Aging Q3 ACOVE #9 Osteoporosis

Jay Brzezinski, MD Medical University of South Carolina 2011

Osteoporosis ACOVE Work Group

 Dr. Jay Brzezinski, Chair  Dr. Bill Moran  Dr. Pam Pride  Dr. Leonard Lichtenstein  Dr. Amy Thompson  Dr. Brad Keith  Dr. Lara Hourani  Tamela Sill, RN

Burden

  25 million Americans have osteoporosis ½ of all post-menopausal women will have an OP related fracture  Up to 20% of hip fracture patients die in one year  Usually asymptomatic until fracture occurs

BONE

 Trabecular bone  Also called Cancellous bone  Vertebral body bone  Bone near joint lines  Has bone marrow  Light weight  Has spiculated pattern

BONE

 Cortical bone  Compact bone  Long bones  Dense  Stiff  hard  heavy

BONE

 Trabecular bone, 25% replaced per year  Cortical bone, 3% replaced per year  Osteoporosis occurs in both  It makes sense that trabecullar bone fractures easier?

RISK FACTORS

         Age Gender Prior fracture Family history Exercise Smoking RA ETOH Drugs….steroids

NON-RISK FACTORS??

 Obesity?

 Athletic childhood?

 Osteoarthritis?

 Diet??

 Family history?

SCREENING( i.e. asymptomatic)

 All women at age 65  Women under 65 with FRAX score >9.3%  9.3% is risk of asymptomatic woman age 65  A previous fracture? We are not screening now!

How to Screen

 DEXA is best  Heel quantitative ultrasound??

DEXA

 Dual energy x-ray absortiometry  One x-ray beam is absorbed by soft tissue  One x-ray is absorbed by everything  Subtract the two and get bone  Problem with ordering a screening BMD on PP???

– Diagnosis: “Pre Menopausal”

T-SCORE

 -1.0 or better is normal  Lower than -2.5 is osteoporosis  -1.0 to -2.4 is osteopenia  What if I have had a compression fracture?

 What if I had a hip replaced?

FRAX

 www.sheffield.ac.uk/FRAX/tool.jsp

Treatment

 Calcium  Vitamin D  Should I measure  What does it mean  Will replacement help  Exercise??

Bisphosphonates

    alendronate (Fosamax ® ) 70 mg qweek Ibandronate (Boniva ® ) 150 mg qmonth risedronate (Actonel ® ) 5 qday,35 qweek, 150 qmonth Zoledronic acid (Reclast ® ) qyear IV

Forteo

®

  Teriparitide sq qday times 2 years Risk…osteosarcoma  Used to treat osteoporosis with prior fracture or high risk who cannot take bisphosphonates

How long to Treat?

 5 years?

 7 years?

 Life?

 Until BMD better?

 Bisphosphonates accumulate in bone and after stopping leach out over 1-2 years

Expert Opinion

 Mild risk: rx 5 years and follow BMD  High risk: rx 10 years and do 1-2 year drug holiday

When to rescan

 Normal with no risks: 3-5 year  Risk factors that persist: 2 years  High risk after menopause: 2 years  Treated patients: 2 years than less if responding

Risks NNH

 Osteonecrosis of jaw=>60,000 and most occurred in cancer patients treated with very high dose zoledronic acid  Atypical femur fracture=? 25,000?

Benefits NNT

Prior Fracture

Any Fracture = 21 Vertebral Fracture = 8 Hip Fracture = 35 - 46 Other Fracture = 21 - 43

No Prior Fracture

100 29 4.5 - 66 35 – 66

Osteoporosis Blue Sheet

Osteoporosis Aging Q3 ACOVE # 9

PCT Ask:

1.

Have you ever had a DXA scan (bone density) for osteoporosis? 4.

Have you ever had a fractured bone?

PCT MD ACTION: CIRCLE: YES or NO

YES NO YES NO 1a. If

YES

, Is the DXA documented in Practice Partner? 1b. If

NO

, Was the patient referred for a 2.

DXA? Was the patient’s risk of fracture 3.

(FRAX) calculated? Did the patient’s FRAX score influence any clinical decisions in today’s visit? 4.

If

YES

, 4a. Did you do a fracture history? 4b. Did the fracture history indicate any need for change in medications or further treatment? If

NO

– No further action needed

CHECK: YES NO MD

 Screening FRAX  DXA o 65+Female with no Dx of Osteoporosis o 65+ Female with previous fracture but no DXA

Osteoporosis Detailing Sheet

Aging Q 3 Osteoporosis and Aging ACOVE #9 An estimated 25million Americans have osteoporosis. It affects elderly people of all races and ethnicities. 20-25% of persons with a hip fracture are unable to return to independent living and 12-20% die within 1 year.           Risk Factors Age Gender Previous fracture Family history Low BMI Physical activity Currently smoking Alcohol use Steroid use * Rheumatoid arthritis *Note: If patient uses >5 mg/day Prednisone or equivalent < 3 months: Warning > 3 months: Rx Bisphosphonate Treat Fracture 65+ Female (Major trauma NA) DXA (Baseline) No Fracture DXA and FRAX http://www.shef.ac.uk/FRAX/tool.jsp?country=9 Look for the FRAX at: FRAX should not be used with persons on treatment for osteoporosis. Treat Treat Treat Screening

DXA for all Women 65+ years

Diagnosis T-Score  Osteoporosis ≤ -2.5   Osteopenia -1.0 to - 2.4 Normal > -1.0 False Positives with Compression Fractures No Treatment >-1.0 DXA < -2.5 -1.0 to - 2.4 DXA ≥ 3% FRAX (Hip Fracture) ≥ 20% FRAX (Osteoporotic Related Fracture)

Practice Partner Template Progress Notes

 If patient is age 65 or over and female, has the patient ever had a DXA scan?

 If patient is 65 or over and female, has the patient’s risk of fracture (FRAX) been calculated?

 Does the patient report ever having a fractured bone?

Osteoporosis ACOVE begins in clinic Thursday, July 21, 2011 Thanks for supporting Aging Q

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