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Osteoporosis

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Osteoporosis

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  1. * For Best Viewing: Open in Slide Show Mode Click on icon orFrom the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

  2. Osteoporosis

  3. Who should be screened for osteoporosis? Those with clinical risk factors for osteoporosis or fracture • Advanced age; female sex • Estrogen deficiency • Hx fracture as adult • Hx fragility fracture in 1°relative • Current cigarette smoking • Alcoholism • Low body weight (<127 lbs) • White race or Asian race • Low calcium intake • Low physical activity • Poor health/frailty; falls • Poor eyesight (despite correction) • Dementia; cognitive impairment • Impaired neuromuscular fxn • Residence in nursing home • Hxglucocorticoids >3 mos • Long-term heparin therapy • Anticonvulsant therapy • Aromatase-inhibitor therapy • Androgen-deprivation therapy

  4. Indications for Bone Mineral Density Testing • All women ≥65 and men ≥70 • Postmenopausal women & men aged 50-69 based on clinical risk profile • Women in menopausal transition w/ increased fracture risk • Adults ≥50 who have a fracture • Adults with a condition or taking a medication associated with low bone mass or bone loss • If pharmacologic Rx for osteoporosis considered • To monitor effect of pharmacologic Rx for osteoporosis • Postmenopausal women discontinuing estrogen

  5. How should screening be done, and how are the results interpreted? • Measure BMD with DXA • To screen for and diagnose osteoporosis • To assess fracture risk • To monitor changes in BMD over time • Use fracture risk assessment tool (FRAX) • Estimates 10-yr probability of hip fracture & major osteoporotic fracture in untreated men & women aged 40-90 • Greater clinical utility than relative risk • Uses limited number easily obtainable clinical risk factors • Can be used with or without BMD

  6. What lifestyle measures are recommended for prevention? • Regular moderate physical activity (especially resistance) • Good nutrition, adequate calcium, vitamin D • Smoking cessation • Reduced alcohol consumption • Avoid or minimize medications with harmful skeletal effects • Prevent falls in frail, elderly

  7. What is the role of calcium and vitamin D in the prevention of osteoporosis? • Essential for maintenance of bone mass in adulthood • Calcium • RDI: ≥1200mg with diet + supplements if ≥50 yrs • Tolerable upper limit intake 2500mg/d • Calcium carbonate: takewith meals to optimize absorption • Calcium citrate: Take with or without food • Monitor with 24-hr urinary calcium measurement • Vitamin D • RDI for vitamin D3: 800-1000 IU/d if ≥50yrs • Minimum blood level serum 25-hydroxyvitamin D: ≈75 nmol/L (30 ng/mL) • Suggest fortified food products plus modest sun exposure

  8. When should pharmacologic treatment be considered for prevention? • If bone loss is rapid or if risk for osteoporosis is high • Such as during early postmenopausal years • May prevent or reverse bone loss • May maintain trabecularmicroarchitecture • May reduce fracture risk • Base decision on expected benefit, potential risks

  9. CLINICAL BOTTOM LINE: Screening and prevention… • Fundamental components of prevention • Healthy lifestyle and good nutrition • Avoidance of medications known to be harmful to bone • Pharmacologic Rx to reduce fracture risk is indicated when: • Patients with osteopenia are at high fracture risk • Patients are anticipated to have rapid bone loss that could soon result in osteoporosis and high fracture risk

  10. How should osteoporosis be diagnosed? • Postmenopausal women & men ≥50—WHO diagnostic criteria • Premenopausal women & men <50—don’t use WHO criteria • Also: diagnose if fragility (low-trauma) fracture occurs • Regardless BMD

  11. What should the initial evaluation of a patient with osteoporosis include? • History • Diet • Lifestyle • Medications • Family history • Falls, fractures • Focused review of systems

  12. Physical: Potentially helpful findings for osteoporosis • Loss of height  ? vertebral fracture • Low body weight  risk for fracture • Weight loss ? hyperthyroidism or malnutrition • Fast heart rate ? hyperthyroidism or anemia • Fast respiratory rate  ? asthma • Poor gait  ? muscle strength, balance • Paralysis or immobility  bone loss, increased fall risk • Joint laxity ? osteogenesisimperfecta, Ehlers-Danlos, Marfan • Inflammatory arthritis glucocorticoid use • OA or lower limb injury reduced load-bearing, bone loss

  13. Physical: Potentially helpful findings for osteoporosis • Blue sclera, poor tooth development, hearing loss, fracture deformities  ? osteogenesisimperfecta • Poor dental hygiene  ? jaw osteonecrosisw/ bisphosphonates • Thyromegaly, thyroid nodules, proptosis? hyperthyroidism • Urticariapigmentosa? sytemicmastocytosis • Kyphosis, short distance ribs to iliac crest  ? vertebral fractures • Abdominal tenderness  ? inflammatory bowel disease • Stretch marks, buffalo hump, bruising  ? glucocorticoid excess • Venous thrombosis ? may contraindicate estrogen or raloxifene • Small testicles  ?hypogonadism

  14. Essential tests • Complete blood count • Serum calcium • Serum phosphorus • Serum creatinine • Serum TSH • Serum liver enzymes • Serum alkaline phosphatase • Serum total/free testosterone (men) • 24-hr urinary calcium • Optional tests* • Serum 25-hydroxyvitamin D • Serum PTH • Serum/urine protein electrophoresis, κ/λ light chains • Serum celiac antibodies • 24-hr urinary free cortisol or overnight dexamethasone suppression test • Serum tryptase • *based on clinical circumstance • Lab studies

  15. Imaging studies • Appropriate for carefully selected patients: • Spine imaging: height loss or kyphosis (? unrecognized vertebral fractures) • Nuclear bone scan or x-ray: unexplained increase in alkaline phosphatase • Barium swallow: swallowing difficulties (? stricture)

  16. When should consultation be considered? • Osteoporosis & metabolic bone disease specialist • Non-traumatic fracture with normal BMD • Recurrent fracture or bone loss despite therapy • Unexpectedly severe or unusual features • Complex management / comorbidites: renal failure, hyperparathyroidism, malabsorption • Suspect 2°causes • Discordant clinical and lab findings • Gastroenterologist • Small bowel biopsy if celiac disease suspected • Oncologist • Labs suggest multiple myeloma, other forms of cancer

  17. CLINICAL BOTTOM LINE: Diagnosis… • History and physical • Lab tests • CBC + serum calcium, phosphorus, creatinine, aspartate & alaninetransaminase, alkaline phosphatase, and TSH and 24h urinary calcium levels (plus testosterone for men) • Additional lab or imaging tests • Depending on clinical circumstances • Refer to osteoporosis specialist • When complex or unusual diagnostic issues arise

  18. What are the goals of treatment? • Improve bone strength • With regular physical activity, calcium & vitamin D, pharmacologic agents • Surrogate markers of bone strength: BMD / markers of bone • Measure at baseline and 1 to 2 yrs after starting therapy • Prevent falls • With quadriceps strengthening, balance training • Assess in office (observe; ? can patient walk in straight line, balance on 1 foot) • Reevaluate periodically  risk may increase with age

  19. What lifestyle measures are recommended? • Smoking cessation • Reduced alcohol use • Weight-bearing and muscle-strengthening exercise • Adequate calcium and vitamin D intake • Home safety evaluation (to reduce risk from falls) • Minimize mind-altering medications • Sedatives, hypnotics, narcotic analgesics

  20. What pharmacologic interventions are effective for treatment? • IV bisphosphonates(zoledronate, ibandronate) • Oral bisphosphonates (alendronate, risedronate, ibandronate) • Increase bone mass; decrease fractures • IV SEs: flu-like symptoms after first dose • Oral SEs: esophageal irritation; discontinue if musculoskeletal pain occurs; jaw osteonecrosis & atypical femur fractures • Raloxifene • Increases BMD; decreases fractures; reduces risk for invasive breast cancer • SEs: thromboembolic risk; vasomotor symptoms; fatal stroke

  21. Teriparatide • Increases BMD; decreases fractures • SEs: Dizziness, nausea • Contraindicated with osteosarcoma, Paget disease, unexplained AlkPhos elevation, open epiphyses, Hx skeletal radiation • Estrogen(with or without medroxyprogesterone) • Improves BMD and reduces the risk for fracture • Not approved for osteoporosis Rx — risks outweigh benefits, even in women at high risk for fracture • Denosumab • Increases bone mass; decreases fractures • SEs: cellulitis, eczema, and flatulence • Calcitonin • Slightly increases BMD; decreases vertebral fractures; may decrease pain from acute or subacute vertebral fractures • SEs: Rhinitis, irritation of nasal mucosa

  22. How should they be chosen? • Injectabledenosumab, ibandronate, zoledronate • If oral bisphosphonatesineffective or contraindicated • Oral bisphosphonatesalendronate, risedronate, ibandronate • 1st-line therapy • Raloxifene • Early postmenopausal women with high breast cancer risk + no thromboembolic disease + low risk stroke, hip fracture • Nasal salmon calcitonin • Forwomen ≥5y postmenopausalunable to take other agents • Teriparatide • If multiple risk factors for osteoporotic fracture + failure/ intolerance other therapy

  23. How should patients be monitored? • Measure BMD to assess changes • Measure bone turnover marker to monitor therapy • Untreated patients • Significant bone loss may influence decision to start treatment • Treated patients • Significant decrease in BMD usually = nonresponse or suboptimum response to therapy • Reevaluate treatment + evaluate secondary causes • Consider contributing factors: ? medication compliance; ? sufficient calcium and vitamin D intake

  24. When should consultation be considered for management? • When expertise needed for associated disorders • Hyperparathyroidism, hyperthyroidism • Vitamin D deficiency, hypercalciuria, osteomalacia • Cushing syndrome, glucocorticoid-induced osteoporosis • Hypopituitarism or hypogonadism (males) • Elevated alkaline phosphatase levels or bone turnover • When routine therapy is not possible or effective • Significant bone loss after ≥1y Rx or combination Rx considered • Standard therapies not tolerated or patients have fractures • Vertebroplasty or kyphoplasty needed

  25. CLINICAL BOTTOM LINE: Treatment… • Those at high risk for fracture most likely to benefit from Rx • Individualize drug selection according to… • Clinical circumstances • Magnitude of fracture risk • Comorbid conditions • Patient preference • Encourage a healthy lifestyle, adequate calcium & vitamin D • Monitor Rx effect using BMD testing or bone turnover markers

  26. What should patients be taught? • The association between low BMD and fracture risk • Importance of adequate calcium & vitamin D intake • Weight-bearing exercise to maintain bone mass • To avoid: smoking, excess alcohol consumption • Benefits and potential risks of pharmacologic agents for osteoporosis

  27. How can falls and bone fractures be prevented? Comprehensive fall-reduction program • Home safety evaluation • To identify potential physical or structural problems at home (slippery floors, impeded pathways) • Exercises that improve strength and balance • Reduction in use of drugs that impair cognitive abilities • Patient education • One-on-one instruction and community resources • Consultation with nutritionist, PT, & exercise physiologist • Regular contact with health care professional improves therapy adherence (BMD increases > with no monitoring)

  28. CLINICAL BOTTOM LINE: Treatment… • Keep patient well-informed • Can lead to improved clinical outcomes • Equip patient to make appropriate decisions on lifestyle and nutrition to optimize skeletal health • Inform patient on benefits and risks of pharmacologic therapy • Monitor patient regularly

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