The Management and Treatment of Osteoporosis

Michele Vaca Hossack, MD

Objectives• To reinforce the US Preventive Services Task

Force Recommendations for Osteoporosis screening

• The management of Osteoporosis in females, males and elderly patients s/p fractures

• The teach the interpretation of Dexa Scans• To present Evidence Based Medicine in

comparing the efficacy of the treatment options for osteoporosis

Definitions

• Osteoporosis- state of severe bone loss and microarchitectural disturbance that renders bone susceptible to fracture with minimal trauma

• Osteopenia- Any state in which bone mass is reduced below normal

Osteoporosis vs. Osteopenia

T -score Degree of Risk of

(No of SD below bone loss Fracturemean of young adults)

0 to -1 Normal None

-1 to -2.5 Osteopenia Small to Moderate

Below 2.5 Osteoporosis Moderate to Severe

WHO

Why is Osteoporosis important?• Of women who survive to age 80 40% will sustain

one major osteoporotic fracture

• 13% of men over 50 will have osteoporotic fractures

• 1 in 3 men aged > 60 will have an osteoporotic fracture

• fractures decrease quality of life

• The annual cost of osteoporotic fractures exceeds 10 billion dollars

Serious Consequences of vertebral fractures

• Compression fractures cause chronic back pain

• Compression fractures are disabling

• fecal incontinence

• can lead to isolation and depression

• increased risk for additional vertebral fractures within 12 months (The mortality rate for multiple fractures is 20%)

• cause of nursing home placement

Serious Consequences of hip fractures

• Hip fractures 20% of women die within one year of fracture

• only 40% regain baseline level of function

• frequent cause of nursing home placement

• if an ORIF of hip is not done in 24-48 hrs a step off walking deformity is common

Clinical Case

• 66 y/o female c chronic back pain x 2yrs. Pt c back pain increasing in intensity over the past week. Pt. recalls falling down on the pavement and landing on her rear end several months ago, but no recent trauma. PMHX sig for osteoarthritis, HTN, and hypercholesterolemia PSHX none

• Meds HCTZ, naprosyn, ranitidine

What would you do?

• Lumbar x-ray

• rest

• ice

• Naprosyn

• Ultram (tramadol) for breakthrough pain

• Dexa Scan

Results

• The patient returns in 4 weeks with some improvement with pain medications, but continues to experience pain 5/10 3x’s a week

• lumbar xray-

• Dexa Scan-

Representative Scheme for Interpreting DEXA Scan

• T-score Degree of Risk of

(No. of SD below bone loss fracturemean of young adults)

0 to -1 none none

-1 to -2 moderate small

-2 to -3 severe moderate

Below -3 Very severe Severe

Osteoporosis vs. Osteopenia

T -score Degree of Risk of

(No of SD below bone loss Fracturemean of young adults)

0 to -1 Normal None

-1 to -2.5 Osteopenia Small to Moderate

Below 2.5 Osteoporosis Moderate to Severe

WHO

Who to treat?• Patients c fractures of hip and spine

• Dexa Score >2.5

• Dexa Score 1.5 to 2.5 if risk factors are present – postmenopausal women– women > 65, men > 70– glucocorticoids – history of fracture – High fall risk – family history of osteoporosis

How would you manage this patient?

• Inquire about medication’s side effects

• Insure adherence with medication plan

• Tailor medication regimen to the patient

• Use non-narcotics first (Naprosyn, Tylenol)

•Narcotics if needed to get patient mobile•Limit bed rest and inactivity•Physical therapy to prevent immobility•heat•nasal calcitonin•orthopaedic referral

Rule out secondary causes of osteoporosis

• CBC

• Chem 10 (calcium, phosphorus, albumin)

• 25-OH Vitamin D

• 24-hr urine calcium

• tsh if on thyroxine

• spep if cbc is abnormal

• PTH if serum or urine calcium abnormal

Treatment

• Calcium intake (1200-1500mg/day)

• Vitamin D (800 IU/day)

• Weight Bearing Exercise (Walking, Biking)

• Life-style modification (moderate alcohol, no smoking)

• Fall Risk Prevention

• avoid sedatives, narcotics, anticholinergics

Treatment• Alendronate (FDA approved)

• Risedronate (FDA approved)

• Raloxifene (FDA approved)

• Nasal Calcitonin (FDA approved)

• Parenteral Calcitonin (FDA approved)

• Teriparatide (FDA approved)– anabolic effect on Bone

Reference

• Wehren et. al, Putting evidence-based medicine into clinical practice: Comparing anti-resorptive agents for the treatment of osteoporosis. Current Medical Resident Opinion. 2004 Jul;20(7): 1161-2

• A Meta-analyses study at the University of Maryland School of Medicine which utilized published data by the Osteoporosis Research Advisory Group, and the Osteoporosis Methodology Group

• Alendronate was 34% more effective than calcitonin (confidence interval .48-.90) on vertebral fracture incidence

• Alendronate was significantly more effective than risedronate, calcitonin, estrogen, etidronate, raloxifene (Relative Risk: .70, .64, .59, .52) on the incidence of non-vertebral fractures

Reference

• Luckey et. al, Once-weekly alendronate 70 mg and raloxifene 60 mg daily in the tretment of postmenopausal osteoporosis. Menopause. 2004; Jul-Aug; 11(4):405-15.

Alendronate 70mg qweek vs Raloxifene 60 mg qd

• 12 month randomized , double-blind study

• 456 women with osteoporosis at 52 sites in the United States

• Endpoint: percent change from baseline after 1 year

• Alendronate significant increase in LS BMD 4.4%, p<.001) than raloxifene 1.9%,

• Alendronate significant increase in hip BMD , p<.001) than raloxifene

•

• Bisphosphonates– proven effective to prevent hip, vertebral, and Colle’s

fractures.

– Side effect GI upset

• Raloxifene– Proven effective in patients with low BMD in the vertebrae

– Not proven effective in patients with low BMD in the appendicular skeleton

– patients who can not tolerate GI side effects of bisphosphonates

• Teriparatide (1-34 Fragment of Parathyroid hormone) – administered parenteral– expensive– oriented for severe osteoporosis– prevalent vertebral fractures

• Stronium (not FDA approved)– anti-fracture efficacy at all sites – good tolerance– may play a role in the future

Women’s Health Initiative

• Estrogen-progestin does not reduce the risk of coronary heart disease

• increases the risk of breast cancer• increases the risk of stroke• increases the risk of venous thromboembolic

events• decreases vertebral compression and hip

fractures

Surveillance Screening

• In this patient, when would you repeat a Dexa Scan?

• Repeat scan after 1 year of treatment

Clinical Case

• 120 lb , 130/80

• 60 y/o f c migraine headaches that occur once a month presents to the office. PMHX: HTN PSHX: none

• After addressing her chief complaint, Do you screen this patient for osteoporosis?

• If this patient was 65 would you screen for osteoporosis?

• www.guidelines.gov

U.S.Preventive Services Task Force Recommendations

• Women aged 65 and older be screened routinely for osteoporosis

• Women aged 60 and older c increased risk for osteoporotic fractures

• Rating of Recommendation B

• No recommendation for or against routine screening for women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.

• Rating of Recommendation C

ORAI-Osteoporosis Risk Assessment Instrument

• Lower body weight (weight < 70 kg)

• no use of estrogen therapy

• age– women

• greater than 65

• greater than 60 c risk factors

– men• greater than 70

Identifying High Risk Patients

• Ask about fractures (low trauma >40)

• Ask about family history

• Measure Height• check weight• check smoking, alcohol• check for

glucorcorticoid use

• early menopause• s/p oopherectomy at an

early age• Disease and medications

that increase risk• caffeine• low calcium and vitamin

D intake• decreased physical

activity

Clinical Case

• 135 lbs, 130/80

• 65 y/o male s c/o.

• PMHX: HTN , Hypercholesterolemia, DM,Prostate Cancer

• PSHX: TURP

• Meds: atenolol, lipitor, glucophage, lupron

• For Health Care Maintenance, Would you screen this patient for osteoporosis?

US Preventive Task Force Recommendation for Men

• Men greater than or equal 70 y/o should have DEXA screening

• Men greater than or equal 65 y/o c risk factor should have DEXA screening

Osteoporosis in Men

• one in three men aged > 60 will have an osteoporotic fracture

• Spinal fractures occur in 5% of men >50• hip fractures occur in 6% of men >50• life expectancy for men 76.8 years

• Diamond, T. Pharmacotherapy of osteoporosis in men. Expert Opinion Pharmacotherapy. 2005 Jan; 6(1):45-58.

Diseases that cause Bone loss• Glucocorticoids • Hypogonadism (GNRH agonist Rx for prostate cancer)• alcoholism• Hyperparathyroidism• COPD• Gastrectomy• Glucocorticoids• Anticonvulsants• Organ Transplantation

Definition of Osteoporosis in Men

• Who criteria based on bone density in wormen only

• ISCD recommends the use of a male database as a reference population

• for the prevalence of osteoporosis is then similar to the prevalence of fractures in men

• NHANES data

What would be your work up to rule out secondary causes

• Cbc• chemistry 10• Phosphorus• 24-hour urine calcium• 25 hydroxyvitamin D• Testosterone• TFTs (if on thyroxine)• PTH (if 24-hour unrine calcium is abnormal)

Treatment• Calcium intake (1200-1500mg/day)

• Vitamin D (800 IU/day)

• Exercise

• Life-style modification (moderate alcohol, no smoking)

• Alendronate (FDA approved)

• Risedronate (FDA approved)

• Raloxifene (FDA approved)

• Teriparatide (FDA Approved)