Osteoporosis and Fractures Are Common, and Becoming More So

1. Osteoporosis and Fractures Are Common, and Becoming More So • About 10 million Americans age >50 years have osteoporosis1 • Almost 34 million more have osteopenia1 • In 2005, >2 million osteoporotic fractures were sustained, costing an estimated $17 billion2 • As the population continues to age, the incidence and prevalence will increase1 • By 2020, 1 in 2 Americans older than age 50 years will have, or be at risk of, developing osteoporosis of the hip1 • By 2025, the number of fractures is expected to increase to >3 million at an estimated cost of $25.3 billion every year2 1. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004. 2. Burge R, et al. J Bone Miner Res. 2007;22:465-475.

2. Osteoporotic Fractures Are Associated with Increased Mortality With permission from Bluic D, et al. JAMA. 2009;301:513-521.

3. “Red Flags” that Warrant Further Assessment • Prior low-trauma fracture as an adult • Family history of osteoporosis, especially parental history of hip fracture • Weight loss of >1%/year in the elderly • Treatment with drugs that adversely affect bone metabolism • Disease or conditions linked to secondary osteoporosis • Unusual cessation of menstrual periods • Anorexia nervosa (marked weight reduction) • Athletic amenorrhea syndrome related to intense physical activity US Department of Health and Human Services. Bone Health and Osteoporosis:A Report of the Surgeon General. Rockville, MD: 2004.

4. Selected Secondary Causes of Osteoporosis in Adults AACE Osteoporosis Guidelines. Endocr Pract. 2003;9:544-564. With permission from the American Association of Clinical Endocrinologists.

5. Who Should Have BMD Screening? The National Osteoporosis Foundation recommends BMD screening for: • Women age ≥65 years and men age ≥75 years, regardless of risk factors • Younger postmenopausal women, women in the menopausal transition, and men age 50–70 years if they have risk factors associated with increased fracture risk • Adults with a previous fracture after age 50 • Anyone at risk for secondary osteoporosis • Anyone receiving osteoporosis treatment, to monitor treatment effect National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation; 2002:1-55.

6. Osteoporosis Defined
Based on DXA Measurement of BMD National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

7. FRAX—Fracture Risk Assessment Toolwww.shef.ac.uk/FRAX • Estimates absolute 10-year risk of a hip fracture or major osteoporotic fracture (ie, vertebral, hip, forearm, humerus)1 • Incorporates clinical risk factors for fracture2,3 • Age • Gender • Previous fragility fracture after age 50 years • History of glucocorticoid use • Parental history of hip fracture • Rheumatoid arthritis • Secondary osteoporosis • Current smoker • Alcohol consumption >3 drinks per day • Body mass index • More sensitive than bone mineral density alone in identifying those at high risk of fracture2 • Pertains only to previously untreated patients1 1. National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55. 2. American College of Rheumatology Hotline summary of FRAX. March 18, 2008. 3. FRAX. WHO Fracture Risk Assessment Tool. 2008. www.shef.ac.uk/FRAX. Accessed April 21, 2009.

8. Primary Prevention for All Patients • Well-balanced nutrition • Calcium = at least 1200 mg/day • Vitamin D = 800 to 1000 mg/day • Active, healthy lifestyle • Regular weight-bearing and muscle-strengthening exercise • Improves agility, posture, and balance • May provide modest increases in bone density • Avoid or stop cigarette smoking • Avoid or stop excessive alcohol consumption (>3 drinks/day) National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

9. Fall Prevention Strategies • Falls frequently cause fractures; preventing falls helps prevent fractures • Address risk factors for falls • Environmental factors: low lighting, obstacles in the walking path, lack of assist devices in the bathroom • Medical factors: poor vision, previous fall, orthostatic hypotension, medications that may affect balance or cause sedation • Consider muscle strengthening and balance retraining US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: 2004.

10. Antiresorptive Agent MOA: reduce bone loss Bisphosphonates Alendronate Ibandronate Risedronate Zoledronate Estrogen Raloxifene Calcitonin Anabolic Agents MOA: build bone Parathyroid hormone Teriparatide Pharmacologic Therapy in Primary Prevention National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.

11. Monitoring Patients on Pharmacotherapy • Assess adherence to therapy and lifestyle modifications • Continue to evaluate and address risk factors for falls • Measure bone mineral density every 2 years in patients on pharmacotherapy • Monitoring with DXA should be in accordance with medical necessity, expected response, and in consideration of local regulatory requirements • Use consistent DXA instrument, facility, and personnel for repeat monitoring • Consider measurement of biochemical markers of bone turnover in patients whose bone density has decreased despite treatment compliance; evaluate for other secondary causes of bone loss National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. 2002:1-55.