Osteoporosis Part 1 of 3: Risk Factors

1. OsteoporosisPart 1 of 3: Risk Factors Ellen Davis-Hall, PhD, PA-C Professor Clare J. Kennedy, MPAS, PA-C Assistant Professor, PA Program SAHP , COM UNMC Omaha, NE. office: 402-559-4738 email: clarekennedy@unmc.edu

2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives • Part 1: Identify risk factors for osteoporosis with an emphasis on modifiable risk factors • Part 2: Describe the most current methods of, and standards for, diagnosis and monitoring of treatment • Part 3: Describe the available treatment modalities for osteoporosis and their effectiveness

4. Scope of the Problem • An estimated 1.5 million people suffer osteoporotic fractures each year. This number is expected to double by the year 2040. (Riggs, et al, 1995) • 50% of all post-menopausal women and 15% of while males greater than 50 years old will have an osteoporotic-related fracture in their lifetime. (Green et al, 2004) • Presently, the treatment of osteoporotic hip fractures n the USA costs $20 billion/year (Field-Munves, 2001)

5. Primary Osteoporosis-Two Types Type I: • A primary bone loss from estrogen deficiency (post menopausal osteoporosis) affecting primarily trabecular bone. Type II: • An age related bone loss, affecting trabecular and cortical bone.

6. Medications: glucocorticoids Heparin loop diuretics gonadotropin releasing hormone agonists phenytoin Disease states Hyperparathyroidism Hyperthyroidism Hypogonadism Cushing’s Disease Malabsorption Metastatic bone disease Multiple myeloma Rheumatoid arthritis Chronic renal failure Secondary Osteoporosis-Causes

7. Osteoporosis Types and Associated Fractures • Vertebrae is mostly trabecular bone • Affected most by Type I primary osteoporosis. • Fractures seen most commonly in post-menopausal women • Femoral bone is more cortical bone • Affected most by Type II primary osteoporosis. • Hip fractures occur with increasing frequency in older adults (both men and women).

8. Risk Factors Non-modifiable: • Advanced age • Female gender • Family history of osteoporosis/fracture • Caucasian and Asian race • Thin body frame

9. Risk Factors Modifiable: • Excessive ingestion of coffee, alcohol or protein • Inadequate exposure to sunlight • Insufficient exercise • Malnutrition (poor calcium and vitamin D intake) • Premature menopause • Smoking • Secondary causes

10. Addressing Potentially Modifiable Risk Factors Excessive ingestion of coffee, protein or alcohol • Even 2 cups of coffee/day is a risk • High protein and sodium intake increases urinary calcium loss • Alcohol inhibits osteoblastic activity and decreases levels of Vitamin D Management: Lifestyle changes and calcium

11. Addressing Potentially Modifiable Risk Factors Inadequate exposure to sunlight • Adequate sunlight is necessary for the skin to make Vitamin D • This problem often exists in homebound or institutionalized elderly • Vitamin should be increased in the diet (ie Viitamin D fortified milk or orange juice) Basic nutritional support goals ( should be for all patients) [i] • Calcium > 1500 mg/day • Vit D 800 IU per day* [ii] • Weight bearing exercises [iii] [i] NIH Consensus Conference JAMA 1994, 272 1942-8 [ii] Trivedi DP et. al. BMJ March 2003;326:469-72 [iii] Feskanich D, Willet W, et. al.. JAMA 2002;288:2300-

12. Addressing Potentially Modifiable Risk Factors Insufficient exercise • Mechanical loading increases bone formation • An additional focus should be placed on strength, coordination and balance • Exercise in middle age can slow bone density decline in later years

13. Addressing Potentially Modifiable Risk Factors Malnutrition (poor calcium and vitamin D intake) • Adequate calcium is especially important for children and adolescents (9-18 years) • Calcium requirement for those with osteoporosis is poorly defined • 2500 mg of Calcium considered a safe upper limit(IOM, 1997)

14. Addressing Potentially Modifiable Risk Factors Premature menopause • Premature menopause, physiologic or surgical may not be preventable • Estrogen replacement should be considered

15. Addressing Potentially Modifiable Risk Factors Smoking • Nicotine decreases intestinal calcium absorption • Associated with earlier menopause • Associated with lower spine density Management: Smoking cessation

16. Addressing Potentially Modifiable Risk Factors • Secondary causes. Pay careful attention to the use of these drugs relative to osteoporosis risk. • Glucocorticoid use is a causative agent in both men and women • Furosemide is known to promote calcium loss • Phenytoin and barbiturates enhance hepatic metabolism of Vitamin D • Heparin, with long standing use, promotes bone loss • Thyroxine, in excessive doses, promotes bone resorption

17. Summary of Part 1: Risk Factors • Risk factor assessment is critically important in helping us to identify individuals prone to develop osteoporosis • Modifiable risk factors must be addressed • Early patient identification and monitoring, plus early lifestyle interventions, can help prevent or slow the development of this disease

18. The End of Module One on Osteoporosis References • Riggs et al. Osteoporosis: Etiology, Diagnosis and Management. Philadelphia, PA: Lippincott-Raven; 1995 • Green et al. Does this woman have osteoporosis? JAMA, 2004;292:2890-2900 • Field-Munves, E. Evidence-based decisions for the treatment of osteoporosis. Ann Longterm Care, 2001;9:70-9 • Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington, DC: National Academy Press; 1997, 432

19. Post-test Which of the following medications are known to promote bone loss when used long term? • Glucocorticoids • Calcium channel blockers • SSRIs • Thiazide diuretics

20. Correct Answer: Glucocorticoids Feedback: Glucocorticoids.This class of drugs, often used to help manage COPD adn Rheumatoid Arthritis, is well known to cause bone loss in both men and women. Calcium channel blockers and SSRIs do not have an effect on bone and thiazides actually act to improve balance by reabsorption. end