1. DeAnn Cummings, MD January 12, 2012
Osteoporosis
DeAnn Cummings, MD
January 12, 2012

2. Why Does it Matter? 44 million people in U.S. with low bone mass
2 million osteoporotic fractures per year
$17 billion spent per year on osteoporotic fractures and their complications
20% increased mortality over 5 years following a vertebral fracture
10-30% increased mortality over one year following a hip fracture
17% for women
30% for men

3. Why Does it Matter? 50% require nursing home care after hip fracture
30% need assistance with daily activities
Only 20% return to previous level of functioning

4. Definition
A microarchitectural deterioration of bone tissue resulting in decreased bone strength which predisposes to an increased risk of fracture
Bone strength = Bone density + Bone quality
Bone mineral density (BMD) is usually used as a surrogate to assess bone strength

5. Bone Mineral Density
Fracture risk increases 2-3 times for each standard deviation below gender-matched young adult mean
T score = #standard deviations from gender-matched young adult mean
Z score = #standard deviations from age and gender-matched mean
T score best correlates with fracture risk

6. World Health Organization Definitions
Normal – T score greater than or equal to -1.0
Osteopenia – T score between -1.0 and -2.5
Osteoporosis – T score less than or equal to
Established osteoporosis – T score < -2.5 and at least one fragility fracture

7. Pathophysiology
Balance between bone resorption and formation (remodeling)
Remodeling is in balance until about age 50
Osteoclasts resorb bone
Osteoblasts form bone
Estrogen inhibits osteoclastic bone resorption
Peak bone mass is established by age 20 for the hip and during the early 30’s for the spine

8. Pathophysiology
Women have increased incidence of osteoporosis compared to men due to:
Lower peak bone mass
Greater bone loss after menopause (10% bone loss)
Men and non-white women have higher peak bone mass than white women
Genetic factors – 70-80% of peak bone mass is genetically determined
Pregnancy and lactation cause transient bone loss

9. Pathophysiology Bone quality May be important in the future
Disruption of microarchitectural elements of trabecular bone
Cortical thinning
Decrease in degree of mineralization
May be important in the future

10. Types of Osteoporosis Primary osteoporosis Secondary osteoporosis
Related to aging and/or decreased gonadal function
Aging bone loss is slower than menopausal
Menopause related bone loss lasts about 10 yrs
Secondary osteoporosis
Due to medications or chronic illnesses that accelerate bone loss
Consider secondary osteoporosis if Z-score is low

11. Chronic Diseases Cushing’s syndrome Hyperparathyroidism
Hyperthyroidism
Multiple myeloma
Lymphoma
Chronic liver disease
Chronic renal disease
Malabsorption syndromes
Paraplegics, quadriplegics
Hypogonadism
Anorexia nervosa
Athletic amenorrhea
Diabetes mellitus
Hemochromatosis
Hyperprolactinemia
Osteogenesis imperfecta
Rheumatoid arthritis
Lupus
Psoriatic arthritis
Vitamin D and Calcium deficiency

12. Medications Glucocorticoids Lithium Chemotherapy GnRH agonist
Anticonvulsants
Phenobarbital
Dilantin
Tegretol
Valproate
Methotrexate
SSRIs
Prolonged heparin use
Coumadin (?)
Cyclosporine (?)
Aromatase inhibitors
Excess thyroid hormone
Medroxyprogesterone
Vitamin A
Proton pump inhibitors

13. Case #1
70 year old female presents with a new vertebral compression fracture after slipping on the ice. She has never had BMD testing.
PMH
HTN
Hyperlipidemia
GERD
Depression

14. Case #1 MEDS Family hx – No hx osteoporosis known
Lisinopril
Zocor
Protonix
Celexa
Family hx – No hx osteoporosis known
Social hx – Non-smoker, no ETOH

15. Case #1 Should her SSRI be stopped? Should her PPI be stopped?
Should she have received BMD testing prior to starting these meds?

16. SSRIs and Osteoporosis
Canadian Multicenter Osteoporosis Trial – 2006
Prospective cohort of 5008 adults 50 years old or greater, followed over 5 years for fractures
137 were on SSRIs
Risk of fragility fracture was increased 2 fold for pts on SSRIs
Relative risk = 2.1 ( )
Relative risk for corticosteroids =
Study did not evaluate duration of SSRI use

17. PPIs and Osteoporosis Prospective trial – (Roux 1/09)
1211 post-menopausal women
For women on omeprazole the relative risk for vertebral fractures was 3.5 ( )
Need more studies
FDA recommends considering shorter duration or lower dose of PPI
PPI may interfere with calcium absorption
Consider calcium citrate supplementation
No studies on initial BMD testing prior to starting med

18. Case #2
16 year old female presents for discussion of birth control options.
PMH – None
Family hx – No hx osteoporosis
Social hx – No smoking, ETOH or drugs
Pt really wants Depo Provera but her Mom is concerned about side effects – she has heard that it weakens bones.

19. DepoProvera Cross-sectional studies show decreased BMD in Depo users
No studies have shown increased fracture risk with depo-users
Bone mass increases with cessation of Depo
FDA recommends stopping Depo after 2 years unless no other viable birth control options
FDA suggests evaluating BMD for use greater than 2 years

20. History – Risk Factors
History of fractures, esp. vertebra, hip or wrist
Family history of osteoporosis or fragility fxs.
Menstrual history – history of estrogen deficiency
Nutrition
Exercise
Habits – tobacco, alcohol and caffeine use

21. History and Physical Exam
No reliable history or physical findings to identify patients with osteoporosis
Look for risk factors and signs of occult vertebral fractures
Look for possible secondary causes of osteoporosis
Consider further laboratory tests only if signs of a secondary cause

22. History – Vertebral Fractures
Back pain – acute or chronic
Loss of height (>1 inch)
Restrictive lung disease symptoms (exertional dyspnea, decreased exercise tolerance)
Symptoms of reduced abdominal cavity (early satiety)
Symptoms of depression, anxiety and fear

23. Physical Exam Measure height and body weight
Look for spinal tenderness and deformities (dowager’s hump)
Look for tooth loss
Look for protuberant abdomen
Signs of secondary osteoporosis
Consider home visit to assess risk for falling

24. Risk Factors for Osteoporosis
Non-modifiable
Female gender
Increased age
White or Asian race
Family history of osteoporosis
Personal history of fracture
Previous hyperthyroidism
Rheumatoid arthritis
Secondary osteoporosis

25. Risk Factors for Osteoporosis
Modifiable
Tobacco use
Sedentary lifestyle
Caffeine use (tea is OK)
Low calcium and vitamin D intake
Alcohol use (> 2 drinks per day)
Hormone deficiency states
Low weight (BMI<21)
Elevated homocysteine levels
Corticosteroid use (5 mg prednisone daily for 3 months)

26. Risk Factors for Fractures
History of falling
Poor physical condition
Neurological disorders
Impaired vision and hearing
Certain meds – sedatives, anti-hypertensives
Environmental hazards

27. Environment Modification
Remove throw rugs
Decrease clutter
Handrails on stairs
Improve lighting, night lights
Handrails in tubs and showers, non-skid surfaces
Cane or walker if needed
Consider hip protectors
Wear supportive, low-heeled shoes
Tape down electric cords

28. Case #3 63 year old female presents for a physical PMH Meds HTN GERD
Anxiety
Meds
Metoprolol
Omeprazole

29. Case #3 Social hx – smokes 1ppd, minimal ETOH
Family hx – No osteoporosis or hip fractures
BMI = 23, Ht = 5-4
Should she be screened for osteoporosis?

30. Screening – Who to Screen?
No studies showing decreased fracture risk with screening
However:
Good evidence for increasing risk of osteoporosis and fracture with age
Good evidence that bone mineral density accurately predicts fracture risk (RR=2.6 for -1SD)
Good evidence that treating asymptomatic women with osteoporosis decreases fracture risk

31. Screening – Who to Screen?
US Preventive Services Task Force recommendations based on current evidence
Screen all women > or equal to 65 years
Screen women yrs. if at increased risk
Lower body wt. is best predictor of low BMD
Consider using FRAX
Grade B recommendations – fair to good evidence to support recommendation, benefits outweigh risks

32. Screening – Who to Screen?
USPSTF recommendations continued
No recommendations for or against routine screening in women <60 yrs. or women yrs. with no increased risk
Screening women at lower risk for osteoporosis can identify additional women who might benefit from treatment but would prevent smaller # fractures.
Grade C recommendation – balance of benefits to harms is too close to make recommendation

33. Screening – Who to Screen?
USPSTF guidelines agree with guidelines of the National Osteoporosis Foundation and the American Association of Clinical Endocrinologists
All recommend screening only if results will influence treatment
If patient not in favor of treatment, DON’T SCREEN!

34. Screening in Men National Osteoporosis Foundation
Recommends screening all men over age 70 regardless of risk factors
Evaluate for risk factors and discuss calcium and vitamin D intake in all men >50
Screen men ages with risk factors
However, very little evidence for or against screening men

35. Screening Disadvantages
Cost
Potential radiation exposure
Potential unnecessary treatment for false positive or misinterpreted results
Increased anxiety and perceived vulnerability – can lead to increase in sedentary habits

36. Risk Factor Assessment
Which are best at predicting osteoporotic fractures?
May help decide who to screen

37. Risk Factor Assessment
Age, weight and history of previous fracture correlate the best with low BMD
FRAX = Fracture Risk Assessment tool
Developed by WHO – 2008
Estimates 10 year probability of major osteoporotic fractures and hip fracture

38. Risk Factor Assessment
FRAX
Age
Gender
Prior fracture
Low BMI
Oral steroids
Rheumatoid arthritis
Secondary osteoporosis
Parental hx of hip fracture
Smoking
ETOH
Plus BMD

39. Case #3 Decision is made to screen this patient
Which test is the best test?

40. Screening – Which Test?
Conventional x-rays – osteopenia not detected until bone mass 40% decreased
Bone turnover markers – experimental, expensive and no good evidence to support use (human osteocalcin, bone alkaline phosphatase)
High false positive rate

41. Screening – Which Test?
All tests below have equivalent fracture risk predictability
Dual-energy x-ray absorptiometry (DEXA)
Quantitative CT
Calcaneal ultrasonography

42. Screening – Which Test? Calcaneal ultrasonography
Usually tests calcaneus only
Reflects other aspects of bone quality
More portable test
No radiation
Low cost
Low precision
Difficult to apply measurements to treatment protocols

43. Screening – Which Test? Quantitative CT Usually tests spine and hip
High radiation
High cost
Good precision

44. Screening – Which Test? DEXA
Best validated test in studies and therefore considered gold standard
Results vary by 6-15% when using machines from different manufacturers
Usually test spine, hip or wrist (lateral spine)
Low radiation
Intermediate cost
Excellent precision – best if same machine is used and same technician

45. Screening – Which Test? DEXA HOWEVER……
DEXA identifies fewer than half the people that go on to have an osteoporotic fracture

46. Case #3 Her DEXA reveals a T-score = -1.5
When should she be retested if at all?

47. Screening – How Often?
Screening more often than every 2 years will not show accurate change in BMD
Repeat screening more likely to be beneficial in older women and women with risk factors
No evidence about follow-up BMD testing after initiation of treatment
NOF recommends follow-up BMD every 2 years on treatment

48. Screening Summary Screen all high risk women Screen every 2 years
Women < 65 with significant risk factors
Men with risk factors
Screen every 2 years
Consider using risk assessment tools to determine high risk
DEXA scan is best test (BUT not perfect)

49. Case #3
She gets repeat screening with DEXA in two years and the T-score is now -2.5
Does she need evaluation for secondary causes of osteoporosis?

50. Evaluating for Secondary Osteoporosis
AACE
CBC
CMP
Ca, Phos
24 hour urine for Ca, Na, creatinine excretion
25-hydroxyvitamin D level
Above eval detects 90% of secondary osteoporosis

51. Case #4
71 year old female presents for a review of her DEXA results which reveal a T-score of She has no hx of fractures and no family hx of fractures. She does not smoke. Her BMI=25.
Do you tell her she has osteoporosis?
Are her results normal?
Do you recommend treatment for osteoporosis and if so what?

52. Who to Treat?
Definite reduction in fractures for treatment of BMD <-2.5 and for pts with history of fragility fractures
Is there any benefit in treating anyone else?

53. What About Osteopenia? T score between -1.0 and -2.5
RCTs show no reduction in fracture risk for patients with T scores -1.6 to -2.5
Individualize management
Decrease modifiable risk factors
Increase calcium and vitamin D intake
Increase exercise
Decrease tobacco, alcohol and caffeine use

54. What About Osteopenia? Use FRAX calculator
If assessed risk of hip fracture is >3% for the next ten years, consider treatment
If risk of major osteoporotic fracture (wrist, vertebral, hip or proximal humerus) is >20% for the next ten years, consider treatment
Using this calculator most pts with osteopenia will not be treated
No actual studies on outcomes using FRAX

55. Treatment Options Exercise Calcium and Vitamin D Estrogen
Bisphosphonates
Raloxifene
Calcitonin
Parathyroid hormone

56. Case #5
65 year old, very healthy female has just found out she has osteoporosis. She does not want to “pollute her body with chemicals” and will only use “natural remedies”
What do you recommend?

57. Exercise
Weight-bearing activity – walking, running, aerobics, stair-climbing, strength training, dancing, court and field sports
No data on cycling, skating or skiing
Exercise 3x/week for minutes duration
Strength training reduces risk of falling also
Short term exercise increases BMD by 2% in meta-analysis of 16 trials

58. Exercise Cochrane review 2002 Meta-analysis 4/2004 (Kelley, et al)
18 RCTs of BMD in postmenopausal women
Increased BMD of spine with any exercise
Increased BMD of hip with walking
Meta-analysis 4/2004 (Kelley, et al)
143 premenopausal women
Resistance exercise did not increase or maintain BMD

59. Calcium and Vitamin D
Randomized controlled trials show improved BMD and decreased fractures with combo
NNT = 48 to prevent one hip fracture after 1.5 years of treatment
Need 1200 mg Ca/day and 800 IU vit. D/day
Calcium better absorbed if taken with food and 600 mg or less at a time
Cost = $5/month

60. Calcium and Vitamin D
Calcium citrate is slightly better absorbed than Ca carbonate
Consider using Ca citrate if patient on acid blocker med
Ca carbonate – Oscal, Caltrate, Tums, Viactiv
Ca citrate - Citracal

61. Calcium and Vitamin D
Side effects of calcium include dyspepsia, gas, bloating and constipation(10%)
May interfere with absorption of tetracycline or quinolones
If history of kidney stones evaluate for hypercalciuria prior to giving calcium
Recent meta-analysis based on WHI showed slight increase in MI and stroke in pts taking Ca with or without vitamin D (Bolland 4/11)
RR of MI = 1.24 ( )

62. Calcium Cochrane review – 2004 15 RCTs, 1806 subjects
Small improvement in bone density after 2-3 yrs
Trend toward decrease in vertebral fractures
Unclear if calcium alone decreases non-vertebral fractures

63. Vitamin D Vitamin D deficiency Decreased calcium absorption
PTH-mediated increase in bone resorption
Decreased muscle strength and increased falls

64. Vitamin D Cochrane review – April 2009
Vitamin D alone showed no sig. effect on hip or vertebral fracture rate
Vitamin D with calcium slightly reduced non-vertebral fractures, but no effect on vertebral fractures
No evidence that analogs of vitamin D offer any advantage over native vitamin D
Vitamin D2 and vitamin D3 equally effective

65. Vitamin D National Osteoporosis Foundation
Recommends 800 – IU daily
Consider testing in pts at risk for deficiency
Elderly
Malabsorption diseases
Chronic kidney disease
Housebound patients
Test serum 25(OH)D level should be between (toxicity > 100)

66. Folate and Vitamin B12 RCT (Sato – 3/2005) 628 pts, s/p stroke
5 mg folate and 1500 mcg of B12 vs placebo
Decreased hip fractures in treated group
NNT = 14

67. Magnesium Often taken by patients
No studies show decrease in fracture rate or increase in BMD

68. Phytoestrogens
Act as weak estrogens but also have anti-estrogen effects
Primary source of phytoestrogens is isoflavones which are found in soybeans(less in tofu) and lignans (flaxseed; some cereals, fruit, vegetables, and legumes)
Secondary sources are black cohosh and red clover

69. Phytoestrogens
Small studies show some decrease in hot flushes and vaginal dryness
No human studies showing effect on bone
Dosage, purity, and adverse effects unknown
Estreven and Remifemin are combinations of isoflavones, black cohosh and red clover

70. Estrogen Replacement Therapy
WHI (Women’s Health Initiative Study)
NNT = 2000 to prevent one hip fracture after 5 years of treatment
Not as effective for treatment but has definite benefit for prevention
Strongest benefit for ERT is for women < 60
HERS showed no sig. decrease in fracture rate over 4 years
FDA approved only for prevention

71. ERT Transdermal and oral forms equally effective
MUST use progesterone with estrogen if patient has intact uterus
Estrogen with or without progesterone is equally as effective
Cost = $14-28/month
Secondary benefit of decreasing menopausal symptoms

72. ERT - Harms
WHI study
Small increased risk of 22% for cardiovascular events (7 additional cases/10,000/yr)
26% increased risk of invasive breast cancer (8 additional cases/10,000/yr)
41% increased risk of stroke (8 additional cases/10,000/yr)
2-fold increased risk of pulmonary embolism
SE’s – Vag. Bleeding, nausea, headache, mood alterations, breast tenderness, bloating

73. Bisphosphonates Work by inhibiting osteoclastic activity
RCT’s show significant and rapid reduction in fracture risk for women with previous fracture and osteoporosis
Evidence not as good for women without previous fracture

74. Alendronate (Fosamax)
NNT = 34 to prevent one vert. fx over 3 yrs.
NNT = 86 to prevent one hip fx over 3 yrs.
Dose = 5-10 mg/day or mg/week
Forms – oral solution, Fosamax with D weekly
Cost = $95/month
SE’s – nausea, dyspepsia, esophageal ulcer, esophagitis
Weekly dosing showed equivalent increase in BMD to daily dosing (no data on fractures)

75. Alendronate Meta-analysis of RCTs – (Papapoulos – 5/05)
Post-menopausal women
Dose = 5-10 mg/day for yrs
Overall risk reduction for hip fractures of 55% in pts with osteoporosis
Clinically sig decrease in hip fractures

76. Risedronate (Actonel)
NNT = 15 to prevent one vert. fx over 3 yrs.
NNT = 91 to prevent one hip fx over 3 yrs.
Dose = 5 mg/day, 35 mg/week, 150 mg/month
Cost = $150/month
SE’s – abdominal pain, nausea, diarrhea but not sig. different from placebo
No sig. GI adverse events even in patients with history of ulcers, GERD, or taking NSAIDS

77. Risedronate Cochrane systematic review – 8/2003 8 RCTs
Postmenopausal women received 5 mg/day, compared to Ca or placebo
Increased BMD after 3 yrs
Decreased vertebral and non-vertebral fractures
No difference in side effects compared to placebo

78. Ibandronate (Boniva) BONE study – (Delmas – 9/2003)
Large multi-national RCT
Oral Ibandronate Osteoporosis Vertebral Fracture Trial in N. America and Europe
2946 post-menopausal women
Daily or intermittent ibandronate vs placebo
Decreased risk for vertebral fractures by 50-62%
NO decreased risk of non-vertebral fractures

79. Zoledronic Acid (Reclast)
Given IV every 12 months
Decreases both vertebral and hip fractures
Expensive
Consider only in certain high risk pts

80. Bisphosphonates Less than 1% of each dose is absorbed
Optimize absorption by taking with full glass of water and 30 mins prior to breakfast
Avoid GI problems by standing or sitting for 30 mins after taking med
Do not use in patients with creatinine clearance <30 ml/min or hypocalcemia
Accumulates in bone – long term effects unknown

81. Bisphosphonates Does one work better than another?
Head to head RCT of alendronate 70 mg/week and risedronate 35 mg/week (Rosen-1/2005)
Total of 1053 postmenopausal women with osteoporosis, studied over 12 months
Alendronate showed greater increase in BMD compared to risedronate
Fracture rate not assessed
Both drugs tolerated equally well

82. Case #6 72 year old female with T-score = -2.7 and no hx fracture.
You have recommended starting a bisphosphonate but she has heard that these drugs cause cancer and a jaw problem.
What do you say?

83. Bisphosphonates Osteonecrosis of the jaw (ONJ)
Canadian Consensus Practice Guidelines (6/2008)
ONJ has been clearly associated with use of high dose IV bisphosphonates in the treatment of cancer
ONJ has NOT been clearly linked with low-dose bisphosphonates used for osteoporosis
Advise good oral hygiene and regular dental visits
Consider holding drug for non-emergent dental surgery

84. Bisphosphonates Atrial fibrillation Systematic review – (Loke – 2009)
Results of studies were mixed
There may be a link with bisphosphonates and atrial fib but data was too heterogeneous to make a determination
No increase in stroke risk or cardiovascular mortality
FDA fells this is a chance finding

85. Bisphosphonates Subtrochanteric fracture Esophageal cancer
Occur after minimal or no trauma
Direct etiologic relationship not yet substantiated
Esophageal cancer
Incidence went from 1 case per 1000 in untreated pts to 2 cases per 1000 in those treated with bisphosphonates for 5 years or more
Consider drug holiday of 1-2 years after 3-5 years of therapy

86. Case #7
75 year old female with hx osteoporotic vertebral fx cannot tolerate the bisphosphonates. She has hx of severe GERD and peptic ulcer disease.
What do you recommend?

87. Selective Estrogen Receptor Modulators
Raloxifene (Evista)
Blocks action of cytokines which stimulate bone resorption
RCT’s show sig. decrease in new vertebral fractures for women with previous history of fracture and osteoporosis
NNT = 29 to prevent one vert. fx over 3 yrs.
NO evidence of decrease in hip fractures

88. Raloxifene Dose = 60 mg/day Cost = $150/month
Secondary benefit may be reduction of breast cancer risk
SE’s – leg cramps(3%), hot flashes(6%), risk of venous thromboembolism (1 in 465 women/yr)
Does not increase risk of endometrial hyperplasia or cancer

89. Salmon Calcitonin Calcitonin nasal spray (Miacalcin)
Large RCT showed decreased new vertebral fractures in women with previous history of osteoporotic vertebral fx.
No effect reported for hip fractures
No definite effect for women with no previous osteoporotic fx.
Increased BMD less than that seen with bisphosphonates or estrogen

90. Salmon Calcitonin Dose = 200 IU/day, 1 spray in 1 nostril qd
Cost = $112/month
SE’s – rhinitis(5%), epistaxis, sinusitis
Alternate nostrils to decrease SE’s
Secondary benefit of decreased pain from vertebral fractures

91. Parathyroid Hormone Stimulates bone formation
Teriparatide (Forteo) – recombinant PTH
RCT shows 1/3 decreased incidence of vert. fx and ½ decreased incidence of non-vert. fx
Dose = 20 mcg SC qd
Less convenient
More expensive - $1000/month
SEs – nausea, headache, hypercalcemia, dizziness, leg cramps, ? risk osteosarcoma
Measure Ca, vitamin D and PTH levels prior to treatment

92. Parathyroid Hormone FDA black box warning
Teriparatide caused osteosarcoma in rats using much higher doses of the drug
Drug is contraindicated in pts at risk for osteosarcoma
Pagets disease of bone
Hx of irradiation involving the skeleton
Unexplained elevation of alkaline phosphatase
Safety after 2 years duration is unknown

93. Parathyroid Hormone RCT – (Neer – 5/01)
1637 post-menopausal women with prior vertebral fractures
Average T-score = -2.6
20 or 40 mcg PTH vs placebo
NNT = 11 to prevent one vertebral fracture
40 mcg dose worked a little better but had more side effects (hypercalcemia)

94. Parathyroid Hormone RCT – (Body–10/02) 14 months duration
Compared PTH to alendronate
PTH increased BMD in hip and spine more than alendronate (12.2% vs 5.6%)
Non-vertebral fracture rate was lower in the PTH group

95. Denosumab Monoclonal antibody against RANKL
Decreases osteoclastic activity
Brand name – Prolia
60 mg SQ every 6 months
Studies show reduced fractures of the hip, spine and non-vertebral sites
SEs – Skin infections, dermatitis, ? osteonecrosis of the jaw

96. Combination Therapy
No studies demonstrating reduction in fracture risk
More improvement in BMD with combined estrogen and alendronate
RCT of combined PTH and alendronate showed no improvement over PTH alone (Finkelstein-2003)
AACE does not recommend combined therapy

97. Treatment Monitoring AACE guidelines DEXA every 1-2 years until stable
BMD should be stable or increasing and there should be no fractures
If this is not the case consider different treatment

98. Osteoporosis in Men 30% of hip fractures occur in males
1.5 million men >65 have osteoporosis
May have higher mortality rate compared to females
2/3 have secondary osteoporosis
Hypogonadism, glucocorticoid use, etc.
Risk increases with age but later than in women

99. Osteoporosis in Men Treatment
1000 mg/day calcium and 800 IU/day vitamin D
Exercise
If hypogonadism, consider testosterone
Bisphosphonates – RCT of alendronate 10 mg/day showed sig increase in BMD and decrease in vertebral fractures (Orwoll – 8/2000)
PTH – RCT of PTH 20mcg/day showed increased BMD (Orwoll – 1/2003)

100. Prevention Summary
Start adequate calcium and vitamin D intake in childhood
Encourage exercise
Decrease risk factors for osteoporosis
Decrease risk factors for falling
Consider bisphosphonate for prevention if high risk

101. Treatment Summary AACE recommendations
1st line – alendronate, risedronate, zoledronic acid, denosumab
2nd line – ibandronate, raloxifene
Last line – calcitonin
Teriparatide only for pts that fail above
No combination therapy

102. References
Prevention and Treatment of Osteoporosis in Postmenopausal Women. JFP October 2002
Screening for Osteoporosis in Postmenopausal Women: Recommendations and Rationale, US Preventive Services Task Force. Ann. Intern. Med. 17 Sept. 2002
Radiologic Bone Assessment in the Eval. of Osteoporosis. AFP April 2002
Cauley, JA. Effects of HRT on clinical fractures and ht loss(HERS). Am J Med
Papapoulos, SE. Meta-analysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women. Osteoporosis Int May.
Delmas, PD. Daily and intermittent oral ibandronate normalize bone turnover and reduce vertebral fracture risk: results from the BONE study. Osteoporosis Int April.

103. References
Calcium Supplements. The Medical Letter April 3, 2000
Osteoporosis: Parts I and II AFP March 2001
Cochrane Database
Petitti, DB. The WHO Study of Hormonal Contraception and Bone Health. Ob-Gyn May.
Orr-Walker, BJ. The effect of past use of the injectable contraceptive depot medroxyprog. acetate on bone mineral density in normal post-menopausal women. Clin Endocrinol Nov.
Kelley, GA. Efficacy of resistance exercise on lumbar spine and femoral neck BMD in premenopausal women: a meta-analysis. J Womens Health April.
Sato, Y. Effect of folate and mecobalamin on hip fractures in pts with stroke: a RCT. JAMA March.

104. References
Bauer, DC. Use of statins and fracture: results of 4 prospective studies and cumulative meta-analysis of observational studies and controlled trials. Arch Intern Med Jan.
Neer, RM. Effect of PTH on fractures and BMD in postmenopausal women with osteoporosis. N Engl J Med May
Body, JJ. A randomized double-blind trial to compare the efficacy of teriparatide with alendronate in postmenopausal women with osteoporosis. J Clin Endocrinol Metab Oct.
Orwoll, E. Alendronate for the treatment of osteoporosis in men. N Engl J Med Aug.
Orwoll, ES. The effect of teriparatide therapy in men with osteoporosis. J Bone Miner Res Jan.
AACE Guidelines for Diag and Treatment of Osteoporosis