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WHO OWNS THE BONES?

WHO OWNS THE BONES?. “Patchwork Quilt” of Women’s Health Who screens? Who treats? Who teaches/ to whom? Whose job it it? Rheumatology Endocrinology Primary Care Gynecology Gerontology Orthopedics Organizations NOF NAMS ISCD. Overview.

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WHO OWNS THE BONES?

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  1. WHO OWNS THE BONES? “Patchwork Quilt” of Women’s Health Who screens? Who treats? Who teaches/ to whom? Whose job it it? Rheumatology Endocrinology Primary Care Gynecology Gerontology Orthopedics Organizations NOF NAMS ISCD

  2. Overview Prevention and Treatment of Osteoporosis • Demographics • Screening • Prevention/Lifestyle • Risk Factors • Pharmaceuticals • Nutriceuticals

  3. Definition Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased fracture risk. BONE DENSITY=BONE DENSITY (70%) + BONE STRENGTH (30%) BONE DENSITY: grams of mineral per area BONE QUALITY: architecture, turnover, damage accumulation, and mineralization NIH Consensus Development Conference on Osteoporosis, 2000

  4. Demographics • 10 Million People have Osteoporosis • 34 Million People have Osteopenia • 1:2 Women will have an osteoporotic fracture in their lifetime • 1.5 Million Fractures Annually • 20% die within one year • $18B Annually www.nof.org

  5. Screening • DEXA is most cost-effective screen today • All women at least 65 yo • Perimenopausal, if risk factors • Any adult > 50 yo with a fracture • Adults with a condition or on a medication associated with bone loss • Patients considering or currently on a medication for osteoporosis • Postmenopausal women considering discontinuation of HRT NOF Clinicians Guide to Prevention and Treatment of Osteoporosis

  6. Unrecognized Vertebral Fractures in Hospitalized Patients

  7. Undertreatment of Hip Fracture in Hospitalized Patients

  8. Densitometry • How often? • Not more than every 2 years • Which bones? • Spine, Hip, Femoral Neck • When to treat? • Osteoporosis • Osteopenia with another risk factor • Lifestyle • Exercise, Calcium, Vitamin D, Smoking, Alcohol • Risk Factors • Age, activity, diet, meds (steroids>3 months), stability, previous fracture, BMI<21,hip fx in a parent, current smoking

  9. Bone Densitometry Values T Score: Standard Deviation comparison of a patient’s bone density to a normal 25 yo. We now have comparison tables by sex and ethnic group. • Normal • T score >-1.0 • Osteoporosis • T score < -2.5 • “Osteopenia” • T score -1.0 to -2.5

  10. National Osteoporosis Risk Assessment (NORA)

  11. FRAX SCOREWHO Fracture Risk Assessment Tool • Uses calculations based on patient data to determine a 10-year risk of hip and major osteoporosis-related fracture • http://www.shef.ac.uk/FRAX/index.htm

  12. NAMS Recommendations Use lowest T-score to define diagnosis Prevention and nutritional measures first Drug Treatment: Any Vertebral Fracture All T-scores < -2.5 Anyone on steroids >3 months T-scores of -2 to -2.5 if one risk factor BMI<21 Fragility Fracture History Hip Fracture History in a Parent

  13. Medical Workup • 25-OH Vitamin D Levels • FSH • TSH • Parathyroid Hormone • Creatinine Clearance • Alkaline Phosphatase • Liver Enzymes • Celiac Antibodies • Protein Electrophoresis • 24-hr. Urine • Calcium, Creatine, Sodium, Free Cortisol

  14. Risk Factors used in FRAX • Geographic Region • Race • Sex • Height/Weight • Previous Fragility Fracture • Family History of Osteoporosis • Current Smoking • Steroid Use (5 mg/da for over 3 months) • Rheumatoid Arthritis • Secondary Osteoporosis • Alcohol (3 or more units daily) • BMD (T score at femoral neck)

  15. So Whom Do We Treat? • Patients with previous hip or vertebral fracture • T score of -2.5 or less at femoral neck, total hip, or spine • T score of -1.0 to -2.5 (Osteopenia) AND: • Other prior fracture • Secondary cause associated with high fracture risk • FRAX risk of 3% or more at hip • FRAX risk of 20% or more for major osteoporosis related fracture at any site

  16. Trends in Treatment Recommendations 2003 2008 Patients with previous hip or vertebral fracture T-score of -2.5 at femoral neck, total hip, or spine T-score of -1 to -2.5 at femoral neck, total hip, or spine AND: Other fracture Other risk factors FRAX of 3% or more at hip FRAX of 20% for other site • Patients with previous hip or vertebral fracture • T-score of -2 at hip • T-score of -1.5 to -2 at hip PLUS additional risk factor.

  17. Treatment Options • Nutrition and Supplements • Exercise • Fall Prevention • Alcohol and Nicotine Avoidance • Pharmaceuticals • Bisphosphanates • SERMs • PTH • HRT • Calcitonin

  18. Bisphosphanates Generic Brand Name Fosamax Actonel Boniva Reclast Aredia Didronel Skelid • Alendronate • Risendronate • Ibandronate • Zoledronic Acid • Pamidronate • Etidronate • Tiludronate

  19. Bisphosphanates

  20. Bisphosphanates • All are indicated for prevention and/or treatment of postmenopausal osteoporosis • Bind permanently to bone to decrease osteoclastic activity and increase bone mass • Concerns about bone quality (“frozen” bone) • Implications for fertility – contraindicated in women planning pregnancy

  21. Bisphosphanates • Similar efficacy • Adverse effects: Esophageal erosion, hypocalcemia, bone pain • Contraindications: esophageal dysmotility, significant renal dysfunction, hypocalcemia • Osteonecrosis of Jaw (ONJ): <1 case/100,000 years of exposure. Usually with high IV doses for cancer Rx. Khann. J.Rheumatol. 2009;Mar;36(3):478-90.

  22. Estrogen Agonist/Antagonist(Formerly called SERMS) Raloxifene (Evista) • Bind to ER, activating some/ blocking others • Decrease vertebral fractures, but no significant effect on hip fractures • One 60 mg tab daily • Adverse Effects: hot flashes, VTE, leg cramps Ettinger et al. JAMA 1999;282:637-645.

  23. Pharmacologic Treatment Options • Anabolics • Teriparatide (Forteo) • Antiresorptives • Calcitonin • Estrogens • SERMS (Raloxifene/Evista) • Bisphosphanates • Alendronate • Risendronate • Ibandronate • Zoledronic Acid

  24. Recombinant Parathyroid Hormone (r-PTH:Teriparatide (Forteo) • Stimulates new bone formation • New fractures are significantly decreased • Vertebral decreased by 65% • Non vertebral decreased by 55% • Concern about malignancies in mice • Dosage • 20 mcg SQ daily for 2 years • Cost - $20. per day Neer, RM, et al. NEJM 2001;344:1434-41

  25. Calcitonin (Miacalcin, Fortical) • Naturally occuring hormone which antagonizes the effects of PTH • Reduces osteoclastic bone resorption • 200 IU intranasal spray achieves 33% reduction in vertebral fractures in postmenopausal women with prior vertebral fractures (PROOF study) Chestnut et al. Am J. Med. 2000;109:267-276.

  26. Compliance FACT After being prescribed a pharmaceutical for osteoporosis or osteopenia, less than 50% of patients have continued therapy at 6 mo • Cost issues • Side effect issues • “Silent Disease” issues How can we affect this statistic???

  27. Lifestyle Issues • Exercise • Calcium • Vitamin D • Medications

  28. Poor Consumption of Vitamin DNHANES III DATA National Health and Nutrition Evaluation Survey J.Amer Diet Assn. 2004:104:980-983

  29. Bone Health Calcium: • 35 RCTs document that calcium prevents or reduces bone loss in adults • Dose • Premenopausal (or on HRT): 1000 mg daily • Postmenopausal: 1500 mg daily Vitamin D: • Oral Vitamin D between 700-800 IU/d significantly reduces the risk of fractures • 400 IU/d is not sufficient for prevention

  30. Working Smarter, not Harder Shared Medical Appointments (SMA) • Basics • Number served • Confidentiality statement • Charges (99214) • 25-40’. 50% Counseling • Dexa SMA • Data reviewed and distributed • Diagnoses established • Lifestyle measures • Therapies discussed

  31. FINISH Thank you

  32. Prescription Nutritionals 3 Primary Concerns for Women’s Health: • Bone Health • Cardiovascular Health • Mental Well-Being Primary Nutrients with Supporting Evidence: • Calcium • Vitamin D • Omega-3 Fatty Acids • Folic Acid • Vitamin B 6

  33. Cardiovascular Health Omega-3 Fatty Acids: • Eskimo observational studies • Nurses Health Study • Physician’s Health Study • RR 0.77 decreased mortality • 850 mg can be expected to save 20 lives per 1000 patients with CHD over 3.5 yrs. Folic Acid • Lowers homocysteine • Improves endothelial function B Vitamins • Nurses Health Study • RR 0.55 of MI in groups with highest levels of Folate and B 6 • SHEEP Study • RR 0.66 of MI in women taking B vitamin supplements Calcium • Significantly increases HDL:LDL Ratio • Suggests 30% reduction in CV events

  34. Mental Well-Being Omega-3 Fatty Acids • Reverses inflammation from Omega-6 and dysmenorrhea • Significant reduction in menstrual symptoms in adolescents Calcium • 48% fewer PMS symptoms than placebo group • Osteoporosis risk much greater in women with history of PMS Folic Acid • Low folate has been linked to depression • Depressed patients have increased homocysteine levels

  35. Prescribing Nutriceuticals Write out above recommendations and send the patient to a pharmacy, healthfood store, Nutritionist, or Sams Club, Or . . . . Prescribe Nutriceuticals ENCORA METAGENICS

  36. Ideal Dosing of Nutritional Supplements for Women Calcium • 1200 mg for women >51 (IOM) • Doses >500 mg should be divided • Better utilized if larger dose is at HS Vitamin D • 400 IU (IOM) wrong • New evidence suggests 700-800 IU • Needed to absorb calcium and prevent hyperparathyroidism Omega-3 Fatty Acids • 500/d in those at risk for CHD • 1000 mg/d if documented CHD (AHA) Folic Acid • 400 mcg/d (IOM) • 0.8-5 mg being studied for CV benefit • Larger dose in AM (prime time for MI)

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