Rami Mortada, MDAssistant Professor

Division of EndocrinologyKansas University – Wichita

OsteoporosisThe silent disease

Outline

• What is osteoporosis ??• Why should you care ??• Who is at risk ??• How/who needs to be checked ??• Treatment

– Ca and Vit D– Medication

Osteoporosis: The silent disease

Fracture might be the initial presentation

What is osteoporosis ?

Definition of Osteoporosis

Thin and brittle bone which make them more fragile with increased risk of fractures

.

Normal Bone Osteoporotic Bone

NIH Consensus Development Panel on Osteoporosis. JAMA. 2001;285:785-795.

Bone is a living organ

Bone remodeling

Remodeling

Bone Remodeling Unit: 1. ActivationAverage time to complete: 2. Resorption

~ 6 months 3. Reversal 4. Formation

Peak bone mass

Why do we get osteoporosis ??

X

X

+++ Resorption + Formation

Why do we get osteoporosis ??

How does osteoporosis happen ??

• FAILURE TO ACHIEVE PEAK BONE MASS

• DISORDER OF BONE REMODELING– BONE LOSS > BONE FORMATION

Why should you care ??

SITE INCREASE IN MORTALITY RISK

Vertebrae 8.6

Hip 6.7

Any Clinical Fracture 2.2

Fracture and risk of death

Who is at risk ??

Risk Factors: female sex

VS

Women have four times risk of osteoporosis compared to men

Risk factors: smoking

Smoking is a major risk factor for osteoporosis

Risk factors: Low body weight

Risk factor: Aging

Risk factor: Menopause

20% bone loss in the 5 years after menopause

Risk factor: fragility factor

• History of fragility fracture• 1st degree relative with Osteoporosis or fragility

fracture

24

Other Risk Factors

• Absence of menstrual cycles • Diet low in calcium, low Vitamin D • Certain medications • Hormone disorder: thyroid, parathyroid, prolactin…

How do you check for osteoporosis ??

Bone density

Bone density: DEXA scan

Bone density images

Who needs a bone density ??

• Age 65 or older• Previous fracture with little trauma or vertebral fracture • Family history of osteoporosis• Long term use of glucocorticoids (like prednisone)• Early Menopause (before age 45)• Alcohol• Smoking

T-score

A SCORE COMPARING BONE DENSITY TO PEAK BONE DENSITY OF AN ADULT OF THE

SAME SEX

Status T-score

Normal +2.5 to −1.0, inclusive

Osteopenia Between −1.0 and −2.5

Osteoporosis ≤−2.5

Severe osteoporosis ≤−2.5 + fragility fracture

T score result

T score is not enough…

0

5

10

15

20

-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1

BMD T-score

Hip

frac

ture

ris

k (%

per

10

Yea

rs)

The relationship between BMD and fracture risk varies with age.

Kanis et al, Osteopor Int 2001

50

60

70

80

AGE

AGE T-Score = -1.0

T-Score= -2.5

50 6 % 11 %

60 8 % 16 %

70 12 % 23 %

80 13 % 26 %

Risk of Fractures Over 10 Years in Women

Who needs to get treated ??

Who needs to be treated ??

• Osteoporosis ( T score > -2.5)

• Osteopenia with increased risk of fracture

Sample FRAX Calculation:

What are the treatment options ??

Universal measurement for osteoporosis prevention and treatment : Risk factor reduction

Universal measurement for osteoporosis prevention and treatment : Risk factor reduction

Stop Moderate Limit GC

Fall prevention: weight bearing exercise

Weightbearing exercise

Universal measurement for osteoporosis prevention and treatment : Fall prevention

1. Make an appointment with your doctor2. Keep moving3. Wear sensible shoes4. Avoid home hazard5. Light up your living space6. Use assistive devices

Treatment

Calcium 1200 mg / day is recommended

Treatment: Vitamin D

Vit D

Vit D

Vit D

Ca ++

Ca ++ Ca ++

Ca ++Ca ++

Ca ++

Ca ++

1000- 2000 U Daily

Medication for osteoporosis

• Anti resorptive-agents: Stop bone loss

• Anabolic agent: Increase bone formation

Bisphosphonates• Fosamax, Actonel, Boniva, Reclast• The big gun in osteoporosis treatment

Effects• Significantly stop bone loss – anti-resorptive• Reduce vertebral fractures 60%-70% at 3 years• Reduce hip fractures 40%-50% at 3 years• Pills: daily, monthly and weekly • Intravenous: once yearly

BMD

Subjects: Postmenopausal women with low BMD

Response to Long-term Alendronate

Adapted with permission from Bone HG, et al. N Engl J Med. 2004;350:1189-1199.

Urinary N-telopeptide

Placebo

Alendronate 10 mg

Alendronate 10 mg

0

4

8

12

16

% c

hang

e fr

om b

asel

ine

-100

-80

-60

-40

-20

0

% C

hang

e fr

om b

asel

ine

0 2 4 6 8 10

Years0 2 4 6 8 10

Years

Lumbar spine

Femoral Neck

Safety of bisphosphonate

• Reflux disease and ulcer• Worsening of kidney disease

Osteonecrosis of the jaw Atypical femur fracture

How about a holiday ???

Bisphosphonate holiday after 5 years

Raloxifene: Estrogen Agonist/Antagonists

Effects• Anti-resorptive: Stop bone loss• Reduces spine fracture and increases BMD• No hip fracture protection• Breast cancer risk reduction• No endometrial proliferation or cancer

Side effects• Blood clots • May increase hot flashes

Evista [package insert]. Indianapolis, IN: Eli Lilly and Company; 2007.

Estrogen

• Anti-resorptive: stop bone loss– Risk reduction of 34% for vertebral and hip fractures after

5 years

• Indications– Prevention of postmenopausal osteoporosis– Long-term treatment not recommended

• Contraindications– Thromboembolic disease, breast cancer, CVD, stroke,

abnormal genital bleeding, estrogen-dependent cancer

Denosumab

• Skeletal Effects – Anti-resorptive– Risk reduction vertebral fracture 38%,

hip fracture 58% after 5 years– Injection,

• Indications– Severe osteoporosis– Intolerance to bisphosphonate

• Side effects– Decreasing Calcium level, increasing

infection ( maybe)– No long term data about safety profile

Teriparatide

• Skeletal Effects –Anabolic – Decrease vertebral fracture 68%,

hip fracture 40%– Daily injection x 3 years

• Indications– Severe osteoporosis ( T -2.5-4)

• Best treatment available, must be followed by a course of anti resorptive therapy

Word of wisdom

The most important prevention and treatment of osteoporosis is likely to remain the same: diet and exercise

Conclusion

• Osteoporosis is a serious but silent disease • Due to decreased bone formation or increased bone loss • Early prevention is the key element to prevent fracture • Diet and exercise is the cornerstone for osteoporosis

prevention and treatment • Screen with bone density at age 65, sooner if any risk factor • Treatment is effective in decreasing fracture risks

Thank you