Osteoporosis and Bone Health

Definitions Scope of the problems Risk Factors Current recommendations Treatment Case Study

Bone Health Over the Lifespan Bone growth is constantly changing Old bone is removed – reabsorption New bone is formed – formation Birth to 30 Bone is formed faster than it is reabsorped After 30 Bone is reabsorped faster than it is formed Small amounts of reabsorption can be tolerated Too much, too fast can cause osteopenia/osteoporosis

Bone Health and Osteoporosis “Fractures due to bone disease are common, costly and often become a chronic burden on individuals and society.” “Left unchecked, the bone health status of Americans is only going to get worse, due primarily to the aging of the population.” Bone Health and Osteoporosis A Report of the Surgeon General 2004

US Dept of HHS. 2004 Surgeon General;s Report of Bone Health

Screening & Diagnosis of Osteoporosis in Men 1 in 8 men will have an osteoporotic fx in his lifetime – 30% of hip fx- 18% of annual cost of osteoporosis Men have almost twice mortality from hip fx compared to women NOF recommend screening all men 70 years or older and men 50-69 with risk factors 50% have secondary cause

Risk Factors for Osteoporosis Lifestyle and Dietary Factors Hx of fragility fx in first degree relative Current cigarette smoker Low body weight (<127 lbs) Personal Hx of Fx in adulthood > 3 mo oral corticosteriod use Female Caucasian Estrogen deficient <45 yrs of age Dementia/cognitive impairment Excessive alcohol use Lifelong low calcium intake Recent falls Inadequate physical activity Poor health/frailty Impaired vision

Risk Factors for Osteoporosis Conditions and Disorders Medications

WHO Criteria for Diagnosis of Bone Status Uses BMD (bone mineral density) test Looks at bone in the femoral neck and lumbar spine Compares results to that of a young normal adult Reported as T-scores T-score below -2.5 SD = osteoporosis T-score -1.0 and -2.5 SD = osteopenia T-score – 1.0 or above = normal bone density

Recommendation for BMD Post menopausal women Those with medical causes of bone loss, regardless of age Those who reach 65 regardless of fracture risk Those < 65 who have had a fracture since menopause who weigh less than 126 lbs who have BMI < 21 Hx of hip fracture in a parent Currently smoke Patients receiving glucocorticoid therapy for more than 2 months Patients with vertebral abnormalities or primary hyperparathyroidism

Surgeon’s General’s Report on Bone Health Identify patient’s at risk Enhance prevention Initiation of drug therapy for patient’s at high risk

Lifestyle Modification Modifiable Risk Factors Smoking cessation Increase muscle mass through regular weight bearing exercises Evaluate/modify the environment Ensure adequate calcium/Vitamin D intake

Nonpharmacologic Treatment Falls Prevention Calcium and Vitamin D Weight bearing exercises

Modifying the Environment Falls prevention Remove/secure loose rugs/cords Functional Tests Get up and go tests Tinetti Assessment Tool for Gait and Balance

Calcium and Vitamin D Calcium plays important role in peak bone mass Vitamin D needed for absorption of calcium Bone mass accumulated early in life is clear predictor of lifelong skeletal health Role of calcium until 30 is bone building, after stabilizes the bone and maintains its strength

Calcium Recommendations Current Recommendations 19-50 years 1000 mg/day of elemental calcium Over 50 years 1200-1500mg/day Supplement or from diet In divided doses No more than 500 mg/dose

Calcium Supplements Single dose should contain 500mg or less of elemental calcium Types: Calcium carbonate Least expensive Requires acid for absorption – take with meals Calcium citrate More expensive Does not need to be taken with meals

Calcium Supplements All can cause constipation and GI upset Absorption of certain medications are affected when taken with calcium Levothyroxine,fluoroquinolones,tetracycline, ACE inhibitors, phenytoin (Dilantin), iron and biphosphonates. Should be taken several hours before or after calcium supplements

Vitamin D Recommendations Checking Vitamin D level Test: 25-hydroxyvitamin D Level should be > 30 ng per mL If below – Rx of oral ergocalciferol (Vitamin D2) in dose of 50,000 IU once weekly for 8 weeks and recheck Maintenance At least 1000 IU (D3) oral cholecalciferol daily

Exercise Weight bearing exercises Walking Dancing Jogging Stair-climbing Racquet sports Hiking

FRAX Online tool for healthcare providers to assess patients for fracture risk Developed by WHO Provides quantitative risk estimate based on BMD and other universal key factors for patients between 40 and 90. Gives 10 year probability of hip fracture and major osteoporotic fracture combined.

Current NOF Clinician Guide Recommendations Limitations Current NOF Clinician Guide Recommendations Initiation of pharmacologic therapy Patients with prior spine or hip fracture Femoral neck or spine BME T-score < -2.5 after secondary causes have been excluded FRAX score of > 3% for 10 year probability of hip fracture or >20% for 10 year probability of major osteoporosis related fracture.

Clinicians should understand the benefits and limitations of FRAX and should use good clinical judgement to determine treatment options.

WHO & NOF Recommendations for Treatment Treating persons with or at risk of osteoporosis NOF – Treatment of post menopausal women and and men with a personal hx of of hip or vertebral fracture, T-score of -2.5 or below or low bone mass (T-score between -1 and -2.5) and 10 year probability of hip fx at least 3% or any major fx of 20% http://osteoed.org/tools.php

Pharmocologic Management Lifestyle modification and adequate Calcium and Vitamin D should be implemented in addition to pharmacological treatment for osteoporosis ( 1000mg/day)

Oral Medications approved by FDA for Osteoporosis Prevention Estrogen with or without progesterone Prevention and Treatment Biphosphonates Alendronate (Fosamax) – generic – 70 mg weekly Ibandronate (Boniva) – 150mg monthly Risedronate (Actonel/Atelvia) – 35mg weekly SERM’s Raloxifene (Evista) – 60mg daily

Intravenous Medications approved for Osteoporosis Ibandronate – 3 mg every 3 months Zoledronic acid (Reclast) – 5mg annually for 3 doses Other Teriparatide (Forteo) – 20mcg SQ daily up to 2 years Calcitonin (Miacalcin ) – 200 IU daily – Nasal spray Denosumab (Prolia) – 60 mg SQ q 6 months

FDA Approved Indications Skeletal Site Fracture Risk Reduction Vertebral Alendronate, risedronate,ibandronate,zoledronic acid, raloxifene, calcitonin, denosumab,teriparatide Hip Alendronate,zoledronic acid, denosumab, teriparatide Non-Vertebral Risedronate,zoledronic acid, denosumab

Action of Pharmacologic Management Antiresorptives/Biposphonates Action: prevent bone breakdown – reduce bone resorption by inhibiting osteoclast activity Known to be effective in reducing risk of fracture Slow further deterioration of the skeleton Allow for some repair and restoration of bone mass/strength

Calcitonin – antiresorptive May decrease vertebral compression fx Not considered first line treatment Raloxifene - SERM Has estrogen agonist activity on bones Effective in reducing vertebral fx

Estrogen Reduces risk of hip/vertebral fractures Lower doses may improve BMD Benefits may not outweigh increase risk of stroke, DVT’s, coronary heart disease and breast cancer FDA recommends HT in women with moderate or severe vasomotor symptoms

Teriparatide (Forteo) Human parathyroid hormone with bone anabolic activity – stimulates bone formation Can be given for 2 years Contraindications: osteosarcoma/Pagets/skeletal radiation/increase Alk Phos Approved for treatment of severe bone loss & who have not improved on biphosphonates

Pharmocologic Management Know side effects Dosing instructions Follow-up When to refer

Prevention/Treatment Any individual dx with osteoporosis by BMD should be evaluated for potential secondary causes – Chronic Medical & Systemic Diseases Endocrine and metabolic disorders Medications Nutrition Drug therapy (antiresorptives) should be initiated

Putting it all together for the Health Care Professional Surgeon General Report – Prevention and Treatment Everyone should be informed of the basic elements of maintaining bone health through nutrition and physical activity Risk factors should be assessed in all older women and men. BMD for all women > 65 regardless of risk Drug therapy for those with osteoporosis Falls prevention for all those with osteopenia/ osteoporosis Individuals with challenging clinical situations may benefit from referral to specialists Bone Health and Osteoporosis, 2004

Case Study 65 y.o. Caucasian female. Menopause @ 52. Has never taken hormone therapy. Hx of ankle fracture. Mother broke her hip @ 80. Non-smoker, no hx of glucocorticoid use, RA or secondary osteoporosis. Drinks 2 glasses of wine with dinner. T-Score of femoral neck on recent Dexascan - -2.0

Frax Score Ten year probability of fracture 30% for major osteoporotic fracture 2.8% for hip fracture

Management Labs – check Vitamin D level Calcium – 1200mg of elemental calcium in divided doses Vitamin D – 1000-2000 iu/daily Weight bearing exercises / Falls prevention Alendronate 70mg once weekly Recheck Dexascan in 1-2 years

Website Resources National Osteoporosis Foundation www.NOF.org National Institutes of Health Osteoporosis and Related Bone Diseases www.niams.nih.gov/bone North American Menopause Society www.menopause.org Frax Score -Online tool http://www.shef.ac.uk/FRAX