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Management of Osteoporosis. Stephanie Fegley, FNP Department of Orthopaedic Surgery Christiana Care Health Services March 28, 2014. Objectives:. Identify populations at risk for low bone density or osteoporosis.
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Management of Osteoporosis Stephanie Fegley, FNP Department of Orthopaedic Surgery Christiana Care Health Services March 28, 2014
Objectives: • Identify populations at risk for low bone density or osteoporosis. • Recognize when it is appropriate to order a Bone Density Scan (DXA) with or without Vertebral Fracture Assessment (VFA). • Select appropriate pharmacologic agent for osteoporosis management based on past medical history and side effect profile. • Utilize “fragility fracture panel” to help rule out secondary causes of osteoporosis.
Nearly an epidemic • Reflects the amount of FF per year in the U.S. • More than MI, CVA & breast cancer combined.
Statistics • At least 44 million Americans are affected by osteoporosis or low bone density. • Due to an aging population, the number of Americans with osteoporosis or low bone density is expected to increase significantly. • Up to ½ of all women will suffer a FF during their lifetime • Up to ¼ of all men will suffer a FF during their lifetime
Cost of Osteoporosis • Direct care expenditure from osteoporosis-related fractures exceeds $19 billion annually. • By 2025, the annual cost of fractures is projected to grow to more than $25 billion, as annual fractures surpass 3 million.
Painful, yet undertreated • Approximately 80% of patients do not receive recommended osteoporosis care following a fragility fracture. • Men, who account for 30% of fractures & 25% of cost, are particularly undertreated.
“No one’s ever died from osteoporosis” • Nearly 25% of patients who suffer a hip fracture die within a year. • Those who do survive experience significant morbidity, as many experience a loss of independence & may require long-term nursing home care. • Others never return to their baseline mobility, and will have to ambulate with a walker or cane & are at increased risk of future falls & fractures.
Provide a “Teachable Moment” • According to AOA, a fragility fracture should be treated as a sentinel event. This will provide opportunities or clinicians to educate patients, fellow physicians & other healthcare providers about the importance of bone health and osteoporosis treatment. • The best time to talk to your patient about a fragility fracture and the likelihood of Osteoporosis is while the fracture is fresh.
Fracture Cascade • About 50% of people with one fracture due to Osteoporosis will have a repeat fracture. • The risk of fracture rises with each new fracture, hence the “cascade effect” • Women who have a vertebral fracture are 4x more likely to have another fracture within the next year, compared to women who have never fractured.
Pathophysiology • Age-related changes in bone microarchitecture: • Decreased bone volume • Decreased trabecular thickness • Decreased trabecular number • Decreased connectivity • Decreased mechanical strength • Increased cortical porosity
Populations at risk… • HIV/AIDS • Ankylosingspondylitis • Blood & bone marrow disorders • Breast cancer • Cushing’s syndrome • Eating disorders • Emphysema • Female athlete triad • Gastrectomy • Gastrointestional bypass procedures • Hyperparathyroidism • Hyperthyroidism • Idiopathic scoliosis • Inflammatory bowel disease • Diabetes mellitus • Kidney disease • Lupus • Lymphoma & leukemia • Malabsorption syndromes (i.e.- Celiac & Crohn’s disease) • Multiple myeloma • Organ transplants • Parkinson’s disease • Poor diet
More at Risk Populations… • Post-polio syndrome • Premature menopause • Prostate cancer • Rheumatoid arthritis • Severe liver disease • Spinal cord injuries • Cerebral Vascular Accident • Thalassemia • Thyrotoxicosis • Weight loss
Medications that will Increase Risk… • Oral glucocorticoids • Anticonvulsants • PPIs • SSRIs • TZDs • Lithium • Aromatase Inhibitors • Gonadotropin-releasing hormone agonists • Chemotherapy • Heparin • Depo-Provera
Other Factors that Increase Risk • Low dietary Calcium intake • Vitamin D Insufficiency or Deficiency • Tobacco use in the past 12 months • Consuming > or = 3 units of alcohol per day • Sedentary lifestyle • 2 or more falls in the past year • Moderate to high caffeine intake
Cheap ways to tell if your patient is at an increased risk for fragility fracture: • Prior history of fracture after age 50 or >, at fall from standing height or less • One of the “At risk populations” • Is/has been taking one of the medications that increase risk • Tobacco abuse • Drinks > or = 3 units of alcohol per day • Sedentary lifestyle • History of > or = 2 falls in the past year • Check a FRAX http://www.shef.ac.uk/FRAX/tool.aspx?country=9
Fracture Risk Assessment Tool (FRAX) • Tool developed by the World Health Organization (WHO) to calculate fracture risk in patients, by combining clinical risk factors with BMD, to generate a 10 year probability of fracture. • 10 year probability of hip fracture • 10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture)
When not to use FRAX: • When the patient has already had a hip fracture • When they have been on treatment for Osteoporosis in the past 2 years • Less than 40 years old • Most DXA reports will include a FRAX score at the end, if not contraindicated. This is to help the provider determine if treatment is necessary.
Recommendations for when to order a DXA: • Women age 65 years and older and men age 70 and older. • Women under 65 and men age 50-69 about whom there is concern based on clinical risk factor profile or FRAX score. • Women and men of any age who have suffered a low-impact fracture. • Women and men of any age who are at increased risk as a result of selected medical conditions or treatment with specific medications.
DXA Guidelines • DXA should be “Central DXA”, with lumbar spine & hips (preferably both hips) scanned. • DXA should be interpreted in accordance with International Society for Clinical Densitometry (ISCD) • The final diagnosis from DXA is based on the lowest t-scorefrom the spine, proximal femur, or femoral neck, whichever is lowest. • Diagnosis from DXA in premenopausal women and men under age 50 is based on z-scores and is reported as normal or low bone density for age.
DXA Guidelines (cont.) • Evaluation of the forearm(s) should be performed if the evaluation of the spine or hip(s) is limited or nondiagnostic. • Absolute fracture risk assessment using FRAX should be included in DXA reports for appropriate patients.
Vertebral Fracture Assessment (VFA) • Lateral spine imaging with densitometric VFA is indicated when lowest t-score from DXA is <1.0 and or more of the following is present: • Women age >/= 70 years or man age >/= 80 years • Historical height loss > 4cm (> 1.5 inches) • Self-reported but undocumented prior vertebral fracture • Glucocorticoid therapy equivalent to >/= 5mg prednisone or equivalent per day for >/= 3 months.
How should you write your script? • Write to perform a “DXA with VFA” or “DXA with VFA, if indicated” • Things to consider: • The patient has to lay on their side to have the VFA performed, so if they have a recent fracture, this may be too difficult/painful. • Insurance coverage
Guidelines for follow-up DXA • Insert Table 1 from CMG
Defining Osteoporosis by BMD • Insert table 2 from CMG
Deciding when to treat using FRAX: • According to the WHO, you should consider a pharmacologic agent if: • 10 year probability of a hip fracture is > 3% • 10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture) is > 20%
Important Physical Exam Findings • Eyes- Sclera • Mouth- Teeth~ In OI can be normal or soft & translucent. Also if you are considering bisphosphonate or Prolia therapy you want to evaluate their dentition to determine increased risk for ONJ. • Musculoskeletal- Postural changes such as kyphosis, “lengthening of the arm-trunk axis” (describes shortening of the trunk w/ comparatively long extremities) & tenderness of the spinous processes • Gait- Try and sneak a peek at them walking in or out of the exam room. Can they get up from a chair without using their hands? • Scars- Fracture repairs they have forgotten about • BMI < 18 increases risk • Height at every office visit!
Determining the cause… • Once you make the diagnosis, don’t forget to rule out secondary causes! • Fragility Fracture Panel: • Serum Creatinine • Calcium • Albumin • Phosphorus • Alkaline phosphatase (ALP) • Thyroid Stimulating Hormone (TSH) • Vitamin D 25-OH • Intact Parathyroid Hormone (iPTH)
Vertebral Compression Fractures • Approximately two-thirds are never diagnosed, because they are written off as pain associated with aging or arthritis. • Think about the cascade • Loss of height (more than 3cm/just over 1 inch) • Sudden severe back pain in the mid & lower spine • Increased stoop or ‘dowager’s hump’
Conservative Treatment for Compression Fxs • Self-Care at home: • Rest • Pain relief with NSAIDs • May also need muscle relaxants • Ice for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better. • Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.
Conservative Treatment for Compression Fxs • Hospital Admission: • Inpatient treatment dependant upon pain control, weakness, ambulatory dysfunction, urinary retention, & caudaequina syndrome. • TLSO (ThoracolumbosacralOrthosis) brace as needed, when out of bed for comfort. • Rest • Pain relief with opiates (usually hydrocodone or oxycodone) • May also need muscle relaxants • Ice for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better. • Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.
Consequences of Vertebral Compression Fractures • Kyphosis • Loss of height • Bulging abdomen • Acute & chronic back pain • Breathing difficulties • Depression • Reflux & other GI symptoms • Limitation of spine mobility (affecting ADL & ambulation) • Need to use walking aid
Own the Bone • Launched by the American Orthopaedic Association (AOA), to help providers drastically improve efforts of fracture prevention. • Christiana Care Health System have been participating in the Own the Bone Registry since January 1, 2012. • OTB focuses on 10 measures for the patient with a history of a fragility fracture
10 Own the Bone Measures • Calcium supplementation • Vitamin D supplementation • Weight-bearing & muscle-strengthening exercise • Fall prevention education • Smoking cessation • Limiting excessive alcohol intake • Pharmacotherapy • Ordering DXA • Physician referral letter to report the patient’s fragility fracture, risk factors, & recommendations for treatment. • Patient education latter to explain bone health risk factors & recommendations for treatment.
Which is the best Calcium? • The majority of these patients should be told to consume 1200mg of calcium per day between diet and supplement combined. • Dietary intake of calcium from food sources should be encouraged as much as realistically possible & fill the gap with a Ca supplement when necessary.
Food Sources of Calcium • Lowfat & non-fat dairy products are high in calcium while certain green vegetables and other foods contain calcium in smaller amounts. • Calcium fortified foods- Orange juice, cereals, soymilk, English muffins, waffles, breads, snacks, & bottled water.
Foods that Reduce the Absorption of Calcium • Foods with high amounts oxalate & phytate reduce the absorption of Ca contained in those foods. • Foods high in oxalate= spinach, rhubarb & beet greens • Foods high in phytate= legumes (pinto beans, navy beans, peas), 100% wheat bran* (*space >/= 2 hours after eating foods that contain bran) • You can reduce the phytate level to get more Ca from legumes by soaking them in water for several hours, discarding the water, & then cooking them in fresh water.
Calcium Side Effects • Gas or constipation may occur from Ca supplements • Some patients complain of nausea • Patient’s should increase fluids & fiber in their diet, but if that does not help, they should try another type or brand of Ca. • When starting a new Ca supplement, start with smaller amounts & drink an extra 6-8 ounces of water with it, then gradually add more Ca each week.
Calcium Supplementation • There are many different types of calcium salts (i.e. glubionate, gluconate, lactate, citrate, acetate, phosphate, & carbonate) • Calcium Carbonate (40% elemental Ca) • Viactiv, Caltrate, Oscal, Tums, numerous store brands • 300-600mg of calcium per pill • Requires hydrochloric acid for best absorption, therefore remind patients to take with meals. • Calcium Citrate (21% elemental Ca) **May need 2 pills per dose • Citracal, some store brands • 200-300mg of calcium per pill • Does not requires hydrochloric acid for absorption, so it can be taken with or without food. • Calcium Phosphate (39% elemental Ca) • Posture • Absorption is very similar to Calcium Carbonate
Is There a “Best” Calcium Salt? • The data suggests that both Calcium carbonate & Calcium citrate, taken with meals, have equivalent bioavailability. • If you have a patient on a H2 blocker, PPI, or you know has achlorhydria and supplements won’t be taken with meals, Calcium citrate is a better choice. • Calcium carbonate is cheaper • Calcium phosphate is equivalent to Calcium carbonate in supporting bone building. • Study suggests that Calcium citrate has better availability than Calcium carbonate after roux-en-Y gastric bypass.
Calcium Supplements • Most important factors are those predicting long-term use: palatability, cost, tolerance • Advertised “differences” more apparent than real • Magnesium may be helpful with constipation • Calcium chews contain Vitamin K- ** Caution in patients taking Coumadin
Why is Vitamin D so Important? • Vitamin D is essential for adequate gastrointestinal absorption of calcium. • Insufficient amounts of vitamin D over time reduces serum calcium levels and can trigger a compensatory release of parathyroid hormone. • This may produce secondary hyperparathyroidism, resulting in mobilization of calcium from the bone and a reduction in bone mineral density.
What is the Best Level to Check for Vitamin D Status? • 25-OH Vitamin D level is best • 1,25 OH2 Vitamin D levels are useful in chronic kidney disease, primary hyperparathyroidism, sarcoidosis, oncogenic osteomalacia, vitamin D-resistant rickets, pseudo- vitamin D deficiency rickets, and hypophosphatemic rickets
What Do the Results Mean? • <10ng/mL Severe Vitamin D Deficiency • 10-19ng/mL Vitamin D Deficiency • 20-29ng/mL Vitamin D Insufficiency • 30ng/mL Normal • 40-60ng/mL Target range for someone with history of Osteoporosis with or without fracture
Health Risk Associated with Vitamin D Deficiency • Ricketts • Osteomalacia • Precipitates & exacerbates Osteoporosis • Increased risk of: deadly cancers, cardiovascular disease, Multiple Sclerosis, Rheumatoid Arthritis, & Type I DM • Can also cause muscle weakness & increased risk for falls
Sources of Vitamin D • Sunlight • Food • Supplements & Medications • NOF recommendations: • Adults < 50 years old: 400-800IU/day • Adults >/= 50 years old: 800-1,000IU/day