THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

1. UNDERSTANDING OSTEOPOROSISStephen L. Kates, MDHansjӧrg Wyss  Professor of Orthopaedic SurgeryDepartment of Orthopedics and RehabilitationAssociate Director, Center for Musculoskeletal ResearchUniversity of Rochester Medical Center AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. What is Osteoporosis? • Skeletal disorder with: • Compromised bone strength • Increased risk of fractures • Deterioration of microarchitecture • Most common bone disease

3. Healthy vertebra Osteoporotic vertebra

4. OSTEOPOROSIS Osteoporosis Normal bone Loss of critical bony interconnections Thinner internal support

5. OSTEOPOROSIS OF THE HIP Loss of critical bony trabeculae occurs with osteoporosis

6. BONY ANATOMYCHANGES WITH AGE

7. What are bones made of? • Minerals bound to proteins • Calcium • Hydroxyapatite • Organized collagen fibers • Cells — osteocytes, osteoblasts, osteoclasts

8. BONE REMODELING

9. Bones change during Life • Modeling as a child and adolescent • Remodeling throughout life • Peak bone mass reached in your 20s • Remodeling allows bones to heal • Resorption in later years

10. WHAT KEEPSNORMAL BONES HEALTHY? • Genetic factors • Moderate physical activity • Calcium • Vitamin D • Hormones • Parathyroid hormone • Calcitonin • Estrogen • Testosterone

11. Causes of Osteoporosis • Primary • Secondary • Nutrition • Lifestyle (Exercise, smoking, alcohol) • Hormonal problems • Age • Medications (steroids, seizure meds)

12. Fragility Fracture • Caused by a fall from a standing height or less • Osteoporosis is the cause • 33%50% of women will develop a fragility fracture • 15%33% of men get a fragility fracture • Likelihood increases with age

13. OSTEOPOROSIS: A 2-STAGE DISEASE • With fracture • Without fracture

14. HIP FRACTURELifetime Incidence in Women 1:6

15. ANNUAL INCIDENCE OFOSTEOPOROTIC FRACTURES (USA) Only 30% of morphometric vertebral fractures are “clinically apparent” 750,000 750,000 500,000 350,000+ 300,000+ Clinically apparent 250,000 200,000 0 Hip Wrist Other Vertebral (Morphometric) Fracture Type

16. Diagnosis of Osteoporosis • DEXA scan is best at present • T score • Compares density relative to peak bone mass (normal healthy 25-year-old) • Matched to sex and race • Z score compares density to peers

17. X-RAY TECHNIQUES pDXA DEXA

18. WHO DEFINITIONS T score Normal > 1 Osteopenia < 1 and > 2.5 Osteoporosis  2.5 Severe osteoporosis  2.5 with fracture Mainly for spine and hip in women

19. WHO SHOULD BE TESTED? • All women aged 65 and older regardless of risk factors • Younger postmenopausal women with 1 or more risk factors (other than being white, postmenopausal, and female) • Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity)

20. CASES IN WHICH MEDICARE COVERS DEXA EVERY 2 YEARS • Estrogen-deficient women at clinical risk of osteoporosis • Individuals with vertebral abnormalities • Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy • Individuals with primary hyperparathyroidism • Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy

21. What about Men? • Fragility fracture • Steroid use • Forearm fracture • Vertebral fracture

22. Osteoporosis is Treatable • Nutrition • Exercise • Lifestyle changes • Medications • Fall prevention

23. CALCIUM • Requirements • Young 1000 mg/day in 2 doses • Older 1500 mg/day in 3 doses • Calcium gluconate • Calcium citrate • Calcium carbonate • Whatever you can tolerate

24. Body weight • Very low weight is a risk factor (<127 lb) • Normal weight is best • Obesity may predispose to falls

25. VITAMIN D3 (1 of 2) • Deficiency is common with age • Lack of sunlight • Deficiency = osteomalacia • Very common in nursing homes • May cause fractured bones not to heal

26. VITAMIN D3 (2 of 2) • Vitamin D3 — not D2 — is best • Dose • Young 400 units/day • Older 600 to 800 units/day — maintenance • If deficient, 50,000 units/day • A blood test is needed to determine deficiency • Sunlight helps — we have very little • Essential for bone health!!!!!!

27. Exercise • Weight-bearing exercise is best • Low-impact exercise can help prevent falls • Weight training • Tai Chi • Exercise helps other body systems too • You have control over this! • Helps to start young

28. Fall Prevention • Medications can cause falls • Poor lighting • Throw rugs • Fall-proofing the home • Exercise, balance, and strength training • Correct your vision • Pets

29. Causes of Falls at Home • Tripping • Slipping • Pets • Ladders • Stairs • Poor lighting

30. Lifestyle • Alcohol in moderation only • Alcohol can cause osteoporosis • Alcohol can cause falls • Cigarette smoking causes osteoporosis • Makes bones heal poorly • Smoking cessation is the best plan

31. Medications • Many medications can hurt your bones • Steroids (prednisone) • Seizure drugs • Elevated thyroid hormone • Cancer drugs (Lupron) • Avoid these if possible • DEXA scans necessary with these

32. Osteoporosis Medications • Antiresorptive drugs • Anabolic therapies

34. ANTI-RESORPTIVE THERAPIES: BISPHOSPHONATES • Nonhormone compounds • Bind to hydroxyapatite crystals in bone • Inhibit the osteoclasts that resorb bone • Cause osteoclasts to die prematurely • Half-life 6 to 10 years in bone • Can be taken by mouth or IV

35. Oral Bisphosphonates • Alendronate (Fosamax) • Risedronate (Actonel) • Ibandronate (Boniva) • IV bisphosphonates are used when oral medications are not tolerated • Work for men and women • Best treatment for steroid osteoporosis

36. ALENDRONATE Reduced the risk of fracture at all key sites in women with osteoporosis Non-vertebral Painful vertebral Vertebral (radiographic) Multiple vertebral Non-vertebral osteoporotic* Anysymptomatic Hip Wrist 27% 30% 31% Fracture Risk Reduction (%) 36% 45% 48% 54% 87% *Fracture of the clavicle, humerus, pelvis, hip, or leg Black DM et al. JCEM. 2000;85:4118-4124.

37. BISPHOSPHONATES: PROBLEMS • Reflux • Must be upright for 1 hour • Mostly GI symptoms • Rare: osteonecrosis of jaw • Long-term effects not known

38. ANTI-RESORPTIVE THERAPIES:SERMs • Raloxifene and tamoxifen • Bind to estrogen receptor • Have a good effect on bone density • For women only • Should be used with calcium, vitamin D • Reduce risk of breast cancer • Increase risk of a blood clot

39. Calcitonin • Hormone that regulates calcium, bone • Synthetic salmon calcitonin • Decreases bone resorption • Reduces pain from vertebral fractures • Nasal spray or injection

40. TERIPARATIDE (FORTEO)(1 of 3) • Synthetic hormone like human parathyroid hormone • Builds bone mass • Improves bone quality • Increases the life span of osteoblasts • Injection for 2 to 3 years

41. TERIPARATIDE (FORTEO)(2 of 3) • FDA-approved for women with: • High fracture risk • Multiple fractures • Failure of other therapies • FDA-approved for men with: • Hypogonadal osteoporosis • High fracture risk

42. TERIPARATIDE (FORTEO)(3 of 3) • Contraindications • Previous radiation therapy • Paget’s disease • Young patients still growing • Very expensive

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