1. Osteoporosis and Bone Health

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

3. 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

6. 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

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

8. 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 with risk factors
50% have secondary cause

9. 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

10. Risk Factors for Osteoporosis
Conditions and Disorders
Medications

11. 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

12. 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

13. 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

14. 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

15. Nonpharmacologic Treatment
Falls Prevention
Calcium and Vitamin D
Weight bearing exercises

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

17. 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

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

19. 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

20. 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

21. 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

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

23. 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.

24. 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.

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

26. 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%

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

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

36. 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

37. 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

38. Case Study
65 y.o. Caucasian female Has never taken hormone therapy. Hx of ankle fracture. Mother broke her 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

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

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

41. Website Resources National Osteoporosis Foundation www.NOF.org
National Institutes of Health Osteoporosis and Related Bone Diseases
North American Menopause Society
Frax Score -Online tool