Osteoporosis

1
Osteoporosis

• Shelley B. Bhattacharya, D.O., M.P.H.
• MS-3 Geriatrics Clerkship
• University of Kansas
• School of Medicine

2
What is osteoporosis?

• MOST COMMON METABOLIC BONE DISEASE IN THE
  ELDERLY!!

3
Definition

• Systemic skeletal disease characterized by low
  bone mass and microarchitectural deterioration of
  bone tissue
• Consequences
• Bone fragility
• Fracture

4
Osteoporotic vs. normal bone

• Men have about 30 more bone mass than women
• African Americans get 10 higher peak bone mass

5
WHO Definition

• Osteopenia
• BMD 1-2.5 standard deviations below young normal
  female mean (T score)
• What is Z score?
• Osteoporosis
• BMD over 2.5 standard deviations below young
  normal female mean

6
National Osteoporosis Foundation Definition

• Osteopenia
• Up to 2 standard deviations below young normal
  females
• Osteoporosis
• Below 2 standard deviations

7
Prevalence

8
Epidemiology

• 300,000 new cases per year
• 1.7 million in Europe per year
• Men and women
• 50 of women over age 50 will sustain a fracture
  in their lifetime

9
Ten-Year Probability of Fracturing the Hip,
Spine, Forearm, or Shoulder in Postmenopausal
Women (Relative Risk Attributable to Prior
Fracture, 1.74)3,9

Kanis JA et al. Ten year probabilities of
osteoporotic fractures according to BMD and
diagnostic thresholds. Osteoporos Int 2001 Dec
12989-95
10
What is BMD?

• Bone Mineral Density
• Accounts for about 70 of bone strength
• Measured by DXA Scan
• Measures density in radius, lumbar spine and
  greater trochanter
• Mass of bone mineral in the path of the beam
  divided by the cross sectional area of the beam,
  expressed as g/cm2

11
Bone Densitometer
12
Beam of densitometer
13
BMD and Fracture risk

• How much is fracture risk increased with drop in
  1 SD in BMD?
• 2.6!
• Not linear. 10 increase fx risk with -2.5 SD in
  BMD
• Usually fracture in distal forearm, hip or spine
• Distal forearm MC nonvertebral fx in white women
  until age 75
• Spine Usually from compressive loading, can be
  painless

14
Fracture risk factors

• 1. Fall risk
• 2. BMD
• Need maximal peak bone mass
• How to increase peak bone mass?
• Need minimal rate of decline with age
• What increases rate of decline?
• 3. Architecture and geometry of the bone

15
10-Year Probability of Fracture in Women by Age
and T-Score
Data from Kanis JA, et al. Osteoporos Int.
200112989-995.
16
Osteoporosis in men

• Awareness growing
• Risk Factors
• Hypogonadism
• Alcoholism
• Glucocorticoid use
• Look for Hypercalciuria why? What syndrome?
• August 2007 article in Clinical Endocrinology
  News found lower quality of life amongst men with
  osteoporosis

Palkhivala, A. Vertebral Fractures Underdiagnosed
in Men, Clinical Endocrinology News, Aug. 2007,
p.21
17
Progression of bone mass

• Peaks at age 30
• Loss worsens after menopause
• Estrogen protects against osteoclastic activity
• Resorption exceeds reabsorption

18
(No Transcript)
19
Vitamin D

• From NHANES III data of 3444 women 51 and older,
  over 70 of the women 51-70 years of age did not
  meet adequate Vitamin D intake guidelines
• 90 of women over 70 did not meet guidelines

20
What are the NIH Vitamin D guidelines?

• Under 70?
• 400 IU
• Over 70?
• 600IU
• NOF guidelines 400-800 IU/d

21
Physical Exam

• Height, weight
• Gait, mobility
• Kyphosis evaluation
• Percussion of spinewhy?
• Signs of steroid use

22
Labwork

• Complete Metabolic Panel
• CBC
• UA
• TSH
• Vit D
• If hi calcium, do PTH
• If male, do free testosterone
• If suspect Multiple Myeloma SPEP/UPEP

23
X-ray finding of normal spine

• Note
• osteopenic
• bones

24
X-ray finding of mild deformity
25
X-ray findings of classic wedge fracture
26
Treatment

• Calcium
• Vitamin D
• Exercise
• Bisphosphonates
• Calcitonin
• PTH
• Estrogen

27
Exercise

• 1998 study at Gregg et al
• Expending 750kcal/wk reduced hip fractures by 36
• Weight bearing, 30-60 min., 3-4x/wk
• Strength training 2x/wk

28
Calcium

• Adolescents 1200mg/d
• Non pregnant adults 1200
• Menopausal women 1200
• Women and men over 65 1500 mg/d
• Usually given as CaCo3 600 bid with dietary
  intake or 500 tid without dietary intake

29
Calcium Supplements

• Use for osteopenia, osteoporosis and poor Ca
  intake patients
• Take 500-600mg at a time
• CaCo3 with meals
• Can be constipating
• Ca Citrate with or without meals
• Take with Vitamin D

30
Vitamin D

• 400-1200 IU/d
• 8oz Vit. D fortified milk has how much Vitamin D?
• 100IU
• Other sources
• Cereals, egg yolk, seaweed, liver

31
Bisphosphonates

• Use when T score below 2.0 SD from normal
• Poorly absorbed
• Take in AM
• 30 minutes before PO
• Standing up or upright in bed
• With 8oz plain water (no juice, no other meds)
• Daily, weekly or monthly
• Use with Calcium/Vitamin D
• Fosamax plus 5600 IU Vit. D released June 2007

32
Bisphosphonate efficacy
33
Ibandronate (Boniva)

• New!
• Monthly bisphosphonate
• Just released q 3 month IV option
• Same administration routine
• Comparable results (50) in vertebral fracture
  reduction in those with and without hx fx

34
Ibandronate efficacy
35
Calcitonin

• 32 amino acid peptide
• Nasal spray 200IU/spray
• 1 spray per day, q o nostril
• Used for analgesia
• Not very effective as monotherapy for future
  fracture reduction

36
PTH (Forteo)

• 34 amino acid recombinant PTH SC qd
• Bone formation stimulator
• Linear BMD effect
• Cost 500/mo2nd line

37
PTH Efficacy
38
Osteonecrosis of the jaw

• Clinically presents as a nonhealing tooth
  extraction or exposed bone in the jaw progressing
  to bone infection
• Cancer patients have 4X higher risk of getting
  this due to concomitant radiation, chemo,
  steroids
• To May 2004, FDA Adverse Event Reporting Database
  found 152 cases associated with all
  bisphosphonates

39
Osteonecrosis of the jaw

• lt1/10,000 patients
• Associated primarily with IV bisphosphonate use
  in cancer patients undergoing dental procedures
• ONJ precaution labeling has been added to all
  bisphosponates
• Risk factors CA with chemo, radiation, anemia,
  infection
• 1 case so far of ONJ without cancer hx

40
Summary

• Always think of osteoporosis in a geriatric
  patient
• Evaluate for risk factors
• Dont forget the men!
• Order DXA at baseline and every 2 years
• Treat based on DXA findings
• Encourage nicotine cessation, steroid wean,
  exercise

41
(No Transcript)