Transcript Care Working Group - Osteoporosis Canada

2010 Guidelines
Case Study #5:
Mrs. FB
2010 Guidelines
Case Presentation
• 82-year-old woman who recently fell at home
– Slipped while in the bathroom
• History of two previous falls
– One coming down stairs four months ago; no
serious injury
– One on her driveway last year: right distal radial
wrist fracture
– Has a fear of falling
2010 Guidelines
Past Medical History
• Hypertension
• Depression (after death of her husband seven
years ago); no prior episodes
• Insomnia
• Gastroesophageal reflux (GERD)
• Dependent pedal edema
• Cholecystectomy
2010 Guidelines
Medications
•
•
•
•
•
•
•
Hydrochlorothiazide 25 mg daily
Amlodipine 10 mg daily
Ramipril 10 mg daily
Sertraline 100 mg daily
Lorazepam 1 mg daily (at bedtime)
Calcium 500 mg daily
Multivitamin 1 daily
2010 Guidelines
Social History
• New to your practice (her previous family physician recently
retired)
• Lives alone in the community in a small two-storey house
(her home of 40 years)
• One supportive daughter (your patient)
• Non-smoker (never smoked)
• One alcoholic drink (“a small glass of wine with dinner”)
most evenings
• Relatively inactive physically (“no one to walk with”)
• Husband died seven years ago
• Retired bookkeeper
2010 Guidelines
Functional History
• Independent in all basic activities of daily living
(e.g., dressing, transferring, bathing)
• Daughter assists with weekly shopping; she is
independent in all other instrumental daily
activities (e.g., medication management,
telephone, laundry and housekeeping)
• Limited driving: “daytime/fair-weather”
– No accidents
• Receives no professional services at home
2010 Guidelines
Family History
• Mother became very stooped, but no history of
fractures
• Father had hypertension
2010 Guidelines
Physical Examination
• Height: 155 cm (61 inches)
– “I used to be 5’ 4”
•
•
•
•
•
Weight: 54.5 kg (120 lbs)
Body mass index (BMI): 22.7
Blood pressure: supine,125/80 mmHg; standing 105/70 mmHg
Rib-to-pelvis: one finger
Get-up-and-go test (timed): Can’t rise from chair without arm
rests; Needs to steady herself before walking; 16 seconds
for 3 m
• One-foot stand: < 1 second on either foot
• Mild kyphosis
2010 Guidelines
Cognitive Assessment
• Montreal Cognitive Assessment:1 27/30
– Not cognitively impaired
• Geriatric Depression Scale (15-item):2 4/15
– Not depressed
1. Available online at: http://www.mocatest.org/
2. Available online at: http://www.rgpc.ca/
2010 Guidelines
Question
• What impact does the fall history have on
Mrs. FB's risk for osteoporosis and future
fractures?
2010 Guidelines
Falls Risk Assessment
• The 2010 guidelines state that a history of falls
over the past year should be elicited, and if
positive, should prompt a falls risk assessment
• History of falls in the last year is one of the most
significant risk factors for predicting future fall1-6
• Dementia and poor physical function have also
been found to be associated with falls and
fractures in older adults2,4,5
1. Tinetti ME. N Engl J Med 2003; 348:42-49.
2. J Am Geriatr Soc 2001; 49:664-672.
3. Ganz DA, et al. JAMA 2007; 297:77-86.
4. Bensen R, et al. BMC Musculoskeletal Disorders 2005; 6:47.
5. Cawthon PM, et al. J Bone Miner Res 2008; 23:1037-1044.
6. Gates S,et al. BMJ 2008; 336(7636):130-133.
2010 Guidelines
Assessment and Management of Falls
Periodic case
finding in
primary care:
Ask all
patients
about falls
in past year
• From a joint guideline
issued in 2001 by:
• American Geriatrics Society
• British Geriatrics Society
• American Academy
of Orthopaedic Surgeons
Recurrent
falls
No
intervention
Single
fall
Gait/
balance
problems
Patient
presents
to medical
facility after
a fall
No
falls
Check for gait/balance
problem
No
problem
Full evaluation*
Assessment
History
Medications
Vision
Gait and balance
Lower limb joints
Neurological
Cardiovascular
Multifactorial intervention
(as appropriate)
Gait, balance & exercise programs
Medication modifications
Posteral hypotension treatment
Environmental hazard modification
Cardiovascular disorder treatment
J Am Geriatr Soc 2001; 49(5):664-72.
2010 Guidelines
Question
• Given Mrs. FB's history, what further testing
would you consider?
2010 Guidelines
Radiologic Investigations
• Physical examination is
highly suggestive of
vertebral fracture
– Guidelines recommend
spine X-ray
• BMD testing is optional
and only required for monitoring, as this patient
needs treatment
2010 Guidelines
Results of Radiologic Investigations
• Lateral thoracolumbar spine plain film
– Vertebral compression fractures of T10 and T12
(> 25% vertebral height loss with end-plate
disruption); significant degenerative changes
throughout
• BMD
– Femoral neck T score = -2.3
– Lumbar spine (L1-L4) T-score = -1.9
2010 Guidelines
Question
• Based on the history and results of
investigations, what is Mrs. FB's risk level for
future fracture?
2010 Guidelines
Mrs. FB: Assessment of
Risk for Fracture
• Based on the history alone, treatment can be
initiated for Mrs. FB
– Age
– History of multiple fragility
fractures (wrist and spine)
– Recurrent falls
Click here to see the risk assessment calculations for Mrs. FB.
2010 Guidelines
Laboratory Investigations
• All laboratory investigations are normal
–
–
–
–
–
–
CBC
Calcium (corrected)
Creatinine
Alkaline phosphatase
TSH
Serum protein electrophoresis
• No evidence for secondary osteoporosis
2010 Guidelines
Question
• What would you recommend for treatment to
reduce Mrs. FB's risk of future fracture?
2010 Guidelines
Considerations for Treatment
• Physical activity can be beneficial in reduction
of fracture risk
• Optimal vitamin D and calcium
intake should be ensured
• Pharmacologic therapy should be initiated
– Importance of adherence needs to be stressed
2010 Guidelines
Question
• Does Mrs. FB's other medical history raise any
possible concerns with pharmacologic therapy
for osteoporosis?
2010 Guidelines
Mrs. FB: Considerations for
Pharmacologic Therapy
• Her history of GERD may be a concern— selecting
an agent with lower incidence of GI side effects may
be helpful
• There may be a possible correlation with SSRI use
and risk of fracture1
– Switching to another antidepressant or tapering off therapy
may be considered
• Polypharmacy: Try to reduce overall pill burden (e.g.,
one-pill combinations of antihypertensives if possible)
1. Ginzburg R, et al. Ann Pharmacother 2009; 43(1):98-103.
2010 Guidelines
Mrs. FB: Conclusions
• Integrating osteoporosis and falls risk
assessment is critical in reducing the risk of
fracture in the older adult
• 10-year fracture-risk assessment may not be
necessary in cases where clinical history
suggests high risk
– Pharmacologic therapy can be initiated without a
10-year risk assessment in such cases
2010 Guidelines
Back-up Material
Additional slides that can be accessed
from hyperlinks on case slides
Case 5 – Mrs. FB
2010 Guidelines
Importance of Weight
• In men > 50 years and postmenopausal
women, the following are associated with low
BMD and fractures
– Low body weight (< 60 kg)
– Major weight loss (> 10%
of weight at age 25)
Return to case
1. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.
2. Waugh EJ, et al. Osteoporos Int 2009; 20:1-21.
3. Cummings SR, et al. N Engl J Med 1995; 332(12):767-773.
4. Papaioannou A, et al. Osteoporos Int 2005; 16(5):568-578.
5. Kanis J, et al. Osteoporos Int 1999; 9:45-54.
6. Morin S, et al. Osteoporos Int 2009; 20(3):363-70.
2010 Guidelines
Importance of Height Loss
• Increased risk of vertebral
fracture
– Historical height loss (> 6 cm)1,2
– Measured height loss (> 2 cm)3-5
• Significant height loss should
be investigated by a lateral
thoracic and lumbar spine
X-ray
Return to case
1. Siminoski K, et al. Osteoporos Int 2006; 17(2):290-296.
2. Briot K, et al. CMAJ 2010; 182(6):558-562.
3. Moayyeri A, et al. J Bone Miner Res 2008; 23:425-432.
4. Siminoski K, et al. Osteoporos Int 2005; 16(4):403-410.
5. Kaptoge S, et al. J Bone Miner Res 2004; 19:1982-1993.
2010 Guidelines
Additional Tests for Clinical
Identification of Vertebral Fracture
Test
Rationale
Method
Interpretation
Rib-pelvis
distance1
To identify
lumbar
fractures
Measure the
distance between
the costal margin
and the pelvic rim
on the mid-axillary
line
< 2 fingerbreadths
is associated with
vertebral fractures
Occiput-to-wall
distance2,3
To help identify
thoracic spine
fractures
Stand straight with
heels and back
against the wall
> 5 cm raises
suspicion of
vertebral fracture
1. Olszynski WP, et al. BMC Musculoskeletal Disorders 2002; 3:22.
2. Green AD, et al. JAMA 2004; 292(23):2890-2900.
3. Siminoski K, et al. J Bone Miner Res 2001; 16(Suppl):S274.
2010 Guidelines
Rib-Pelvis and Occiput-to-Wall Distances
4 cm
8 cm
3 cm
Height loss
12 cm 8 cm
3 FBs
Return to case
2 FBs
2010 Guidelines
Plain Radiographic
Examinations of the Spine
Type
Use(s)
Plain radiographs,
complete
To investigate symptoms such as
back pain or after trauma
Plain radiographs,
limited
Specifically to look for osteoporotic fracturing
Plain radiographs,
incidental
Incidental views of the spine on radiographs
undertaken for other purposes (e.g., lateral chest films)
2010 Guidelines
Other Radiographic Examinations
of the Spine
Type
Use(s)
Incidental to dual X-ray absorptiometry (DXA)
Vertebral fracture
– provides lower-resolution images of the
assessment (VFA), T4 to L4
spine, not subject to projection distortion
Computed tomography (CT) To clarify subtle or uncertain findings on
of the spine
radiographs
Magnetic resonance
imaging (MRI) of the spine
Radionuclide bone
scanning
Return to case
To examine soft tissues or clarify the
acuteness of spinal fracturing
To look for disease activity or distribution
May also be helpful in diagnosing such
conditions as metastatic disease and
acuteness of injury
2010 Guidelines
Indications for BMD Testing
•
•
All women and men age > 65
Postmenopausal women, and men aged 50 – 64 with clinical risk factors
for fracture:
–
–
–
–
–
–
–
–
–
–
Return to case
Fragility fracture after age 40
Prolonged glucocorticoid use†
Other high-risk medication use*
Parental hip fracture
Vertebral fracture or osteopenia
identified on X-ray
Current smoking
High alcohol intake
Low body weight (< 60 kg) or major weight loss (>10% of weight at age 25)
Rheumatoid arthritis
Other disorders strongly associated with osteoporosis
†At
least three months cumulative therapy in the previous year at a prednisone-equivalent dose > 7.5 mg daily;
* e.g. aromatase inhibitors, androgen deprivation therapy.
2010 Guidelines
10-year Risk Assessment for Women
(CAROC Basal Risk)
Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].
2010 Guidelines
10-year Risk Assessment for Women
(CAROC Basal Risk)
Age
Low Risk
Moderate Risk
High Risk
50
above -2.5
-2.5 to -3.8
below -3.8
55
above -2.5
-2.5 to -3.8
below -3.8
60
above -2.3
-2.3 to -3.7
below -3.7
65
above -1.9
-1.9 to -3.5
below -3.5
70
above -1.7
-1.7 to -3.2
below -3.2
75
above -1.2
-1.2 to -2.9
below -2.9
80
above -0.5
-0.5 to -2.6
below -2.6
85
above +0.1
+0.1 to -2.2
below -2.2
Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].
2010 Guidelines
Risk Assessment with CAROC:
Important Additional Risk Factors
• Factors that increase CAROC basal risk by
one category (i.e., from low to moderate or
moderate to high)
– Fragility fracture after age 40*1,2
– Recent prolonged systemic glucocorticoid use**2
Mrs. FB goes from moderate risk to high risk
because of her history of fragility fractures
* Hip fracture, vertebral fracture, or multiple fracture events should be considered high risk
** >3 months use in the prior year at a prednisone-equivalent dose > 7.5 mg daily
1. Siminoski K, et al. Can Assoc Radiol J 2005; 56(3):178-188.
2. Kanis JA, et al. J Bone Miner Res 2004; 19(6):893-899.
2010 Guidelines
FRAX: Risk Calculation for Mrs. FB
Mrs. FB is
high risk
using FRAX
Return to case
www.shef.ac.uk/FRAX.
2010 Guidelines
Recommended Vitamin D
Supplementation
Group
Recommended
Vitamin D
Intake (D3)
Adults < 50 without osteoporosis or conditions
affecting vitamin D absorption
400 – 1000 IU daily
(10 mcg to 25 mcg
daily)
Adults > 50 or high risk for adverse outcomes from
vitamin D insufficiency (e.g., recurrent fractures or
osteoporosis and comorbid conditions that affect
vitamin D absorption)
800 – 2000 IU daily
(20 mcg to 50 mcg
daily)
Hanley DA, et al. CMAJ 2010; 182:E610-E618.
2010 Guidelines
Vitamin D: Optimal Levels
• To most consistently
improve clinical
outcomes such as
fracture risk, an optimal
serum level of 25hydroxy vitamin D is
probably > 75 nmol/L
– For most Canadians,
supplementation is
needed to achieve this
level
Hanley DA, et al. CMAJ 2010; 182:E610-E618.
2010 Guidelines
When to Measure Serum 25-OH-D
• In situations where deficiency is suspected or where
levels would affect response to therapy
– Individuals with impaired intestinal absorption
– Patients with osteoporosis requiring pharmacotherapy
• Should be checked no sooner than three months after
commencing standard-dose supplementation in
osteoporosis
• Monitoring of routine supplement use, and routine
screening of otherwise healthy individuals are not
necessary
Hanley DA, et al. CMAJ 2010; 182:E610-E618.
2010 Guidelines
Recommended Calcium Intake
• From diet and supplements
combined: 1200 mg daily
– Several different types of calcium
supplements are available
• Evidence shows a benefit of
calcium on reduction of fracture
risk1
• Concerns about serious adverse effects with
high-dose supplementation2-4
Return to case
1. Tang BM, et al. Lancet 2007; 370(9588):657-666.
2. Bolland MJ, et al. J Clin Endocrinol Metab 2010; 95(3):1174-1181.
3. Bolland MJ, et al. BMJ 2008; 336(7638):262-266.
4 Reid IR, et al. Osteoporos Int 2008; 19(8):1119-1123.
2010 Guidelines
Summary Statement for Other
Nonpharmacologic Therapies
Statement
Strength
Weight bearing, balance, and strengthening exercises can
improve outcomes in individuals with osteoporosis
Level 2
Exercise-focused interventions improve balance and
reduces falls in community-dwelling older people
Level 2
Hip protectors may reduce the risk of hip fractures in longterm care residents; however adherence with their use may
pose a challenge for the older adult
Level 2
Return to case
2010 Guidelines
First Line Therapies with Evidence for Fracture
Prevention in Postmenopausal Women*
Bone
formation
therapy
Antiresorptive therapy
Type of
Fracture
Bisphosphonates
Raloxifene
Risedronate
Zoledronic
acid
Denosumab
Alendronate
Hormone
therapy
(Estrogen)**
Vertebral







Hip




-

-
Nonvertebral+




-


Teriparatide
* For postmenopausal women,  indicates first line therapies and Grade A recommendation. For men requiring treatment,
alendronate, risedronate, and zoledronic acid can be used as first line therapies for prevention of fractures [Grade D].
+ In clinical trials, non-vertebral fractures are a composite endpoint including hip, femur, pelvis, tibia, humerus, radius, and clavicle.
** Hormone therapy (estrogen) can be used as first line therapy in women with menopausal symptoms.
Return to case
2010 Guidelines
Importance of Adherence
in Treatment Success
• The expectation is that treated patients will
experience antifracture benefits similar to
those reported in clinical trials
• Suboptimal adherence reduces or eliminates
antifracture benefits1-3
1. Silverman S. et al. Rheum Dis Clin North Am 2006; 32(4):721-731.
2. McCombs JS, et al. Maturitas 2004; 48(3):271-287.
3. Gold DT, et al. Curr Osteoporos Rep 2006; 4(1):21-27.
2010 Guidelines
Poor Adherence Leaves Patients At
Higher Risk of Fracture
Probability of fracture
0.12
0.11
0.10
0.09
50% adherence leaves
patients at approximately
the same fracture risk
as no therapy
0.08
0.07
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
MPR
Siris E, et al. Mayo Clin Proc 2006; 81:1013-22.
2010 Guidelines
Types and Rates of Nonadherence
in Osteoporosis Therapy
• Types of non-adherence1-3
– Frequently missed doses
– Failing to take the medication correctly to optimize
absorption and action
– Discontinuation of therapy
• Reported one-year adherence rates:
25%–50%1,3
– Marginally better with less frequent dosing
regimens
1. Silverman S. et al. Rheum Dis Clin North Am 2006; 32(4):721-731.
2. McCombs JS, et al. Maturitas 2004; 48(3):271-287.
3. Gold DT, et al. Curr Osteoporos Rep 2006; 4(1):21-27.
2010 Guidelines
Approaches for Optimizing Adherence
•
•
•
•
•
Reminders
Patient information
Counselling
Simplification of the dosing regimen
Self-monitoring
Return to case
2010 Guidelines
Adverse Events of Osteoporosis
Therapies
• Consult individual product monographs for
adverse event information for approved
therapies (click on drug names below to link to online
resources)
– Bisphosphonates: alendronate, risedronate,
zoledronic acid
– Calcitonin
– Denosumab
– Raloxifene
– Teriparatide
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