Transcript Understanding Osteoporosis

UNDERSTANDING
OSTEOPOROSIS
Stephen L. Kates, MD
AGS
Hansjӧrg Wyss Professor of Orthopaedic
Surgery
Department of Orthopedics and
Rehabilitation
Associate Director, Center for
Musculoskeletal Research
University of Rochester Medical Center
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
WHAT IS OSTEOPOROSIS?
• Skeletal disorder with:
 Compromised bone strength
 Increased risk of fractures
 Deterioration of microarchitecture
• Most common bone disease
Healthy vertebra
Osteoporotic vertebra
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OSTEOPOROSIS
Normal bone
Osteoporosis
Loss of critical bony interconnections
Thinner internal support
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OSTEOPOROSIS OF THE HIP
Loss of critical bony
trabeculae occurs with
osteoporosis
Slide 5
BONY ANATOMY
CHANGES WITH AGE
Slide 6
WHAT ARE BONES MADE OF?
• Minerals bound to proteins
• Calcium
• Hydroxyapatite
• Organized collagen fibers
• Cells — osteocytes, osteoblasts, osteoclasts
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BONE REMODELING
Slide 8
BONES CHANGE DURING LIFE
• Modeling as a child and adolescent
• Remodeling throughout life
• Peak bone mass reached in your 20s
• Remodeling allows bones to heal
• Resorption in later years
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WHAT KEEPS
NORMAL BONES HEALTHY?
• Genetic factors
• Moderate physical activity
• Calcium
• Vitamin D
• Hormones




Parathyroid hormone
Calcitonin
Estrogen
Testosterone
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CAUSES OF OSTEOPOROSIS
• Primary
• Secondary
• Nutrition
• Lifestyle (Exercise, smoking, alcohol)
• Hormonal problems
• Age
• Medications (steroids, seizure meds)
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FRAGILITY FRACTURE
• Caused by a fall from a standing height or less
• Osteoporosis is the cause
• 33%50% of women will develop a fragility
fracture
• 15%33% of men get a fragility fracture
• Likelihood increases with age
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OSTEOPOROSIS: A 2-STAGE DISEASE
• With fracture
• Without fracture
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HIP FRACTURE
Lifetime Incidence in Women 1:6
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ANNUAL INCIDENCE OF
OSTEOPOROTIC FRACTURES (USA)
Only 30% of morphometric vertebral fractures are “clinically apparent”
750,000
750,000
500,000
350,000+
250,000
Clinically
apparent
300,000+
200,000
0
Vertebral
Hip
Wrist
Other
(Morphometric)
Fracture Type
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DIAGNOSIS OF OSTEOPOROSIS
• DEXA scan is best at present
• T score
 Compares density relative to peak bone mass
(normal healthy 25-year-old)
 Matched to sex and race
• Z score compares density to peers
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X-RAY TECHNIQUES
pDXA
DEXA
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WHO DEFINITIONS
Normal
Osteopenia
Osteoporosis
Severe osteoporosis
T score
> 1
< 1 and > 2.5
 2.5
 2.5 with fracture
Mainly for spine and hip in women
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WHO SHOULD BE TESTED?
• All women aged 65 and older regardless of
risk factors
• Younger postmenopausal women with 1 or
more risk factors (other than being white,
postmenopausal, and female)
• Postmenopausal women who present with
fractures (to confirm the diagnosis and
determine disease severity)
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CASES IN WHICH MEDICARE COVERS
DEXA EVERY 2 YEARS
• Estrogen-deficient women at clinical risk of
osteoporosis
• Individuals with vertebral abnormalities
• Individuals receiving, or planning to receive, long-term
glucocorticoid (steroid) therapy
• Individuals with primary hyperparathyroidism
• Individuals being monitored to assess the response or
efficacy of an approved osteoporosis drug therapy
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WHAT ABOUT MEN?
• Fragility fracture
• Steroid use
• Forearm fracture
• Vertebral fracture
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OSTEOPOROSIS IS TREATABLE
• Nutrition
• Exercise
• Lifestyle changes
• Medications
• Fall prevention
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CALCIUM
• Requirements
 Young 1000 mg/day in 2 doses
 Older 1500 mg/day in 3 doses
• Calcium gluconate
• Calcium citrate
• Calcium carbonate
• Whatever you can tolerate
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BODY WEIGHT
• Very low weight is a risk factor (<127 lb)
• Normal weight is best
• Obesity may predispose to falls
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VITAMIN D3 (1 of 2)
• Deficiency is common with age
• Lack of sunlight
• Deficiency = osteomalacia
• Very common in nursing homes
• May cause fractured bones not to heal
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VITAMIN D3 (2 of 2)
• Vitamin D3 — not D2 — is best
• Dose
 Young 400 units/day
 Older 600 to 800 units/day — maintenance
 If deficient, 50,000 units/day
• A blood test is needed to determine deficiency
• Sunlight helps — we have very little
• Essential for bone health!!!!!!
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EXERCISE
• Weight-bearing exercise is best
• Low-impact exercise can help prevent falls
• Weight training
• Tai Chi
• Exercise helps other body systems too
• You have control over this!
• Helps to start young
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FALL PREVENTION
• Medications can cause falls
• Poor lighting
• Throw rugs
• Fall-proofing the home
• Exercise, balance, and strength training
• Correct your vision
• Pets
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CAUSES OF FALLS AT HOME
• Tripping
• Slipping
• Pets
• Ladders
• Stairs
• Poor lighting
Slide 29
LIFESTYLE
• Alcohol in moderation only
• Alcohol can cause osteoporosis
• Alcohol can cause falls
• Cigarette smoking causes osteoporosis
 Makes bones heal poorly
 Smoking cessation is the best plan
Slide 30
MEDICATIONS
• Many medications can hurt your bones
 Steroids (prednisone)
 Seizure drugs
 Elevated thyroid hormone
 Cancer drugs (Lupron)
• Avoid these if possible
• DEXA scans necessary with these
Slide 31
OSTEOPOROSIS MEDICATIONS
• Antiresorptive drugs
• Anabolic therapies
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ANTI-RESORPTIVE THERAPIES:
BISPHOSPHONATES
• Nonhormone compounds
• Bind to hydroxyapatite crystals in bone
• Inhibit the osteoclasts that resorb bone
• Cause osteoclasts to die prematurely
• Half-life 6 to 10 years in bone
• Can be taken by mouth or IV
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ORAL BISPHOSPHONATES
• Alendronate (Fosamax)
• Risedronate (Actonel)
• Ibandronate (Boniva)
• IV bisphosphonates are used when oral
medications are not tolerated
• Work for men and women
• Best treatment for steroid osteoporosis
Slide 35
ALENDRONATE
Reduced the risk of fracture at all key sites in women with osteoporosis
Fracture Risk Reduction (%)
Vertebral
(radiographic)
Multiple
vertebral
Painful
vertebral
Nonvertebral
Non-vertebral
osteoporotic*
Hip
27%
Wrist
Any
symptomatic
30%
31%
36%
45%
48%
54%
87%
*Fracture of the clavicle, humerus, pelvis, hip, or leg
Black DM et al. JCEM. 2000;85:4118-4124.
Slide 36
BISPHOSPHONATES: PROBLEMS
• Reflux
• Must be upright for 1 hour
• Mostly GI symptoms
• Rare: osteonecrosis of jaw
• Long-term effects not known
Slide 37
ANTI-RESORPTIVE THERAPIES:
SERMs
• Raloxifene and tamoxifen
• Bind to estrogen receptor
• Have a good effect on bone density
• For women only
• Should be used with calcium, vitamin D
• Reduce risk of breast cancer
• Increase risk of a blood clot
Slide 38
CALCITONIN
• Hormone that regulates calcium, bone
• Synthetic salmon calcitonin
• Decreases bone resorption
• Reduces pain from vertebral fractures
• Nasal spray or injection
Slide 39
TERIPARATIDE (FORTEO)
(1 of 3)
• Synthetic hormone like human parathyroid
hormone
• Builds bone mass
• Improves bone quality
• Increases the life span of osteoblasts
• Injection for 2 to 3 years
Slide 40
TERIPARATIDE (FORTEO)
(2 of 3)
• FDA-approved for women with:
 High fracture risk
 Multiple fractures
 Failure of other therapies
• FDA-approved for men with:
 Hypogonadal osteoporosis
 High fracture risk
Slide 41
TERIPARATIDE (FORTEO)
(3 of 3)
• Contraindications
• Previous radiation therapy
• Paget’s disease
• Young patients still growing
• Very expensive
Slide 42
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