Osteoporosis

1. Osteoporosis Faye N. Hant, DO, MSCR Assistant Professor of Medicine Division of Rheumatology Medical University of South Carolina

2. What is Osteoporosis? Osteoporosis causes bones to lose density, become weak, and fracture easily Osteoporosis affects the entire skeleton Osteoporosis predicts fracture risk

3. Osteoporosis Osteoporosis, or porous bone, is a devastating disease that reduces bone mass. Affects both men and women Can affect all ethnic types and age groups Normal Osteoporosis

4. Osteoporosis Normal Spine Osteoporotic Spine Source: National Osteoporosis Foundation, 2000

5. Why Do We Care About Bone Density? Osteoporosis is common 44 million Americans have either osteoporosis or low bone mineral density 10 million with osteoporosis Osteoporosis is serious Osteoporotic fractures cause disability and increased mortality Osteoporosis is easy to diagnose Bone density testing can detect osteoporosis before the first fracture occurs Good treatmentsare available Fracture risk can be reduced by about 50%

6. Economic Toll • Osteoporosis-related fractures • > 432,000 hospital admissions annually¹ • ~ 2.5 million medical office visits¹ • 180,000 nursing home admissions annually¹ • Cost to the healthcare system • $17 billion for 2005² • Hip fractures account for 14% of incident fractures and 72% of fracture costs² • Due to the aging population, the Surgeon General estimates that the number and costs of hip fractures could double or triple by the year 2040² 1. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2004. 2. Burge RT, Dawson-Hughes B, Solomon D, Wong JB, King AB, Tosteson ANA. Incidence and economic burden of osteoporotic fractures in the United States, 2005-2025. J Bone Min Res. 2007;22(3):465-475.

7. Facts about fractures Most osteoporotic fractures spine, hip, and wrist 2/3 of spine fractures are asymptomatic Fractures lead to disability and increased death rates

8. Fracture and Mortality 5 Year Excess Mortality Spine 18% Hip 19% Forearm 0%Cooper et al, Am J Epidemiol, 1993

9. Impact of Osteoporosis 40% of women over 50 will suffer an osteoporosis-related fracture in their lifetimes. Each year, the risk of suffering a fracture from osteoporosis is greater than the combined risk of suffering a heart attack, stroke, or breast cancer in women.

10. BMD: Better Predictor of OP Fracture Than Cholesterol Is for CHD 12 BMD/Fracture 10 Cholesterol/CHD 8 Relative Incidence 6 4 2 0 Increasing Cholesterol /Decreasing BMD Assessment of Fracture Risk and Its Implication to Screening for Postmenopausal Osteoporosis. World Health Organization (WHO), Geneva 1994.

11. Who is at risk for developing osteoporosis? Post-menopausal women; increasing age Caucasian or Asian Small body stature (<127 pounds) Family history and/or personal history of fractures as an adult (non-traumatic) Inactive lifestyle Cigarette smoking, excessive alcohol use Inadequate Calcium/Vitamin D intake Medications prednisone, heparin, thyroid supplementation, breast cancer treatments, seizure medications

12. Diagnosis

13. How to Detect Osteoporosis DXA (dual-energy x-ray absorptiometry) Gold standard Measures hip, and spine Compares BMD to that of a young adult (T-score) Peripheral measures (ankle, hand, finger) A screening tool Indicate possible risk of future fracture Does not confirm the presence of osteoporosis Not WHO approved to make the diagnosis

14. Who Should Get a Baseline BoneDensity Test? National Osteoporosis Foundation Recommendation: All women 65 years old or older All women with a history of fragility fractures All postmenopausal women with at least one risk factor Adults with a disease or medication history associated with bone loss

15. What is a fragility fracture? Fracture that occurs when falling from a standing height or less in a woman age > 45 years Not sustained as a result of trauma

16. BMD Testing in Men Consideration for testing at and above age 65 to 70 years Presence of secondary conditions (eg, hypogonadism, alcoholism) Use of medications associated with bone loss (eg, Prednisone) Previous fractures Xray evidence of bone loss Orwoll ES. Osteoporosis in Men. Academic Press; 1999.

17. Bone Densitometry

18. Interpretation: T-score is key The most clinically relevant value on the report The T-score compares the bone density of the patient to that of peak bone density (approximately age 30)

19. Fracture Risk Doubles With Every SD Decrease in BMD RR for Fx T-score

20. Approach to Treatment

21. Weight-Bearing Exercise

22. Fall prevention in the home • Use handrails on stairs, bathroom • Keep rooms free of clutter • Keep floors clean but not slippery • Wear supportive, low-heeled shoes. Do not walk in socks or floppy slippers • Use 100 watt bulbs in all rooms • Install ceiling lighting in bedrooms • Use rubber mat in shower/tub • Keep a flashlight at bedside • Check posture in mirror often

23. Medications Available for Treating Post-Menopausal Osteoporosis Calcium and Vitamin D supplementation Estrogen Evista® Miacalcin® Nasal Spray Actonel® Fosamax® Boniva® Reclast® Forteo® Prolia®

24. How Much Calcium is Enough? Varies for age 1,200-1,500 mg every day after age 50 From diet or supplement or both Good Sources of Calcium Milk-300 mg/glass (4 glasses per day) Yogurt-400 mg/cup Broccoli-172 mg/cup

25. How Much Vitamin D? 800 IU every day From fortified foods or supplements or both Higher doses if Vitamin D deficient Good sources of Vitamin D Milk (100 iu per glass) Multi-vitamins(most have 400 iu)

26. A Few Myths About Osteoporosis

27. “Osteoporosis is not serious enough for me to worry about” It is a progressive disease and irreversibly weakens bones Any movement or bump can cause a debilitating fracture Chronic pain and disability are the potential outcomes Hip and spine fractures can lead to death Myth # 1

28. Osteoporosis Myths Myth # 2 “It only affects Caucasian women, so I am not at risk.”

29. Osteoporosis Myths Never too early to prevent it Can strike any age Myth # 3 “I’m too young to worry about osteoporosis now.”

30. Osteoporosis Myths Oh yes they do! 1 in 4 men over 50 will develop it 1/3 of male hip fx are related Under diagnosed Myth # 4 “Men don’t get osteoporosis.”

31. Osteoporosis Myths Myth # 5 “It’s too late for me to do anything about osteoporosis.”

32. U.S. Surgeon General “An estimated 10 million Americans over the age of 50 have osteoporosis (the most common bone disease); while another 34 million have osteopenia or low-bone mass. This problem affects men and women of all ethnicities. Due to the aging of baby boomers, we will have many more people at risk over the next two decades, if we do not take immediate action. It is vital that Americans know how to prevent and treat bone disease and take action that can lead to better bone health.”

33. The Osteoporosis Challenge To educate all patients on measures to maintain good bone health To identify patients at high risk for osteoporosis To use bone densitometry to detect low bone density BEFORE a fracture occurs To use medications appropriately