1. Osteoporosis: Definition A condition of skeletal fragility characterized by compromised bone strength predisposing to an increased risk of fracture NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000. Source: Dempster DW, et al. J Bone Miner Res. 1986:1:15-21; Reprinted with permission from the American Society of Bone and Mineral Research Normal BoneOsteoporosis

2. 1,500,000 0 500,000 1,000,000 1,500,000 2,000,000 Osteoporotic Fractures 1. Riggs, B.L., and Melton, L.J. III, Bone 17(5)(Suppl.):505S-511S, 1995 2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart Association 3. Cancer Facts & Figures—1996, American Cancer Society * annual incidence all ages ** annual estimate women 29+ † annual estimate women 30+ ‡ 1996 new cases, women all ages * 513,000 Heart Attack ** 228,000 Stroke † 184,300 Breast Cancer ‡ 750,000 vertebral 250,000 other sites 250,000 forearm 250,000 hip Annual incidence of common diseases Frequency of Common Medical Events in Women

3. Osteoporosis is a health threat for an estimated 44 million Americans. Of that 44 million : 10 million individuals already have the disease 80% of these are women 34 million more are estimated to have low bone mass and increased risk for osteoporosis. Prevalence Osteoporosis affect people of all ethnic backgrounds. While osteoporosis is often thought of as an older person's disease, it can strike at any age.

4. Osteoporosis is highly preventable. However, if the toll of osteoporosis is to be reduced, the commitment to osteoporosis research must be significantly increased. It is reasonable to project that with increased research, the future for definitive treatment and prevention of osteoporosis is very bright. Cost The estimated national direct expenditures for osteoporotic hip fractures was $18 billion dollars in 2002. Office visits have increased five-fold (from 1.3 to 6.3 million) in the past 10 years. In 2001, about 315,000 Americans age 45 and over were admitted to hospitals with hip fractures.

5. An average of 24 percent of hip fracture patients aged 50 and over die in the year following their fracture. Only 15 percent of hip fracture patients can walk across a room unaided 6 months later. Hip fractures AND vertebral fractures are linked with an increased risk of death. One in five hip fracture patients ends up in a nursing home, a situation that participants in one study described as less desirable than death. Fractures

6. Hip fracture risk is increasing most rapidly among Hispanic women. Women with a hip fracture are at a four-fold greater risk of a second one. Osteoporotic fractures lower a patient’s quality of life. Fractures Annually, 1.5 million osteoporotic fractures occur: 300,000 hip fractures 700,000 vertebral fractures 250,000 wrist fractures 300,000 fractures elsewhere One in two women and one in four men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime.

7. Non-Hispanic white and Asian women: 20% have osteoporosis;52% have low bone mass. Non-Hispanic black women: 5% have osteoporosis; 35% have low bone mass Hispanic women: 10% have osteoporosis; 49% have low bone mass. Osteoporosis is under-recognized and under-treated not only in Caucasian women, but in African-American women as well. Estimates of Osteoporosis in Women >50 yr old

8. Bone density can be temporarily lost during breastfeeding. Several studies have shown that recovering full bone density occurs within six months after weaning. Bone loss during breastfeeding? White women ≥65 year old have twice the fracture incidence versus African-American women. Women have a hip fracture rate two to three times higher than men. A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer. Shrinking is NOT an Inevitability of Aging and IS NOT normal!! Osteoporosis and Women

9. amyloidosis use of glucocorticoids Iatrogenic osteoporosis caused by the therapeutic Rheumatologic disorders rheumatoid arthritis, ankylosing spondylitis Marfan syndrome hemochromatosis Hypophosphatasia epidermolysis bullosa Etiology homocystinuria porphyria Menkes' syndrome INHERITED DISORDERS OTHER DISORDERS immobilization, pregnancy and lactation scoliosis chronic obstructive pulmonary disease osteogenesis imperfecta Ehlers-Danlos syndrome glycogen storage diseases

10. Hypogonadal states Turner syndrome, Klinefelter syndrome, Kallmann Syndrome, anorexia nervosa, hypothalamic amenorrhea, hyperprolactinemia. Nutritional and gastrointestinal disorders malnutrition, parenteral nutrition, malabsorption syndromes, gastrectomy, severe liver disease (especially biliary cirrhosis), pernicious anemia. Hematologic disorders/malignancy multiple myeloma, lymphoma and leukemia, mastocytosis, hemophilia, thalassemia. Etiology Endocrine disorders Cushing's syndrome, hyperparathyroidism thyrotoxicosis, insulin-dependent diabetes mellitus, acromegaly, adrenal insufficiency

11. Osteoporosis, the "silent disease," has bone loss without symptoms. Onset only occurs with sudden strains, bumps, or fall causes a fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis or stooped posture. Symptoms

12. WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998. T-Score World Health Organization (WHO) Osteoporosis Guidelines 1.4 1.3 1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 20304050607080 Age BMD Mean –2 SD Consider preventive intervention Consider therapeutic intervention Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s Life Adapted from AACE Guidelines. Endocr Pract. 2001;7:293-312. Bone Mineral Density Values

13. DEXA scan: Hip T-Score

14. Postmenopausal women who present with fractures Estrogen deficient women at clinical risk for osteoporosis Individuals with vertebral abnormalities Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy Individuals with primary hyperparathyroidism Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy. Who Should Be Tested? *Medicare covers BMD testing for the following individuals age 65 and older. Medicare permits individuals to repeat BMD testing every two years. All women aged 65 and older.* Younger postmenopausal women with multiple risk factors

15. Risk Factors for Hip Fracture -Low BMD (T< -2.5) -Previous Fx -Family history Fx -Smoking Fx Risk Risk Risk of Hip Fx = Skeletal Risk Factors for Fx Non-Skeletal Risk Factors for Falls/Fx -Age (>80 yr) -Poor balance/gait -Impaired eyesight -Meds that increase risk of falling -Loss of soft tissue hip padding -History of falls -Fall-related injury -Smoking

16. Detection: Bone Mineral Density Tests DXA (Dual Energy X-ray Absorptiometry)spine, hip or total body pDXA (Peripheral Dual Energy X-ray Absorptiometry) wrist, heel or finger SXA (single Energy X-ray Absorptiometry)wrist or heel QUS (Quantitative Ultrasound)heel, shin bone and kneecap QCT (Quantitative Computed Tomography)spine pQCT (Peripheral Quantitative Computed Tomography) wrist RA (Radiographic Absorptiometry)hand DPA (Dual Photon Absorptiometry)spine, hip or total body SPA (Single Photon Absorptiometry)wrist Type of Test Area tested

17. Therapeutic Agents Used in Osteoporosis Inhibitors of bone resorption: –Calcium –Estrogens +/- progest –SERMs –Bisphosphonates –Calcitonin Stimulators of bone formation –PTH –Fluoride A.Normal Spine B. Moderately Osteoporotic Spine C. Severely Osteoporotic Spine

18. Copyright ©1996 American Society for Clinical Investigation Rodan, G. A. et al. J. Clin. Invest. 1996;97:2692-2696 Mechanism of Action: inhibition of the production of essential lipid compounds inside osteoclasts decreased osteoclast activity induction of cell death. decreases bone turnover slowing the rate at which new bone remodeling units are formed reducing the depth of resorption. increase in bone mass over time. Bisphosphonates 1.Alendronate and alendronate plus vitamin D (brand name Fosamax® and Fosamax® plus D) 2.Ibandronate (brand name Boniva®) 3.Risedronate and risedronate with calcium (brand name Actonel® and Actonel® with Calcium) 4.Calcitonin (brand name Miacalcin®)

19. Women's Health Initiative Trial Hip and vertebral fractures decreased by at least one-third in both of the trials and total fractures decreased by 24%-30%. The clear fracture benefits of postmenopausal hormone therapy (HT) are offset by the adverse effects: – increased risk of stroke, –cognitive impairment, and –deep vein thrombosis HT provided no cardioprotective benefit, and increased the risk of breast cancer. (AMA) Estrogen/Hormone Therapy 1.Estrogens (brand names, such as Climara®, Estrace®, Estraderm®, Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle® and others) 2.Estrogens and Progestins (brand names, such as Activella™, FemHrt®, Premphase®, Prempro® and others) 3.Parathyroid Hormone – Teriparatide (PTH (1-34) (brand name Fortéo®)

20. The use of an anabolic and antiresorptive agent is less effective than an anabolic agent alone. Since the effects of antiresorptive therapy with bisphosphonates are long-lasting, until more is known, bisphosphonate use should be discontinued before initiating PTH. Combination therapy with two antiresorptive agents is generally reserved for those who: have experienced a fracture while on therapy with a single drug start out with a very low BMD and a history of multiple fractures have a very low BMD and lose more bone mass on therapy with a single drug Combination therapy

21. Algorithm for women Older than 80 Discuss calcium, vitamin D, nutrition, exercise. Rx Xray No further work-up Discuss fall prevention Consider hip pads Hip DEXA or heel ultrasound Already Fx? Height loss >4cm? Taking estrogen? Older women do not convert vitamin D in the skin & should be on an oral supplement Check sedative use, vision, muscle weakness, balance, environmental problems (cords, rugs, poor lighting). Hip padding for thin women. yes no No Fx Fx Raloxifene, calcitonin, or low- dose bisphosphonate. Do not start hormones. BMD not needed to decide treatment.

22. Counsel All Women on: Risk factors for osteoporosis Adequate calcium and vitamin D intake The need for weight bearing exerciseweight bearing exercise Fall prevention strategies Avoidance of tobacco and moderate use of alcohol Consider Bone Mineral Density Screening for: Women over 65 years of age Women 50 to 64 with one or more of the following clinical risk factors Any fracture after age 40 Family history of osteoporosis Current smoking Weight <127 lbs. Post-menopausal women who present with a fracture Compiled by Judith Chilcot School of Nursing University of Washington Medical Center Consider Treatment of Post-menopausal Women with: T-score of < 2.5 or less T-score of - 2.0 or less in the presence of one or more risk factors listed Any vertebral or hip fractures Web Resources http://www.osteoed.org/ Check out OsteoEd, an educational web site, for quick answers to osteoporosis questions. *Guidelines from pamphlet for providers by the National Osteoporosis Foundation. http://www.nof.org/physguide/impact_and_overview.htm#synopsis http://www.nof.org/physguide/impact_and_overview.htm#synopsis

23. 98% of a woman’s skeletal mass is acquired by age 20 Optimal strategies for building strong bones occurs during childhood and adolescence A study of disease management in a rural healthcare population demonstrated that a preventive program was able to reduce hip fractures and save money. 1.A balanced diet rich in calcium and vitamin D 2.Weight-bearing and resistance- training exercises 3.A healthy lifestyle with no smoking or excessive alcohol intake 4.Talking to one’s healthcare professional about bone health 5.Bone density testing and medication when appropriate Five Steps Toward Prevention

24. The best predictor of fracture is a previous fracture. Treatment can improve fracture risk considerably. Fractures can lead to decreased mobility and an additional risk of deep venous thrombosis and/or pulmonary embolism. Vertebral fractures can lead to severe chronic pain of neurogenic origin, which can be hard to control. Prognosis Although osteoporosis patients have an increased mortality rate due to the complications of fracture, most patients die with the disease rather than of it.