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Osteoporosis

Osteoporosis. 06/25/12. José L. González, PGY3. Definition. Reduction in bone strength  increase risk of fx T-score: < -2.5 SDs T-score: 30 yo, matched for sex and race Osteopenia: <-1 to 2.5 SDs. Epidemiology. >10 million 8 million women & 2 million men

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Osteoporosis

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  1. Osteoporosis 06/25/12 José L. González, PGY3

  2. Definition • Reduction in bone strength  increase risk of fx • T-score: < -2.5 SDs • T-score: 30 yo, matched for sex and race • Osteopenia: <-1 to 2.5 SDs

  3. Epidemiology • >10 million • 8 million women & 2 million men • Most fractures occur in women w/ osteopenia • Rate of collesfx increases initially, later hip • May be due to the way we fall • Vertebral > Hip > Colles

  4. Risk Factors • Age, female sex, cigarette smoking, prior fxs, low body weight, excess etoh • Meds: glucocorticoids, cyclosporine, heparin, levothyroxine, anticonvulsants • Diseases • Vision • Dementia • Chronic inflammatory diseases • RA • Crohns

  5. Bone Remodeling • Bone mass is 50-80% heritable • Peak skeletal mass  early adulthood. Constant mass 30-45 yoa, then increased resorption • Estrogens, androgens, vitamin D, PTH • 2 functions • Repair microdamage of the skeleton • Maintain [Ca2+] serum

  6. Risk Factors: Parathyroid Hormone • Kidneys • 1. ↑ hydroxylation  1,25OH vit D • 2. decreased Ca2+ loss • Small Intestine • ↑Ca2+ absorbtion • Bone • Release of Ca2+

  7. Risk Factors: vitamin D / Calcium • Calcium: RDI 1000 – 1200 • Vitamin D: RDI 800-1000 units daily • RFs for low vit D: • High latitude • Low intake • Chronic liver or renal disease • Estrogen • Physical Activity • ↓risk in rural communities

  8. Diagnosis • US, CT scan, single energy absorptiometry, DXA • DXA • Lumbar and hip m.c. used • Z-score: age matched • T-score: 30 yo, race and sex matched

  9. Who to test: • All women > 65 yoa • Estrogen deficient women @ risk • Vertebral abnormality of x-ray suggestive • Primary hyper parathyroidism • Steroids > 7.5mg x 3 months • Monitoring response to meds • Repeat @ 2 year intervals

  10. Who to treat: • T-score < -2.5 SDs • Post-menopausal women w/ RFs • RFs: age, prior fx, family hx, low weight, smoking, RA, etoh • FRAX calculator

  11. Treatment: SERMs, PTH, Calcitonin • Raloxifene: • tx & pv of ER+ breast ca • Tx & pv of osteoporosis • PTH: in small amounts • Calcitonin: (intranasal) • Hormone produced by thyroid • decreases osteoclast activity • Decreases vert. fxs only

  12. Treatment: Estrogens • Estrogens (in the form of combined OCPs) • Decrease fracture risk by 50% • Increase risk of MI by 29% • Increase stroke risk by 40%  dementia 2x • Increase risk of breast ca by 26% • Decrease risk of colon ca by 37% • Increase risk of VTE by 100% • 10,000 patients: • prevents (5 hip, 6 colles & 44 clinical fxs) • leads to (8 breast cas, 8 MIs, 18 VTEs)

  13. Treatment: Bisphosphonates • Alendronate: • 5mg x 2 yrs, 10mg x 9 months  90% ↓vert. fx, 50% ↓hip fx • 70mg PO dose once weekly • Risedronate: • use in steroid-induced OP • Ibandronate • Zolendronic Acid: • 70mg IV q yearly • for hyperCa2+

  14. Bisphosphonates: Side Effects • Osteonecrosis of the jaw • hypocalcemia • GI side effects • Esophagitis, ulceration • Contraindicated in strictured esophagus • Drink w/ full glass H20 and remain upright x 30min

  15. Sources: • Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2005:946.

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