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Comprehensive Guide to Postmenopausal Osteoporosis Management

Learn about postmenopausal osteoporosis, WHO criteria, risk factors, treatments, and prevention strategies. References included.

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Comprehensive Guide to Postmenopausal Osteoporosis Management

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  1. Postmenopausal osteoporosis M.M.EMAM MD Rheumatologist SBMU

  2. WHO criteria for osteoporosis • Normal a value of Tscore >-1 • Osteopenia a value of -1>Tscore>-2.5 • Osteoporosis a value of T-score<-2.5 • Severe Osteoporosis Osteoporosis + fragility fracture References:WHO 1994

  3. T-Score Z-Score

  4. TBS especially informative in : • Hyperparathyroidism • DM type 2 • Osteoarthritis • Clinical and subclinical hypercortisolism

  5. Osteoporosis Treatment :

  6. Who should be treated? If threshold WHO criteria T<-2.5 =60% lost of osteoporotic fractures

  7. Who should be treated? In Postmenopausal women and men age 50 and older • T- score<-2.5 • Fragility fracture(hip and spine) after age 50 Osteopenia when: • 10-year overall major fracture risk > 20% or the 10-year hip fracture > 3% • In 10 -20 % according to judgment of physician NOF's New Clinician's Guide to Prevention and Treatment of Osteoporosis., 2013

  8. 20% 3 %

  9. The case represents a woman the original FRAX probabilities for major osteoporotic and hip fracture, respectively, were 16 and 5.9%. The probabilities after entering the TBS value of 1.08 are shown.

  10. Basic therapy for osteoporosis : • Calcium & Vit.D supplementation • Counteract individual risk factors • Recommendation for physical activity • Prevention of falls • Smoke & alcohol ceasation References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  11. Basic therapy for osteoporosis : • Calcium & Vit.D supplementation • Recommendation for physical activity • Prevention of falls • Smoke & alcohol ceasation Counteract individual risk factors References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  12. Risk Factors for Osteoporosis and Fracture Non-Modifiable • Age • Female sex • Maternal family history of hip fracture • Low birth weight • Disease predisposing to osteoporosis Potentially Modifiable • History of falls • Body mass index • Drug therapy (e.g. corticosteroid use, use of anti-convulsants) • Primary or secondary amenorrhea • Early menopause • Smoking • Excessive alcohol consumption • Dietary calcium and vitamin D deficiency Risk factors taken from Jordan & Cooper Best Practice and Res Clin Rheumatol, 2002 Categorized by Eli Lilly & Co.

  13. Basic therapy for osteoporosis : • Calcium & Vit.D supplementation • Counteract individual risk factors • Prevention of falls • Smoke & alcohol ceasation Recommendation for physical activity References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  14. Exercises : • At least 30 minute 3 times per week • Any weight bearing exercises especially jogging accepted • Can increase BMD & muscle strength & propensity to fall

  15. Basic therapy for osteoporosis : • Calcium & Vit.D supplementation • Counteract individual risk factors • Recommendation for physical activity • Smoke & alcohol ceasation Prevention of falls References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  16. Prevention of falls & complications : • Correction of decreased visual acuity • Reduction of drug consumption that altered wakefulness & balance • Improve cardiac & neurologic function • Improve muscle strength • Improving home environment • Wearing hip protectors References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  17. Mechanism Of Treatment Resorption Formation • Teriparatide • Anabolic hormones • Rocaltrol • Statins • Fluoride !??? • Bisphosphonates • Miacalcic • EPT • SERM • Prolia • Strontium ranelate

  18. Mechanism of treatment Resorption Formation • Teriparatide • Anabolic hormones • Rocaltrol • statins • Fluoride !??? • Bisphosphonates • Miacalcic • EPT • SERM • Prolia • Strontium ranelate

  19. Bisphosphonates : • First line treatment in postmenopausal ,steroid induced & men • Alendronate or FOZAMAX (10 mg/day or 70 mg once weekly) or risedronateor Actonel (5 mg/day, 35 mg once weekly, or 150 mg once monthly), and ibandronateor Bonviva (150 mg once monthly or 3 mg intravenously every three months) are effective for both the prevention and treatment of osteoporosis andZoledronicacid (ZA) or aclasta , 5 mg administered intravenously (IV) once yearly, is also effective for the treatment of osteoporosis • Has good effect on spinal & hip BMD & fracture risk • Low intestinal absorption(So use in fasting state) • Recently Actonel SR available that can be use after breakfast

  20. Mechanism Of Treatment Resorption Formation • Teriparatide • Anabolic hormones • Rocaltrol • Statins • Fluoride !??? • Bisphosphonates • Miacalcic • EPT • SERM • Prolia • Strontium ranelate

  21. Calcitonin • A less popular choice for treatment of osteoporosis is nasal calcitonin 200 international units daily. • modest effect on BMD and weak antifracture efficacy • Don't use in first years of menopause and fast looser state and hip involvement • Had some analgesic effect • Long term use associated with an increase risk of some cancers

  22. Mechanism Of Treatment Resorption Formation • Teriparatide • Anabolic hormones • Rocaltrol • Statins • Fluoride !??? • Bisphosphonates • Miacalcic • EPT • SERM • Prolia • Strontium ranelate

  23. Denosumab

  24. Denosumab • Denosumab is a humanized monoclonal antibody against RANKL that reduces osteoclastogenesis. • In several trials, Denosumab reduces the incidence of vertebral fractures by about 68 percent, hip fractures by about 40 percent and • non-vertebral fractures by about 20 percent over three years • 60 mg subcutaneously every 6 months

  25. Denosumab Drug safety • Hypocalcemia. Hypocalcemia must be corrected before starting • increased the risk of serious skin infections (cellulitis) and skin rash. • ONJ both when used to treat osteoporosis and to treat patients with cancer, although it is much more common in the latter setting • Atypical femur fractures

  26. long-term extension(8 years ) trial with Denosumab • Zoledronate extending to 9 years that were also presented at the ASBMR meeting did not show similar progressive improvements in bone density or declines in fracture rates • Denosumab seems to exert superior effects in the long term compared with the bisphosphonates American Society for Bone and Mineral Research 2013 Annual Meeting. ; Abstract LB-MO26, presented October 7, 2013

  27. Combined teriparatide and denosumab increased BMD more than either agent alone and more than has been reported with approved therapies. Combination treatment might, therefore, be useful to treat patients at high risk of fracture Lancet 2013 Jul 6;382

  28. Forteo (PTH) (Cinopar)

  29. Forteo (PTH) • Increase bone formation at existing remodeling sites

  30. Teriparatide • Increase bone formation at existing remodeling sites • Greater cost compared to other treatments • Limited in severe osteoporosis or in patient who had progression despite of treatments • No good effect on hip osteoporosis • Duration of treatment in most studies 18 months but can use for 2 year

  31. Teriparatide • Use 20 mcg/d by sc injection • Contraindicated in : Hypercalcemia Hyperparathyroidism Unexplained elevated ALP Exposure to external beam radiation or prior skeletal radiation

  32. Strontium Ranelate : • Trace element with Dual action • Predominantly taken up by adsorption onto bone mineral • Agonist of calcium -sensing receptor(independent PTH ,1 25 D) • Dose 1-2gr/d • After 3y has 11.5% increase in lumbar BMD & 41% in Fx rate References:1. Spector TD. Rheum Dis Clin North Am 16:513-537, 1990. 2. Alarcón GS. Rheum Dis Clin North Am 21:589-604, 1995. 3.Goronzy JJ, Weyand CM, in Klippel JH (ed), Primer on the Rheumatic Diseases. 11th ed. Atlanta, Ga: Arthritis Foundation, 1997, pp 155-161.

  33. A review of available safety data for strontium ranelate (Protelos) has raised concern about its cardiovascular safety beyond the already recognised risk of venous thromboembolism. An analysis of randomised controlled trial data has identified an increased risk of serious cardiac disorders, including myocardial infarction (relative risk compared with placebo was 1.6 [95% CI 1.07–2.38]). Meeting highlights from the Committee for Medicinal Products for Human Use (CHMP) 22-25 April 2013

  34. OP BP severe spinal OP prolia forteo BP BP

  35. Thank You

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