
Preventable and treatable!
4.
5. In the USA, the estimated
prevalence of osteopenia
is 15 million in women and
3 million in men.
The estimated prevalence
of osteoporosis is 8
million in women and 2
million in men.
Although, osteoporosis
affects >10 million
individuals in the United
States, only 10 to 20% are
diagnosed and treated
80% are women
Osteoporosis - Prevalence
10. Osteoporotic Fractures:
Comparison with Other Diseases
1996 new cases,
all ages184 300
750 000
vertebral
250 000
other sites
250 000
forearm
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 BL & Melton LJ 3rd, Bone, 1995;17(5 suppl):505S-511S
11. All fractures are Associated With
Morbidity
Cooper C, Am J Med, 1997;103(2A):12S-17S
40%
Unable to walk
independently
30%
Permanent
disability
20%
Death within
one year
80%
One year after an
hip fracture:
Patients(%)
Unable to carry out at
least one independent
activity of daily living
12. Osteoporosis Is a Serious Public Health
Problem
• Affects 10 million
Americans (80%
women)
• 2 million fractures yearly
• Direct cost $17 billion
Distribution of Fractures
13. Primary Care Providers Are Critical for Osteoporosis
Management, Screening, Diagnosis, and Treatment
14. Why Recognize & Treat Osteoporosis?Why Recognize & Treat Osteoporosis?
To Prevent FracturesTo Prevent Fractures
• 1.5 million fractures/yr1.5 million fractures/yr
• $17 billion direct costs$17 billion direct costs
• 300,000 hip fractures/yr300,000 hip fractures/yr
– 20% die20% die
– 25% confined to long-term care facilities25% confined to long-term care facilities
– 50% long-term loss of mobility50% long-term loss of mobility
17. Vision:
Towards a society free from
osteoporotic fractures.
Mission:
Promote health awareness among Saudi
society about osteoporosis and it's
relative high risk factors ,build up
screening programs and comprehensive
health care.
18. The plan contain 7 targets:
•primary prevention of Osteoporosis.
•secondary prevention of Osteoporosis.
•improve the quality of health services at
it's three levels provided to Osteoporosis
patients.
•support monitoring, follow up, evaluation
methods related to Osteoporosis control
program.
• implement and support research methods
and respective studies related to
Osteoporosis.
19. Types of osteoporosis
Primary Osteoporosis
•Postmenopausal Osteoporosis
•Senile Osteoporosis
Secondary Osteoporosis
• Diet
• Drug
• Endocrine disease
• Other Systemic Disorders.
20. Impact of OsteoporosisImpact of Osteoporosis
Signs
Kyphosis
Loss of height
Abdo bulges
Clinically
diagnosed
fracture
Symptoms
Neck becomes
weak
Pain in back
Breathing
difficulties
Indigestion & GOR
Stress incontinence
Difficulty with
mobility following
a fracture
21.
22.
23. Risk Factors
• Chronic liver disease
• Excessive secretion of cortisol (Cushing's syndrome)
• Radiographic evidence of osteopenia or vertebral
deformity
• Previous fracture not caused by a major accident
• Cancer
• Significant loss of height or an abnormal bend in the
upper spine (thoracic kyphosis)
Risk factors that have the potential to be
modified include:
• Cigarette smoking
• Excessive alcohol intake
• Inactivity
• Low body weight
• Poor general health
• Prolonged immobilization
Risk factors that cannot be
modified include:
• Caucasian race
• Advanced age
• Female sex
• Premature menopause (<45 years)
• Prolonged time (>1 year)
without a menstrual period
Conditions associated with
osteoporosis:
• Anorexia nervosa
• Malabsorption syndromes
• Excessive secretion of parathyroid
hormone
• Excessive secretion of thyroid
hormone
• Post-transplantation
• Chronic renal disease
28. Vertebrae
Hip
Wrist
50 60 70 80
40
30
20
10
Age (Years)
Annualincidence
per1000women
Incidence of
Osteoporotic Fractures in Women
Wasnich RD, Osteoporos Int 1997;7 Suppl 3:68-72
31. Combined Effect of Bone DensityCombined Effect of Bone Density
and Risk Factorsand Risk Factors
Rate of
Hip Fracture/
1000
Woman-Years
Bone Density
Cummings SR et al. N Engl J Med. 1995;332:767-773.
Number of
Risk Factors
27.3
14.7
9.4
0
5
10
15
20
25
30
Lowest Third Middle Third Highest Third
≥5
3-4
0-2
37. Example of Applying the FRAX Tool
Which Woman is at Higher Fracture Risk?
54 year old smoker with a T-score of -2.0
or
81 year old with no prior fracture with a T-score of
-1.4
10 year risk of hip fracture = 2.5%; major osteoporotic fracture = 10%
10 year risk of hip fracture = 3.2%; major osteoporotic fracture = 26%
38. a 10 year probability of fracture in women
with relation to age and T-score
41. Determinants Of Peak Bone Mass
Peak Bone Mass
Physical activity Gonadal status
Nutritional statusGenetic factors
42.
43. BoneMass
Age (years(
Attainment of Peak
Bone Mass
Consolidation Age-related Bone Loss
Men
Women
Menopause
0102030405060
Fracture
Threshold
Compston JE. Clin Endocrinol 1990; 33:653–682.
Age Related Changes in BoneAge Related Changes in Bone
MassMass
44.
45.
46.
47. Pathogenesis
• Diminished bone mass can result from:
– failure to reach an optimal peak bone mass in early adulthood
– increased bone resorption
– decreased bone formation after peak bone mass has been
achieved
• All three of these factors probably play a role in most
elderly persons. Low bone mass, rapid bone loss, and
increased fracture risk correlate with high rates of bone
turnover (ie, resorption and formation).
• In osteoporosis, the rate of formation is inadequate to
offset the rate of resorption and maintain the structural
integrity of the skeleton
48.
49.
50.
51. Osteoporosis – Screening
X-ray findings are generally insufficient for the screening of
primary osteoporosis:
• A normal x-ray of bone cannot reliably
measure bone density but is useful to
identify spinal factures, explains back
pain, height loss or kyphosis.
• X-rays may detect osteopenia only when bone
loss is > 30%.
• X-ray findings can also suggest other causes
of metabolic bone disease, such as the lytic
lesions in multiple myeloma and the pseudofractures characteristic of
osteomalacia.
Bone densitometry is the only method for diagnosing
or confirming osteoporosis in the absence of a fracture
52. Screening- Ultrasound Densitometry
Ultrasound densitometry can assess the density and
structure of the skeleton and appears to predict fracture
risk in the elderly. The apparatus is relatively inexpensive,
portable, and uses no radiation but can be used only in
peripheral sites (eg, the heel), where bone is relatively
superficial. Ultrasound devices do not expose the patient
to ionizing radiation.
53. Dual-Energy X-Ray
Absorptiometry
• “Gold Standard” test to determine a
diagnosis
• Measures hip & spine
• Painless, safe and requires no
injections
• Takes 5-10 minutes
• Determines risk for fracture
54.
55. Screening - DEXA
Dual energy x-ray absorptiometry (DEXA)
• DEXA measures areal density (ie, g/cm2) rather than
true volumetric density.
• The test is non-invasive and involves no special
preparation.
• Radiation exposure is minimal, and the procedure is
rapid. This is the most popular and accurate test to
date and the test only takes about 20 to 40 minutes,
with a 5 mrem dose of radiation (a full dental x-ray is
300 mrem).
59. USPSTF 2010 Recommendations :
Screening for Osteoporosis
BMD testing for women 65 & older
BMD in 60-64 yo if ↑ fx risk
- Use WHO FRAX® risk tool
If clinical based fracture risk of 9.3%
then order bone density
measurement
Nelson et al Ann Int Med July 2010
60. Who Should Have a Bone Density Test?
AAFP and NOF
AAFP: Sweet MG, et al. Am Fam Physician. 2009;79(3):193-200.
NOF: National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis.
www.nof.org. Accessed August 2014.
Women age 65 and older Men age 70 and older
Postmenopausal women and men ages 50–69
with clinical risk factors
Adults who have a fracture after age 50
Adults with a condition (e.g., rheumatoid arthritis) or
taking a medication (e.g., glucocorticoids(
associated with low bone mass or bone loss
61. T-score
Normal ≥ -1
Osteopenia < -1 and > -2.5
Osteoporosis ≤ -2.5
Severe
Osteoporosis
≤ -2.5 with Fracture
Osteoporosis
World Health Organization Criteria
Postmenopausal Caucasian with DXA measure
WHO Study Group JBMR 1994
62. Screening - DEXA
DEXA of the proximal femur in a young
woman, age 37, with unsuspected
femoral-neck osteopenia (T score, -1.6).
DEXA of the lumbar spine in a young
woman, age 37, with unsuspected lumbar
spine osteopenia (T = -1.8)
65. T scores vs. Z scores
T score – number of SDs a patient’s BMD
deviates from a reference population of
normal young adults
Z score – number of SDs a patient’s BMD
deviates from a reference population of
subjects of the same age and sex
Z scores indicate whether the BMD result is
expected for the patient’s age. If it is
much less than expected, suspect a
secondary cause of osteoporosis (use –2
as a cutoff(
66.
67.
68.
69.
70.
71.
72. 2014Universal Recommendations
http://www.nof.org/hcp/practice/tools. Accessed August 2014.
Counsel on the risk of fractures
Eat a diet rich in fruits and vegetables (supplemented
if necessary) to a total calcium intake of
•1000 mg per day for men 50-70
•1200 mg per day for women ≥ 51
•1200 mg per day for men ≥ 71
Vitamin D intake should be 800-1000 IU per day (age
≥50), supplemented if necessary
Regular weight-bearing and muscle-strengthening
exercise
Fall prevention evaluation and training
Cessation of tobacco use and avoidance of excessive
alcohol intake
73. The good news: Osteoporosis is
preventable for most people!
74.
75. 75
Calcium requirements vary by age
Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:
What It Means to You at http://www.surgeongeneral.gov/library/bonehealth
If this is your age
Then you need
this much calcium
each day (mg)
0 to 6 months 210
7 to 12 months 270
1 to 3 years 500
4 to 8 years 800
9 to 18 years 1,300
19 to 50 years 1,000
Over 50 years 1,200
Growth
spurt
77. 77
Calcium
An easy way to meet calcium needs
is consuming 3 cups
(8 oz.) each day of fat-free or low-
fat* milk or equivalent milk products
in combination with
a healthy diet. Children ages
2–8 years need 2 cups.
MyPyramid equivalents:
• 8 oz. milk
• 1 cup yogurt
• 1-1/2 oz. natural
..or 2 oz.
processed ..cheese
* Fat-free and low-fat are for
health but not for calcium
differences
78. % DV calcium: Milk group
• Yogurt
1 cup (8 oz.) = 30% DV
• Milk
1 cup = 30% DV
• Cheese
1 ½ oz. natural/2 oz. processed = 30% DV
• Milk pudding
1/2 cup = 15% DV
• Frozen yogurt, vanilla, soft serve
½ cup = 10% DV
• Ice cream, vanilla
½ cup = 8% DV
• Soy or rice milk, calcium-fortified
1 cup = varies—check label
Choose fat-free
or low fat
most often
79. % DV calcium: Grain products
group
• Cereal,
calcium-
fortified
Serving size
and amount of
calcium varies
—check label
80. % DV calcium: Vegetable
group
• Broccoli, raw
1 cup = 9% DV
• Collards كرنب
1/2 cup = 20% DV
• Turnip greens, لفت
1/2 cup = 10% DV
81. % DV calcium: Fruit group
• Orange juice and
other calcium-fortified
beverages
6 oz. = 20 to 30% DV,
varies—check label
Look for 100% juice
82. % DV calcium:
Meat & Beans Group
• Baked beans
1 cup = 14% DV
• Salmon, canned, with edible
bones
3 oz. = 18% DV
• Sardines, canned, in oil, with
edible bones
3 oz. = 32% DV
• Soybeans, cooked
1 cup = 26%
• Tofu, firm, with calcium
½ cup = 20% DV; check label
84. Calcium carbonate vs. citrate
Calcium carbonate
• Needs acid to
dissolve and for
absorption
• Less stomach acid
as we age
• Often taken at
meals when more
stomach acid
Calcium citrate
• Doesn’t require
stomach acid for
absorption
• May be taken
anytime—check with
your healthcare
provider
• May cost more
85. Limit calcium to 500 mg at
a time
Our bodies can best
handle about 500
mg calcium at one
time from food
and/or supplements.
Spread your calcium
sources throughout
the day.
86. Increase amount slowly
• Start supplements with 500 mg
calcium daily for about a week,
gradually adding more.
• Gas and constipation can be
side effects:
– Increase fluids and high fiber
foods if diet is low in whole grains
and fruits and vegetables.
– Try a different type of supplement
if side effects continue.
87. 87
Vitamin D from sunlight exposure
• Vitamin D is manufactured in your skin
following direct exposure to sun.
• Amount varies with time of day, season,
latitude and skin pigmentation.
• 10–15 minutes exposure of hands, arms
and face 2–3 times/week may be
sufficient (depending on skin sensitivity).
• Clothing, sunscreen, window glass and
pollution reduce amount produced.
Source: National Osteoporosis Foundation Web site; retrieved July 2005 at http://www.nof.org
88. You need more vitamin D as
you age
Age
Daily
vitamin D needs
in International
Units (IU)
89. Food Sources of Vitamin DFood Sources of Vitamin D
Cod liver oil – 1 TBS
Salmon 3.5 oz.
Mackerel 3.5 oz.
Tuna, canned, in oil, 3 oz.
Sardines 3.5 oz.
Milk (fortified) 8 oz.
Ready to eat cereal (fortified) ¾ -
1 cup
Egg 1 whole
Liver, 3.5 oz.
Cheese, swiss 1 oz.
1,360 IU
360
345
200
250
98
40
20
15
12
90. 90
Sources of Vitamin D?
Main dietary sources of vitamin D are:
• Fortified milk
(400 IU per quart)
• Some fortified cereals
• Cold saltwater fish
(Example: salmon, halibut, herring,
tuna, oysters and shrimp)
• Some calcium and vitamin/mineral
supplements
95. Osteoporosis
Falls Break Bones
• You can prevent most falls
– Improve your balance, coordination, and strength
through weight-bearing physical activity such as
dancing or Tai Chi
– Review medicines with a health care professional
(some medicines may cause drowsiness or
dizziness)
– Have your vision checked
– Make your home safer
96. Protect Your Bones
Ways to Make Your Home Safer
1
2
3
4
5
6
7
8
9
10
11
Have handrails and plenty of light in all stairways.
Wear shoes that give good support and have non-slip soles.
Don’t use stepstools. Keep items you need within easy
reach.
Maintain a clear path to the bathroom.
Make sure your walkways are wide enough.
Remove all small rugs. They can make you trip.
Move phone and electrical cords away from walkways and
open areas.
Make sure that all areas are well lit. Use bright light bulbs.
Be aware that some medications, including over-the-counter
medicines, can make you dizzy or sleepy.
Get your vision checked.
Remove things that you may trip over from stairs and places
where you walk.
97. Protect Your Bones
Ways to Make Your Home Safer
12
5 Remove all small rugs. They can make you trip.
Use non-slip mats in the bathtub or shower. Have grab bars
put in next to your toilet and in the bathtub or shower.
98.
99.
100. Whom to Treat: NOF Guidelines 2014Whom to Treat: NOF Guidelines 2014
Women ≥ 65 and men ≥ 70
(younger with risk factors)
T-score between -1.0 and
-2.5
T-score ≤ -2.5 in the lumbar spine,
total hip, or femoral neck
or
Hip or spine fracture (clinical or radiographic)
DXA test
≥ 3% for hip fracture
or
≥ 20% for major osteoporotic fractures
FRAX
10-y fracture risk
Candidate for
TREATMENT
YES
YES
nof.org/hcp/resources/913. Accessed August 2014.
101. Osteoporosis Therapy Algorithm
Postmenopausal Women
At Risk/Osteopenia Osteoporosis Severe OsteoporosisSTAGE
LowerHigher
-2.5BMD (T-score)
Raloxifene
PTH
CalcitoninHRTHRT
HRTHRT
During Hot
Flushes
Post Vasomotor Symptoms
Pre fracture
Post Fracture
Risk
of Fracture
AGE
Bisphosphonates Or
Strontium Ranelate
50 55 60 65 70 75 80 85 90
102. Osteoporosis Prevention and Treatment
Age
Hormonal Replacement
Bisphosphonates
Strontium
SERM
20 40 60 80
Vitamin D
PTH
Life Style
Treatment
choice
103. One-Minute Treatment DecisionOne-Minute Treatment Decision
Therapy Decision
Treat all patients with
an existing fracture
High Risk-
Treat
Moderate Risk -
Treat if other risk factors
Low Risk-
Check again in 1-2 years
T-Score *
Below -2.0
-1.5 to -2.0
Above -1.5
National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of
Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998.
112. Estrogen Treatment (ET)
• Several approved oral and transdermal preparations
• Treats symptoms of estrogen deficiency
• Skeletal effects:
– Decrease in biochemical markers of 50% to 60%
– 2-year BMD increase of 4% to 6% at hip and spine
– Decreased incidence of vertebral and hip fractures (34%) after 5
years in the Women’s Health Initiative (WHI)
– Effects in women with osteoporosis have not been evaluated in
randomized controlled trials
• Concern about adverse effects
• Long-term use not recommended
Rossouw JE, et al. Writing Group for the Women’s Health Initiative Investigators. JAMA. 2002;288:321-333.
113.
114. The Concept of a SERM
Selective Estrogen Receptor Modulator
(EAAs: Estrogen Agonist/Antagonists(
Binds to the estrogen receptors
Produces an estrogen agonist effect in some
tissues
Produces an estrogen antagonist effect in
others
115. Raloxifene
• Raloxifene (60 mg daily)
• Skeletal effects:
–Decrease in biochemical markers of 30%
–3-year BMD increases of 2% to 3% at hip and spine
–Decreased incidence of vertebral fractures (30% to 50%) in
women with pre-existing vertebral fractures or low bone density. No
effect on nonvertebral or hip fractures has been observed
• Extra-skeletal effects: reduction in invasive
breast cancer
Ettinger B, et al. JAMA. 1999;282:637-645.
116. Raloxifene
Adverse effects
Hot flashes
2- to 3-fold increased risk of venous
thromboembolic events
No increased risk of stroke, but Black Box
Warning for increased risk of death following
stroke
Leg cramps
Sontag A, Wan X, Krege JH. Curr Med Res Opin. 2010;26:71-76.
117. Calcitonin
Calcitonin (200 units daily by nasal spray)
Skeletal effects:
Decrease in biochemical markers of 20%
Small effect (1% to 2%) on bone density in spine
Reduced incidence of vertebral fractures (36%) in women with pre-
existing vertebral fractures
No effect on nonvertebral or hip fractures has been observed
Adverse effects
Nasal stuffiness
Possible increased cancer risk
Chesnut CH 3d, et al. Am J Med. 2000;109:267-276. http://effectivehealthcare.ahrq.gov/slides/?
pageaction=displaySlides&tk=49&dpg=9&scroll=314. Accessed: September 13, 2013. European Medicines Agency.
Press release. July 20, 2012. Available at:
http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2012/07/WC500130122.pdf. Accessed:
September 13, 2013.
118. Bisphosphonates
Alendronate, Risedronate, Ibandronate, and Zoledronic Acid
• Alendronate: 10 mg daily (tablet) or 70 mg weekly (tablet or
liquid) for treatment, 5 mg daily or 35 mg weekly for
prevention
• Risedronate: 5 mg daily or 35 mg weekly (tablet); 150 mg
monthly (tablet)
• Ibandronate: 150 mg monthly by tablet; 3 mg intravenously
over 15 to 30 seconds every 3 months
• Zoledronic acid: 5 mg by intravenous infusion over a minimum
of 15 minutes once every year for treatment—and every other
year for prevention
*
2012 Jun 25;172(12):930-6
National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National
Osteoporosis Foundation; 2013. Available at: http://www.nof.org/hcp/clinicians-guide. Accessed September 13, 2013.
119. Clinical Benefit of Bisphosphonates
• Relative risk reduction for fractures
• Postmenopausal women with osteoporosis
• 3 years bisphosphonate treatment
Vertebrae Hip
Khosla S, et al. J Clin Endocrinol Metab. 2012;97(7):2272-2282.
120.
121. Bisphosphonates: Indications
Treatment and prevention of postmenopausal
osteoporosis
Alendronate, risedronate, ibandronate, zoledronic acid
Prevention and/or treatment of glucocorticoid-
induced osteoporosis
Risedronate, zoledronic acid, alendronate
Treatment of men with low bone density
Alendronate, risedronate, zoledronic acid
122. Contraindications/Warnings/Precautions
– Hypocalcemia
– Creatinine clearance <30 cc/min (<35 cc/min for zoledronic acid)
– For oral dosing: Esophageal stricture or impaired esophageal motility (alendronate);
inability to stand or sit for at least 30 minutes (alendronate/risedronate) or 60
minutes (ibandronate)
Notes: UGI symptoms per se are not a contraindication to oral dosing.
Use in pregnancy: Class C
Oral dosing requirements
– Tablets (with exception of delayed release risedronate) taken on an empty stomach
after overnight fast with 6 to 8 oz of plain water while in an upright position
– Patients should not eat or lie down for at least 30 minutes (alendronate
and risedronate) or 60 minutes (ibandronate)
– Calcium and vitamin D supplements, if needed, should be taken at a different time
of day than the oral bisphosphonate
Bisphosphonates
National Osteoporosis Foundation. Med Lett. 2011;53(1360):24.
123. • “Class warning” regarding UGI symptoms
(no increase in UGI complaints in randomized
controlled trials)
• Influenza-like symptoms may occur after first
monthly oral dose of IV bisphosphonate
• “Class warning” regarding infrequent bone,
joint, and/or muscle pain
• “Class warning” regarding jaw osteonecrosis
• “Class warning” about atypical fractures
following long-term therapy
Bisphosphonates: Side Effects
124. “Osteonecrosis” of the Jaw (ONJ(
An area of exposed alveolar or palatal bone that typically
shows poor healing over several months
95% of cases have been reported with high-dose,
chronic IV bisphosphonate treatment of myeloma and
cancer metastatic to bone1
Can occur with denosumab2
Pain in 2/3 cases: infection may or may not be present
Known risk factors: invasive dental procedures, oral
trauma, periodontitis, poor oral hygiene, radiotherapy to
the jaw, chemotherapy, corticosteroids, infection
Pathogenesis is not known3
1. Woo SB, et al. Ann Intern Med. 2006;144:753-761. 2. Sutton EE, Riche DM. Ann Pharmacother. 2012;46:1000-1009.
3. Khosla S, et al. J Bone Miner Res. 2007;22:1479-1491.
125. Atypical Fractures of Femur in Patients
Taking Anti-Resorptive Agents Long Term
Park-Wyllie LY, et al. JAMA. 2011;305:783-789. Shane E, et al. J Bone Miner Res. 2013 May 28. [Epub ahead of print].
Watts NB, Diab DL. J Clin Endocrinol Metab. 2010;95:1555-1565. Meier RP. Arch Intern Med. 2012;172:930-936.
• May begin with stress reaction or stress
fracture of lateral femoral cortex (A)
• Transverse fractures of femoral diaphysis
or in subtrochanteric region (B)
• Often bilateral
• Prodromal pain in thigh or groin in 70%
• Occurs in untreated patients, but
increased incidence with long-term
antiresorptive therapy, particularly
bisphosphonates and denosumab
126. Bisphosphonate Therapy:
“Long-Term” Treatment Stopping treatment in high-risk patients
After 5 years of alendronate-decline in BMD, rise in biochemical
markers, no increased fracture risk except clinical vertebral fractures1
After 3 years of risedronate, spine BMD rose, vertebral facture risk
was still reduced compared with control patients2
After 3 years of zoledronic acid, slight increase in morphometric
fractures vs clinical vertebral fractures3
Long-term treatment has not clearly been associated with safety
issues or loss of efficacy
Cessation of treatment after 2 to 5 years is associated with some
persisting effect on biochemical markers, as well as BMD; this has
been best characterized for alendronate and zoledronic acid
1. Black DM, et al. JAMA. 2006;296:2927-2938. 2. Watts NB, et al. Osteoporosis Int. 2008;19:365-372. 3. Black DM, et
al. J Bone Miner Res. 2012;27:243-254.
127. Recently Approved
• Boniva – 150 mg monthly
– 2.5 mg daily approved May, 2003
– Vertebral fracture efficacy shown with daily
– Based on 1 year BMD data, 150 mg monthly is
superior to the 2.5 mg daily
– 60 minute post dose fast, not 30 minute
• Fosamax PLUS D – 70 mg/2800 IU
weekly
128. How Long to Treat with bisphosphonates?
5–10 years appears to be safe for most patients
Assess for risk:
and Diab D. J Clin Endocrinol Metab. 2010;95(4):1555-1565.
Drug Holiday
After 3-5 years
Drug Holiday
After 3-5 years
Drug Holiday
After 10 years
Drug Holiday
After 10 years
Higher RiskLower Risk
129. Baseline 3 Years
VERT-NA: Placebo Patient
Increased perforation
Trabecular
thinning
Borah, et al, JBMR 16 (Suppl 1),
130. Similar thickness of trabeculae and number of perforations
Baseline 3
Years
Borah, et al, JBMR 16 (Suppl 1), 2001
VERT-NA: Risedronate Patient
131. Bisphosphonates for Osteoporosis
• Benefit: reduction of fracture risk (alendronate,
risedronate, ibandronate)
• Problem: poor adherence to therapy
• Cause: multifactorial, including issues of
convenience (complexity of dosing) and
tolerability (GI irritation in clinical experience)
• Possible solutions: larger doses given less
frequently, parenteral administration
132. Bisphosphonates:
Molecular Mechanisms of Action
• Interfere with the action of osteoclasts
– Recruitment, differentiation, and action
– Two mechanisms:
• Incorporated into cytotoxic ATP analogs (etidronate)
– Affect cellular activity
• Interfere with the mevalonate pathway (nitrogen-containing BPs)
– Cause apoptosis
Russell R, et al. Osteoporos Int. 1999;(suppl 2):S68-S80.
133. Bisphosphonates:
Contraindications and Warnings
• Contraindications
– Hypocalcemia
– Known hypersensitivity to any component of this product
– Inability to stand or sit upright for at least 30 minutes
• Warnings
– Bisphosphonates may cause upper gastrointestinal disorders such
as dysphagia, esophagitis, and esophageal or gastric ulcer
.
134.
135.
136. Denosumab
Monoclonal antibody to RANKL
60 mg subcutaneous injection every 6 months
9% increase in spinal BMD after 3 years in the pivotal
FREEDOM trial; 4% to 5% increase in hip BMD
Reduction in fracture risk after 3 years:
68% decrease in new vertebral fractures
40% decrease in hip fractures
20% decrease in nonvertebral fractures
8-year data: continued increase BMD, reduced bone
turnover, good safety
Cummings SR, et al. N Engl J Med. 2009;368:756-765
Prolia (prescribing information). Thousand Oaks, CA: Amgen; June 2012.
McClung MR, et al. Osteoporos Int. 2013;24(1):227-235.
137. Denosumab Binds RANK Ligand and Inhibits Osteoclast
Formation, Function, and Survival
RANKL
RANK
OPG
Denosumab
Bone Formation Bone Resorption
Inhibited
Osteoclast Formation, Function,
and Survival Inhibited
CFU-GM Prefusion
Osteoclast
Osteoblasts
Hormones
Growth Factors
Cytokines
Adapted from: Boyle WJ, et al. Nature. 2003;423:337-342.
138. Proven osteoporotic fracture reduction
throughout the skeleton
In the pivotal FREEDOM study (published in the New England Journal of
Medicine), Denosumab reduced the risk of fracture at key osteoporotic
fracture sites versus placebo
PROLIA®: PROTECTION AGAINST FRACTURE
The absolute risk reductions demonstrated for Prolia® versus placebo
were 4.8%, 1.5% and 0.5% for vertebral, non-vertebral and hip
fractures respectively. 1
6
P
139. Denosumab Adverse Events
Adverse events that occurred more commonly in
denosumab group (as listed in the PI):
Serious infections leading to hospitalization
Dermatitis, eczema, rashes
Back pain, pain in the extremity, musculoskeletal pain,
hypercholesterolemia, cystitis
Pancreatitis
Osteonecrosis of the jaw
Significant suppression of bone remodeling
Prolia (prescribing information). Thousand Oaks, CA: Amgen; June 2012.
140. Teriparatide: rhPTH [1-34[
• The only treatment agent that is anabolic—stimulates bone
formation rather than inhibiting bone resorption
• 20 μg daily (subcutaneously) for no more than 2 years
• Indication: treatment of men and postmenopausal women
with osteoporosis who are at high risk for fracture
• Effects:
– Increased bone density in spine by 9% and hip by
3% vs placebo over 18 months
– Reduced incidence of vertebral fractures (65%) and
nonvertebral fragility fractures (53%) in women with
pre-existing vertebral fractures
– Studies too small to evaluate effect on hip fractures
• Adverse reactions: arthralgia, pain, nausea; warning about
osteosarcoma risk in rats
Neer RM, et al. N Engl J Med. 2001;344:1434-1441.
Forteo (prescribing information). Indianapolis, IN: Eli Lilly and Company; March 21, 2012.
141.
142. Latest in Osteoporosis Treatment
1.Carotenoids, Lycopene Reduce Fracture Risk
(Antioxidants)
“…reactive oxygen intermediates may be involved in the bone-
resorptive process and that fruit and vegetable-specific
antioxidants, such as carotenoids, are capable of decreasing this
oxidative stress. Therefore carotenoids may help in preventing
osteoporosis.
In particular, an inverse relation of carotenoids and lycopene
with biochemical markers of bone turnover has recently
been demonstrated.”
143. 2.Omega-3 Fatty Acids Reduce hs-CRP1
“This study provides evidence that in healthy individuals,
plasma n-3 fatty acid concentration is inversely related to
hs-CRP…”
“High sensitivity C-reactive protein (hs-CRP) is a marker of
low grade sustained inflammation.”
“Increased hs-CRP by just 1SD increases fracture risk by an
amazing 23 percent2
.”
Consider supplementing the diet with omega-3 fatty acids
(fish oil). They’re a great way to help reduce inflammation,
hs-CRP, cardiovascular disease, and fractures related to
osteoporosis.
1. Micallef M A et al., European Journal of Clinical Nutrition, 2009; April 8 [Epub ahead of print].
2. Pasco et al. JAMA. 2006;296(11):1353-1355
144. 3.Vitamin K Improves Bone Strength and Reduces
Fractures
Review of RCTs showed that vitamin K(1) and vitamin K(2)
supplementation reduced serum undercarboxylated
osteocalcin levels regardless of dose but that it had
inconsistent effects on serum total osteocalcin levels and
no effect on bone resorption.”
Iwamoto J et al., Nutrition Research, 2009; 29(4): 221-228.
Editor's Notes
NOTE TO PRESENTER: Read the slide to the audience then use the following speaker notes for emphasis.
Osteo means bone.
Porosis means full of holes.
Osteoporosis means bones full of holes.
Osteoporosis is a serious and complicated disease that progresses silently and typically without symptoms until a fracture occurs. Osteoporosis may go undetected for many years. People may not realize they have it until they fracture a hip, vertebra or another bone. By this time, they have probably lost a significant amount of bone and even routine activities such as lifting a bag of groceries or turning over in bed can cause a fracture. (NEXT SLIDE)
NOTE TO PRESENTER: Be familiar with this chart and able to point out the impact of osteoporosis. **Please note that the chart is based on number of incidents and not on $$$dollars. You may want to add that medical expenses from osteoporosis-related bones fractures costs $18 billion annually. (NEXT SLIDE) (2002 $ figure)
**Chart made available from the Surgeon General’s Report on Bone Health and Osteoporosis.
NOF Fast Facts. www.nof.org. Accessed February 2013.
http://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer. Accessed May 2013.
Burge R, et al. J Bone Miner Res. 2007;22:465-475.
http://seer.cancer.gov/statfacts/html/prost.html#risk. www.cdc.gov/uscs. Accessed May 2013.
Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD. 2004.
NOF Fast Facts. www.nof.org. Accessed February 2013.
http://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer. Accessed May 2013.
Burge R, et al. J Bone Miner Res. 2007;22:465-475.
http://seer.cancer.gov/statfacts/html/prost.html#risk. www.cdc.gov/uscs. Accessed May 2013.
Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD. 2004.
Fractures are an important consequence of osteoporosis and this slide shows some of the effects it can have on a patient
Osteoporosis can initially exist without many signs or symptoms. However, over time, more symptoms due to deformity will present and may result in decreased quality of life for the patient
The clinical signs are deformity such as kyphosis and loss of height. In addition, the patient may complain of a number of symptoms
Pain can be present in the whole or part of the back, and the vertebral deformity can lead to other complications such as breathing difficulties and digestive problems
Moreover, fractures can impair mobility. Overall, these factors can combine to lead to a loss of independence and dignity
Permission required
Fig 3 p.993
NOTE TO PRESENTER: USE THE SPEAKER NOTES BELOW TO EMPHASIZE THE DIFFERENT BONE GROWTH CATEGORIES.
From birth through adolescence, new bone is built faster than old bone is removed and bones grow larger, heavier and denser. Remember when I discussed remodeling where bone is broken down and rebuilt? Bone mass increases progressively during growth and for some time after adult height is reached. Peak bone mass is achieved in women in their early 20s with gradual bone loss beginning in their 30s, paralleling an age-related decline in muscle mass.
Depending on lifestyle and other factors: the accelerated bone loss is thought to be related to an increase in the breaking down of bone compared to the building of bone. We will discuss lifestyle and risk factors later in this presentation.
After menopause in women, bone removal increases due to a decrease in estrogen. We will discuss the effects of menopause and the role of estrogen in the NEXT slide. Bone loss often occurs without symptoms or warning signs. (NEXT SLIDE)
**Chart made available from the Surgeon General’s Report on Bone Health and Osteoporosis.
This figure illustrates the changes in bone mass throughout life and shows the rapid bone loss that occurs in women at the menopause
Bone mass in both men and women increases until a peak is attained at around age 30 years. In both sexes, a slow rate of bone loss starts at around age 40 years
However, in women, the accelerated postmenopausal phase of bone loss is superimposed on top of this slow loss phase. Rates of bone loss in postmenopausal women can be as great as 6% per year
In women, oestrogen deficiency is the major determinant of bone loss after the menopause
__________
Compston JE. Clin Endocrinol 1990; 33:653–682.
NOTE TO PRESENTER- START OFF THIS SLIDE BY DISCUSSING THE FOLLOWING:
The only way to determine whether you have osteoporosis is to have your bone mass measured. The measurement is called a bone mineral density test or BMD. Various types of machines using different technology are available for measuring bone density however, the most commonly used today is the DXA or Dual Energy X-Ray Absorptiometry, similar to the one on this slide.
INDICATE THAT THIS TYPE OF TEST IS CONSIDERED THE “GOLD STANDARD” TEST TO DETERMINE A DIAGNOSIS. MOVE ON TO NEXT BULLET POINT.
The test typically measures your bone density in the most common sites for osteoporotic fractures such as the hip, spine and/or wrist.
Note to Presenter: You want to mention that there are other machines that scan sites such as the heel, finger and wrist that can identify individuals that may have low bone density. These machines should not be used for diagnoses or to monitor a person being treated for osteoporosis to evaluate if the treatment is working. You may wish to ask how many in the audience have had screenings on these types of machines. Point out: If they have been screened on this type of a machine and the results indicated low bone density; encourage them to talk with their doctor since low bone density, at any site, can be a red flag for a variety of conditions. MOVE ON TO NEXT BULLETIN.
The test is painless, safe and requires no injections.
The test takes approximately 5-10 minutes.
To predict your fracture risk, test results are compared to the average bone density in a large population of young adults, of the same sex, who have reached peak bone mass. The result is expressed in the form of a T-Score. (NEXT SLIDE)
http://nof.org/hcp/clinicians-guide
Conditions, Diseases and Medications That Cause or Contribute to Osteoporosis and Fractures
Lifestyle factors
Alcohol Abuse High salt intake Falling
Low calcium intake Inadequate physical activity Excessive thinness
Vitamin D insufficiency Immobilization
Excess vitamin A Smoking (active or passive)
Genetic factors
Cystic fibrosis Homocystinuria Osteogenesis imperfecta
Ehlers-Danlos Hypophosphatasia Parental history of hip fracture
Gaucher’s disease Idiopathic hypercalciuria Porphyria
Glycogen storage diseases Marfan syndrome Riley-Day syndrome
Hemochromatosis Menkes steely hair syndrome
Hypogonadal states
Androgen insensitivity Hyperprolactinemia Premature ovarian failure
Anorexia nervosa and bulimia Premature menopause Athletic amenorrhea
Turner’s & Klinefelter’s syndromes Panhypopituitarism
Endocrine disorders
Adrenal insufficiency Cushing’s syndrome Central Adiposity
Diabetes mellitus (Types 1 & 2) Hyperparathyroidism Thyrotoxicosis
Gastrointestinal disorders
Celiac disease Inflammatory bowel disease Primary biliary cirrhosis
Gastric bypass Malabsorption
GI surgery Pancreatic disease
Hematologic disorders
Multiple myeloma Monoclonal gammopathies Sickle cell disease
Hemophilia Leukemia and lymphomas Systemic mastocytosis
Thalassemia
Rheumatologic and autoimmune diseases
Ankylosing spondylitis Lupus Rheumatoid arthritis
Other rheumatic and autoimmune diseases
Central nervous system disorders
Epilepsy Parkinson’s disease Stroke
Multiple sclerosis Spinal cord injury
Miscellaneous conditions and diseases
AIDS/HIV Congestive heart failure Muscular dystrophy
Alcoholism Depression Post-transplant bone disease
Amyloidosis End stage renal disease Sarcoidosis
Chronic metabolic acidosis Hypercalciuria Weight loss
Chronic obstructive lung disease Idiopathic scoliosis
Medications
Aluminum (in antacids) Cyclosporine A and tacrolimus Proton pump inhibitors
Anticoagulants (heparin) Depo-medroxyprogesterone (premenopausal contraception) Selective serotonin reuptake inhibitors
Anticonvulsants Glucocorticoids (≥ 5 mg/d prednisone or equivalent for ≥ 3 months) Tamoxifen® (premenopausal use)
Aromatase inhibitors GnRH (Gonadotropin releasing hormone) antagonists and agonists Thiazolidinediones (such as Actos® and Avandia®)
Barbiturates Lithium Thyroid hormones (in excess)
Cancer chemotherapeutic drugs Methotrexate Parenteral nutrition
Developed by a study group of the WHO in 1994 to help epidemiologists compare data from different countries and regions.
Has been applied to clinical practice of bone densitometry, in particular to central DXA.
Note that osteopenia does NOT include either –1 or -2.5 (-1 is normal; -2.5 is osteoporosis).
NOTE: A FRAGILITY FRACTURE WITH ANY T-SCORE=OSTEOPOROSIS
Not because this was part of WHO definition, but because this is a standard practice.
Just because we have a densitometric definition does not mean that the clinical definition (fragility fracture) should be discarded.
As highlighted by the recent US Preventive Services Task Force recommendations (http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.htm) vitamin D and calcium remain controversial. The NOF guidelines extracted for this slide describe vitamin D insufficiency [serum 25-hydroxyvitamin D (25(OH)D) &lt; 30 ng/ml (75 nmol/L)] as a risk factor for falls and adds that “Patients with recent fractures, multiple fractures or very low BMD should be evaluated for secondary etiologies and, when considering osteomalacia or vitamin D insufficiency, a serum 25(OH)D level should be obtained.” Thus clinical judgment should dictate whether supplementation alone or with serum monitoring is appropriate for each patient.
The 2010 AACE guidelines (Watts et al. 2010. http://aace.metapress.com/content/813555l642h443v5/?id=813555L642H443V5) are explicit about monitoring vitamin D: “Maintain adequate vitamin D intake; supplement vitamin D, if needed, to maintain serum levels of 25-hydroxyvitamin D [25(OH)D] between 30 and 60 ng/mL (Grade A; BEL 1).”
This slide shows the increased need for calcium as we age. Our youth and adolescent years are critical to building a better bone mass so an increase in calcium is needed. Building a better bone mass affects our bones for the rest of our lives so we need to concentrate on letting teens know the importance of the bone building years. Prevention is better than treatments and pain in later years! Low calcium intake before age 30-35 can make bones not as dense as they should be; low calcium intake after age 35 may lead to faster bone loss.
Sun exposure is a significant source of vitamin D for young people; it causes your skin to make its own vitamin D.
As we age our ability to manufacture vit D decreases. Without adequate amounts of Vit D, if we do get our calcium- it will not be used in our bones unless vit D is in adequate amounts too. We must have both!
Calcium supplements: Calcium supplements: Carbonate VS. Citrate- Calcium carbonate: Needs acid to dissolve and for absorption; less stomach acid as we age; Often taken at meals when more stomach acid.
Calcium citrate: Doesn’t require stomach acid for absorption; May be taken anytime—check with your healthcare provider; May cost more. Choose a supplement with vitamin D unless obtaining vitamin D from other sources. It’s not necessary to consume calcium and vitamin D at the same time to get the benefit of enhanced calcium absorption.
The body does not use more than 500 mg. If you are taking supplements and they are 1000 mg tablets-your body will only utilize about 500mg, the rest is excreted in the urine.
Divide the dosage and take part in the morning and at night. Follow age group recommendation. Avoid going over a daily combined total of 2,000 IU or 50 mcg from food and supplements.
NOTE TO PRESENTER: Music will automatically start. After music stops, read slide to audience. (NEXT SLIDE)
NOTE TO PRESENTER- USE THE INFORMATION BELOW TO EXPLAIN THIS SLIDE: GO OVER SOME OF THE ITEMS LISTED ON THIS SLIDE AND THE NEXT SLIDE FOR EMPHASIS.
If you have osteoporosis, changing your environment can reduce your risk of falling and suffering a fracture. Or maybe you have an older family member or friend who could benefit from these same tips. Look around your home or home of a family member or friend.
(NEXT SLIDE)
NOTE TO PRESENTER- AGAIN, EMPHASIZE THE FOLLOWING STATEMENT:
When you visit an elderly family member or friend, remember these tips and take a look around and don’t be afraid to make suggestions.
(NEXT SLIDE)
One can rapidly assess within one minute a patient’s risk and need for treatment by reviewing T-scores. A T-score above -1.5 indicates the patient is at low risk and should be checked again in 1-2 years. A T-score between -1.5 to -2.0 indicates the patient is at moderate risk and should be treated if he/she has other risk factors. A T-score below -2.0 is an indication of high risk and the patient should be treated.
JP’s diagnosis of osteoporosis based on the WHO criteria along with his other risk factors are an indication for pharmacologic treatment.
Paget’s dose: alendronate 40 mg/day x 6 mo., risedronate 30 mg/day x 2 mo.
FDA advisory board found that evidence did not support calcitonin salmon for the
treatment of osteoporosis (March 5, 2013)
This summary is an overview, based on evidence of various strength.
Task force definition: Located anywhere along the femur from just distal to the lesser trochanter to just proximal to the supracondylar flare • Associated with no trauma or minimal trauma, as in a fall from a standing height or less • Transverse or short oblique configuration • Noncomminuted • Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex.Minor features • Localized periosteal reaction of the lateral cortexc • Generalized increase in cortical thickness of the diaphysis • Prodromal symptoms such as dull or aching pain in the groin or thigh • Bilateral fractures and symptoms • Delayed healing • Comorbid conditions (eg, vitamin D deficiency, RA, hypophosphatasia) • Use of pharmaceutical agents (eg, BPs, GCs, PPIs)
ournal of Bone and Mineral Research
Volume 25, Issue 11, pages 2267–2294, November 2010
The exact mechanism by which bisphosphonates (BPs) affect osteoclasts has been difficult to determine, as studies on these relatively rare cells are difficult to undertake. Most of the data are derived from observations in osteoclast surrogates, namely macrophages. The effects of BPs in macrophages are similar to those seen in osteoclasts.
It is proposed that BPs affect the function of osteoclasts via 2 mechanisms:
1. They are incorporated into adenosine triphosphate (ATP) analogs that are cytotoxic. This is the predominant mechanism for BPs that do not contain nitrogen.
2. They interfere with the mevalonate pathway, leading to disruption of cellular function and, ultimately, cell death. This is the predominant mechanism for the nitrogen-containing BPs.
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Reference: Russell R, et al. Osteoporos Int. 1999;(suppl 2):S68-S80.
The Contraindications and Warnings noted in the product labeling for Actonel are outlined here. Please see the package insert for full prescribing information.
Denosumab is the first fully human monoclonal antibody in clinical development that specifically targets RANK ligand, an essential mediator of osteoclast formation, function, and survival. 1,2
References
Lewiecki EM. RANK ligand inhibition with denosumab for the management of osteoporosis. Exper Opin Biol Ther. 2006;6:1041-1050.
McClung MR, Lewiecki EM, Cohen SB, et al. Denosumab in postmenopausal women with low bone mineral density. N Engl J Med. 2006;354:821-831.
PROLIA®: PROTECTION AGAINST FRACTURE
Prolia®: proven osteoporotic fracture reduction throughout the skeleton1
•FREEDOM was an international, randomised, placebo-controlled trial
•Patients received subcutaneous injections of either 60 mg Prolia® or placebo every 6 months for 36 months
•The study included 7,868 women aged 60–90 years old with a bone mineral density (BMD) T-score of less than –2.5, but not less than –4.0, at the lumbar spine or total hip.
•Approximately 24% of the study population had a vertebral fracture at baseline, and about 32% of patients were aged ≥ 75 years. The primary endpoint was the incidence of new vertebral fractures1
In FREEDOM - one of the largest registrational studies ever conducted in postmenopausal osteoporosis (7,868 patients enrolled) - Prolia® significantly reduced the risk of osteoporotic fractures at vertebral, hip and non-vertebral sites1
Presenters Notes Reference:
1.Cummings SR et al. N Engl J Med 2009; 361: 756–765.
Lycopene is the most common carotenoid found in blood and its levels have correlated with reduced risk of cancer and heart attacks in prior studies. The beneficial effects of lycopene are contributed to its antioxidant activity. In this study the authors concluded that data compiled from the Framingham Study indicated long-term carotenoid (lycopene) intake had beneficial effects on bone density in elderly men and women. In addition, the authors cited several studies that found high serum lycopene to be inversely associated with bone resorption markers such as N-telopeptide (NTX). Tomatoes are a great source of lycopene.
Sahni S et al. Protective effect of total carotenoid and lycopene intake on the risk of hip fracture: a 17-year follow-up from the Framingham Osteoporosis Study. J Bone Miner Res. 2009 Jun;24(6):1086-94.
In vitro and in vivo studies suggest that carotenoids may inhibit bone resorption, yet no previous study has examined individual carotenoid intake (other than beta-carotene) and the risk of fracture.
We evaluated associations of total and individual carotenoid intake (alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, lutein + zeaxanthin) with incident hip fracture and nonvertebral osteoporotic fracture.
Three hundred seventy men and 576 women (mean age, 75 +/- 5 yr) from the Framingham Osteoporosis Study completed a food frequency questionnaire (FFQ) in 1988-1989 and were followed for hip fracture until 2005 and nonvertebral fracture until 2003. Tertiles of carotenoid intake were created from estimates obtained using the Willett FFQ adjusting for total energy (residual method). HRs were estimated using Cox-proportional hazards regression, adjusting for sex, age, body mass index, height, total energy, calcium and vitamin D intake, physical activity, alcohol, smoking, multivitamin use, and current estrogen use.
A total of 100 hip fractures occurred over 17 yr of follow-up. Subjects in the highest tertile of total carotenoid intake had lower risk of hip fracture (p = 0.02). Subjects with higher lycopene intake had lower risk of hip fracture (p =0.01) and nonvertebral fracture (p = 0.02). A weak protective trend was observed for total beta-carotene for hip fracture alone, but associations did not reach statistical significance (p = 0.10). No significant associations were observed with alpha-carotene, beta-cryptoxanthin, or lutein + zeaxanthin. These results suggest a protective role of several carotenoids for bone health in older adults.
Omega-3 fatty acids have anti-inflammatory properties and the purpose of this study was to investigate whether their concentration in the blood is related to levels of the inflammatory marker, hs-CRP. Abnormally elevated hs-CRP is correlated to excess production of interleukin-6 (Il-6), a molecule produced in the body during times of chronic inflammation. High levels of hs-CRP are correlated to cardiovascular disease as well as low bone mineral density (BMD) and increased fracture risk.
Reducing hs-CRP by just one point will reduce fracture risk by an amazing 23 percent
An age-stratified sample of 1494 women (99% white), representing 77.1% of eligible participants, was randomly recruited from electoral rolls for the Geelong Osteoporosis Study. The inclusion criterion of age 65 years or older was met by 522 women. Of these, 33 were excluded because serum was unavailable for analysis and 45 were excluded for baseline use of hormone therapy or oral glucocorticoids for at least 6 months, leaving a study population
of 444 women. Baseline assessments were performed from 1994 to 1997, and participants were followed up until fracture, death, migration from the study region, or the end of 2002.
The unadjusted HR for fracture increased by 23% for each SD increase in ln-hsCRP (HR, 1.23; 95% confidence interval, 1.01-1.51). The age-standardized absolute risk of fracture during the study period increased from 16.3% (95% CI, 6.8%-25.8%) for ln-hsCRP less than −1 SD (0.96 mg/L) to 28.9% (95% confidence interval, 17.7%-40.1%) for ln hsCRP greater than +1 SD (6.35 mg/L). Multivariate models consistently included significant contributions from lnhsCRP, prevalent fracture, and BMD. For each SD increase in ln-hsCRP, there was an independent 24% to 32% increase in fracture risk, depending on site-specific BMD used in the model. Fracture risk was independently increased 52% to 79% for each SD decrease in BMD and 52% to 73% by previous fracture.
So supplementing the diet with omega-3 fatty acids (fish oil) should be considered. They’re a great way to help reduce inflammation, hs-CRP, cardiovascular disease, and fractures related to osteoporosis.
Despite the lack of a significant change or the occurrence of.“Despite the lack of significant change or the occurrence of only a modest increase in bone mineral density, high-dose vitamin K1 and vitamin K2 supplementation improved indices of bone strength in the femoral neck and reduced the incidence of
In a review of the literature to assess the effects of vitamin K supplementation on bone in postmenopausal women, the authors of this study found that high-dose vitamin K improves bone strength in the hip and reduces fracture. This reduction in fracture appears to be more from changes to the quality of bone rather than quantity, as only 7 randomized controlled trials found (modest) increases in bone mineral density.
There was only a modest increase in bone mineral density, but high-dose vitamin K(1) and vitamin K(2) supplementation improved indices of bone strength in the femoral neck and reduced the incidence of clinical fractures