Transcript Slide 1
COMMONWEALTH OF AUSTRALIA
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Dr Kylie Williams
9351 6063
[email protected]
Briefly discuss the aetiology, epidemiology and
signs & symptoms of osteoporosis.
Describe prevention strategies for osteoporosis.
Discuss treatment options for osteoporosis.
A skeletal disorder characterised
by compromised bone strength
that increases risk of fracture.
NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis and Therapy, 2001
peak bone mass: by 30 years of age
cortical and trabecular bone
menopausal trabecular bone loss
women have 30% less bone mass than men
age
prevalence with age
sex
women to men (4:1)
people with osteoporosis
4 / 5 don’t know they have it
3 / 4 with a fracture not treated
peak bone mineral density
WHO criteria (bone densitometry)
max. 3rd decade
genetic, environmental, lifestyle
normal: T-score > -1
low bone density: -1 - -2.5
osteoporosis: < -2.5
bone fractures
56% of women and 29% of men
significant morbidity and mortality
spine, hip, wrist fractures most common
Non-modifiable
gender
ing age
caucasian or asian
family history
small stature
low weight
early menopause or oophorectomy
Risk Factors
Modifiable
sedentary lifestyle/decreased mobility
decreased sun exposure
low calcium and/or Vitamin D intake
excessive alcohol consumption
cigarette smoking
predisposing medical factors: hyperparathyroidism,
Cushing’s syndrome
medications: corticosteroids, thyroxine, anticonvulsants, SSRIs
early: pain
pain precipitated by usual activities
restricted spinal movement
loss of height
curvature of the spine
dowager’s hump
fracture history
medical history
risk factors
indicators of bone turnover
bone mineral density scan:
dual x-ray absorptiometry (DXA)
www.sheffield.ac.uk/FRAX
maximise bone mass
calcium / vitamin D
weight bearing exercise
avoid or modify risk factors
prevent postmenopausal bone loss
calcium / vitamin D
? HRT
bisphosphonates, raloxifene, strontium
Hormone Replacement Therapy
prevention & treatment
prevents postmenopausal bone loss
benefit v risk1
fractures
breast cancer and cardiovascular events
oestrogen + progestogen if intact uterus
no longer widely recommended for primary
prevention of osteoporosis
1. Women’s Health Initiative Study, JAMA 2002;288:321-333
calcium
+
vitamin D
HRT/tibolone
bisphosphonates
Selective oEstrogen Receptor Modulators
densoumab
teriparatide
strontium ranelate
Calcium
800-1000mg/day before menopause,
1200-1500mg/day after menopause
ideally from diet
carbonate or citrate
tablets vary in amount of elemental calcium
S/Es: gastrointestinal, hypercalcaemia
D/Is: calcitriol
bisphosphonates
iron, tetracyclines, quinolones
Vitamin D
deficiency Ca++ absorption and bone loss
falls
cholecalciferol (vit D3) [ergocalciferol (vit D2)]
prevention of vitamin D deficiency
may bone density & risk of fracture
dose: 200 (5mcg) - 1000IU (25mcg) daily
cholesterol (diet)
provitamin D (skin)
vitamin D3 (cholecalciferol)
25-hydroxycholecalciferol
1,25-dihydroxycholecalciferol
Vitamin D
calcitriol
metabolite of vitamin D3
bone density & ? risk of fracture
monitoring of calcium necessary
caution with calcium intake
hypercalcaemia: n & v, constipation, headache,
polyuria, thirst, apathy
Bisphosphonates
1st line agents
bind to active bone remodelling sites and inhibit
bone resorption: BMD, fracture risk
alendronate
risedronate
10mg daily or 70mg weekly
5mg daily, 35mg weekly or 150mg monthly
zoledronic acid
5mg IV yearly
poor oral absorption (& by food, Ca, Fe)
S/Es: GI; oesophagitis, oesophageal erosions/ulcers;
osteonecrosis of the jaw (ONJ)
D/Is: antacids, calcium, iron
counselling:
take first thing in the morning
take with a full glass of water
take at least 30 mins before food, drink, other meds
do not lie down for 30 mins
therapeutic effects last ~ 5yr after ceasing therapy
Raloxifene
selective oestrogen receptor modulator (SERM)
2nd line agent
beneficial effects:
adverse effects:
bone density (< oestrogen, bisphosphonates)
improves lipid profile ( LDL)
risk of breast cancer
risk of venous thromboembolism
may aggravate hot flushes
60mg daily
New Therapies
Teriparatide - parathyroid hormone
promotes bone formation
20mcg sc daily
max. 18 months treatment
ADRs:
hypercalcaemia, nausea,
leg cramps, dizziness
New Therapies
Strontium ranelate
bone resorption & bone formation
2g at bedtime
ADRs:
nausea, diarrhoea, headache,
dermatitis, eczema; risk of VTE
New Therapies
Denosumab
bone resorption & bone formation
60mg sc every 6 months
ADRs:
skin disorders, infections, pancreatitis,
ONJ, hypocalcaemia;
long term safety issues?
use lowest effective dose of corticosteroid
use topical or inhaled preparations when possible
maintain adequate calcium intake (diet or supplements)
bisphosphonates (prevention & treatment)
calcitriol (prevention)
modify risk factors eg alcohol, smoking, exercise, calcium
Osteoporosis Australia
www.osteoporosis.org.au
Prevent the next fracture: Pharmacist Guide
Calcium, Vitamin D and Osteoporosis: A guide for
Pharmacists