Bone Health and Fracture Statistics

Hip Fracture Statistics

• One in five people who suffer a hip fracture end up in a nursing home within a year.
• Some people never walk again after a hip fracture.

Common Bone Breaks

• The most common breaks in weak bones are in the wrist, spine, and hip.

Bone Loss

• After age 35, bone mass slowly decreases.
• Women lose bone mass faster after menopause.
• Men also lose bone mass.

Risk Factors

• Talk to your health care professional if you have any of these risk factors.

Modifiable Risk Factors

• Poor health
• Smoking
• Small body build
• Eating disorder
• Early menopause before age 45
• Never gotten enough calcium
• Drinking more than two alcoholic drinks several times a week
• Frequent falls
• Sedentary lifestyle

Non-Modifiable Risk Factors

• Age greater than 65
• Family history of osteoporosis
• Fracture after age 50

Medical Conditions Associated with Weak Bones

• Hyperthyroidism
• Chronic lung disease
• Cancer
• Inflammatory bowel disease
• Chronic liver or kidney disease
• Hyperparathyroidism
• Vitamin D deficiency
• Cushing's disease
• Multiple sclerosis
• Rheumatoid arthritis

Medications That Can Contribute To Weak Bones

• Oral glucocorticoids (steroids)
• Cancer treatments (radiation, chemotherapy)
• Thyroid medication
• Antiepileptic medications
• Gonadal hormone suppression
• Immunosuppressive agents
• Aluminum
• Heparin

Diagnosis

• Bone density measurement
• History of fragility fracture regardless of bone density

FDA-Approved Osteoporosis Drugs

• Bisphosphonates
  • Alendronate, Alendronate plus D (Fosamax®, Fosamax Plus D®)
  • Risedronate, Risedronate with Calcium (Actonel®)
  • Ibandronate (Boniva®)
• Calcitonin (Miacalcin®, Fortical®, Calcimar®)
• Parathyroid Hormone [PTH (1-34), teriparatide] – Forteo®
• Selective Estrogen Receptor Modulators (SERMs) - Raloxifene (Evista®)
• Estrogen/Hormone Therapy (ET/HT) – Premarin®, Estrace®, Prempro®

Bisphosphonates

• Approved for:
  • Prevention and treatment of osteoporosis in postmenopausal women.
  • Treatment to increase bone mass in men with osteoporosis.
  • Treatment of glucocorticoid-induced osteoporosis in men and women receiving glucocorticoids.
  • Treatment of Paget’s disease of bone in men and women.
• Mechanism: bisphosphonates reduce osteoclastic activity and bone resorption by binding bone mineral, where they are absorbed by mature osteoclasts, inducing osteoclast apoptosis and suppressing resorption.

Bisphosphonates – Clinical Benefit

• Reduce risk of fracture:
  • 3 years bisphosphonate treatment in postmenopausal women with osteoporosis
  • Relative risk reduction for vertebrae and hip fractures

Bisphosphonates – Administration

• Must be taken at least one-half hour before the first food, beverage, or medication of the day with plain water only.
• Should only be taken upon arising in the morning.
• Tablet should be swallowed with a full glass of water (8 oz).
• Patient should remain upright for at least 30 minutes (60 minutes for monthly ibandronate).
• Should supplement with calcium/vitamin D if dietary intake is inadequate.

Bisphosphonates – Adverse Effects

• Hypocalcemia (18%)
• Hypophosphatemia (10%)
• Musculoskeletal pain, cramps – FDA warning
• Gastrointestinal
  • Abdominal pain
  • Acid reflux
  • Dyspepsia
  • Esophageal ulcer
  • Gastritis
• Osteonecrosis of the jaw (IV bisphosphonates)
• Visual disturbances (rare)

Zolendronic Acid (Reclast®, Aclasta®)

• Approved for treatment of osteoporosis in postmenopausal women.
• Single 5 mg infusion given IV over > 15 minutes, once yearly.
• Should still supplement with calcium/vitamin D.
• May be ideal for those with GI contraindications to the oral formulations.

Bisphosphonate Treatment Duration

• Long-term treatment with bisphosphonates has a long residence time in bone.
• There are concerns about long-term treatment.
  • Safety concerns
  • Cumulative exposure to drug may lead to a reservoir in bone with continued benefits when therapy is stopped.
• 5–10 years of bisphosphonate treatment appears to be safe for most patients.
• Drug holidays can be considered.
  • Lower Risk: After 3-5 years
  • Higher Risk: After 10 years

Denosumab

• Human monoclonal antibody to RANKL
• Decreases osteoclast number and function
• Reduces risk of spine, hip and nonvertebral fractures
• SC dose every 6 months
• No dose adjustment for decreased kidney function
• Effect is reversible within 6–12 months of stopping.

Denosumab Mode of Action

• A fully human monoclonal antibody that binds the cytokine RANKL (receptor activator of NFκB ligand), an essential factor initiating bone turnover.
• RANKL inhibition blocks osteoclast maturation, function and survival, thus reducing bone resorption.

Teriparatide

• Recombinant human PTH (1-34)
• Mechanism of action differs from other agents (anabolic)
• Daily SC injection
• Indicated for patients at high risk for fracture:
  • Postmenopausal women with osteoporosis
  • Men with primary or hypogonadal osteoporosis
  • Men and women with osteoporosis associated with sustained systemic glucocorticoid therapy
• Treatment limited to 2 years, then follow with antiresorptive agent

PTH (1-34) – Adverse Effects

• Most common:
  • Dizziness
  • Rash
  • Nausea
  • Headache
  • Leg cramps
  • Arthralgia
  • Rhinitis
  • Transient hypercalcemia

PTH (1-34) – Safety Considerations

• Osteosarcoma risk in animals
• FDA black box warning

PTH (1-34) – Treatment Considerations

• Due to safety concerns, PTH treatment should be limited to those most severely affected and for a maximum of two years.
• Combination therapy with a bisphosphonate is not recommended because effects do not appear additive.
• Cost of daily SQ injections may be prohibitive.

Monitoring

• Monitor patients with DXA every 1–2 years.
• Do not overinterpret changes in DXA.
• Be happy when BMD is stable OR increasing.
• Some patients lose BMD on treatment.
  • Adherence
  • Drug pharmacokinetics
  • Underlying disorders that need to be addressed
• Patients whose BMD remains low are at high risk of fracture and may benefit from longer treatment.

Secondary Fracture Prevention

• Fracture is a sentinel event.
• A fracture in a person over 50 is the most powerful risk factor for a future fracture.
• Many high-risk patients have the fracture successfully treated but do NOT receive subsequent medical assessment and treatment to prevent another fracture.

Fall Prevention

• Improve lighting.
• Remove loose rugs.
• Add grab bars near bathtubs, toilets and stairways.
• Formal home safety evaluation.
• Physical therapy for core strength and balance.
• Eliminate medications that affect alertness and balance.
• Assistive device evaluation and training.

Take Home Message

• Improve the ability to assess risk factors for osteoporosis and apply evidence-based screening recommendations.
• Develop strategies to improve the treatment of patients with osteoporosis.
• Utilize tools and other information, including patient education tools and systems-based approaches, to facilitate improving the assessment and care of patients with osteoporosis.

Bone Health Building Blocks

• Focus on improving bone health to decrease fracture risk.
• Maintain good calcium intake.
• Participate in regular weight-bearing exercise such as walking or running.
• Get adequate Vitamin D.
• Stop smoking and limit alcohol intake.

Osteoporosis: A Silent Threat

• A hip fracture can lead to a nursing home stay for 1 in 5 affected individuals.
• Hip fractures can sometimes result in permanent inability to walk.
• Common fracture locations include the wrist, spine, and hip.
• Bone mass declines gradually after the age of 35, with women experiencing faster bone loss post-menopause.
• Several factors can increase the risk of osteoporosis, including:
  • Fracture after age 50
  • Family history of osteoporosis
  • Poor health
  • Smoking
  • Small body frame
  • Age over 65
  • Eating disorders
  • Early menopause before age 45
  • Inadequate calcium intake
  • Alcohol consumption exceeding two drinks multiple times per week
  • Frequent falls
  • Sedentary lifestyle
  • Underlying medical conditions such as:
    • Hyperthyroidism
    • Chronic lung disease
    • Cancer
    • Inflammatory bowel disease
    • Chronic liver or kidney disease
    • Hyperparathyroidism
    • Vitamin D deficiency
    • Cushing's disease
    • Multiple sclerosis
    • Rheumatoid arthritis
  • Medication use such as:
    • Oral glucocorticoids (steroids)
    • Cancer treatments (radiation, chemotherapy)
    • Thyroid medication
    • Antiepileptic medications
    • Gonadal hormone suppression
    • Immunosuppressive agents
    • Aluminum
    • Heparin
• Osteoporosis assessment involves:
  • Reviewing symptoms, including back pain
  • Inquiring about any previous fragility fractures
  • Physical examination, looking for signs like:
    • Height loss
    • Kyphosis (Dowager's hump)
    • Back pain upon palpation
• Osteoporosis diagnosis relies on:
  • Bone mineral density measurement using DEXA scans
  • History of fragility fractures regardless of bone mineral density
  • DEXA scans measure bone mineral density in the hip and lumbar spine
• Additional investigations to rule out other causes of bone loss include blood tests for:
  • Complete blood count for anemia
  • Bone profile for calcium & alkaline phosphate levels
  • Vitamin D levels
  • Parathyroid hormone levels (essential for bone turnover)
  • Thyroid function tests (hyperthyroidism can cause osteoporosis)
  • Cortisol level (low cortisol may indicate exogenous steroid use)
• Plain film x-rays of the lumbar spine are used to detect thoracic and lumbar vertebral fractures.
• Bone density testing is recommended for:
  • Women aged 65 and older
  • Men aged 70 and older
  • Younger postmenopausal women and men aged 50-69 with risk factors
  • Individuals who have experienced a fracture after age 50
• The Fracture Risk Assessment Tool (FRAX) helps predict the 10-year probability of a fracture.
• FRAX calculates the percentage chance of major osteoporotic and hip fractures within the next 10 years.
• Treatment becomes cost-effective when the 10-year fracture risk is over 4%.
• The World Health Organization (WHO) defines osteoporosis based on T-scores, which compare an individual's bone mineral density to the mean value of young adults:
  • Normal: T-score above -1.0
  • Low bone mass (osteopenia): T-score between -1.0 and -2.5
  • Osteoporosis: T-score below -2.5

Osteoporosis Management: Prevention and Treatment

• Treatment goals for patients with osteoporosis are to:
  • Identify individuals at risk for fractures
  • Reduce fracture incidence
  • Maintain quality of life through:
    • Physical activity
    • Independence
    • Good health
• Simple preventive steps:
  • Get daily recommended calcium and vitamin D intake.
  • Engage in physical activity every day.
    • Improve strength and balance.
    • Include walking, stair climbing, dancing, tennis, and yoga to enhance muscle strength and balance.
    • Weight-bearing exercises can modestly increase bone density and reduce fall risk.
  • Avoid smoking and excessive alcohol consumption.
  • Talk to your doctor about bone health.
  • Get a bone density test and take medication when appropriate.
• Assess calcium and vitamin D intake using food and supplement labels.
• Vitamin D deficiency is prevalent in older adults and may contribute to fracture risk due to:
  • Impaired muscle function
  • Increased risk of falls
• Maintaining 25-hydroxyvitamin D3 levels above 40 ng/mL is recommended.
• Vitamin D treatment: 50,000 IU of vitamin D weekly for 6-8 weeks, then assess for the need for chronic monthly therapy.
• Main dietary sources of vitamin D include:
  • Fortified milk (400 IU per quart)
  • Fortified cereals
  • Cold saltwater fish (salmon, halibut, herring, tuna, oysters, shrimp)
  • Some calcium and vitamin/mineral supplements
• Sunlight exposure can also help produce vitamin D in the skin.

Medications for Osteoporosis Treatment:

• FDA-approved medications for osteoporosis include:
  • Bisphosphonates:
    • Alendronate, Alendronate plus D (Fosamax, Fosamax Plus D)
    • Risedronate, Risedronate with Calcium (Actonel)
    • Ibandronate (Boniva)
  • Calcitonin (Miacalcin, Fortical, Calcimar)
  • Parathyroid Hormone (PTH [1-34], teriparatide) (Forteo)
  • Selective Estrogen Receptor Modulators (SERMs):
    • Raloxifene (Evista)
  • Estrogen/Hormone Therapy (ET/HT):
    • Premarin, Estrace, Prempro
• Bisphosphonates:
  • Antiresorptive agents that reduce osteoclastic activity and bone resorption.
  • FDA-approved for:
    • Prevention and treatment of osteoporosis in postmenopausal women
    • Treatment to increase bone mass in men with osteoporosis
    • Treatment of glucocorticoid-induced osteoporosis in men and women
    • Treatment of Paget’s disease of bone in men and women
• Clinical benefits of bisphosphonates:
  • Significant reduction in fracture risk in postmenopausal women with osteoporosis after 3 years of treatment.
• Bisphosphonate administration:
  • Take at least 30 minutes before the first food, beverage, or medication of the day with plain water only, upon arising.
  • Swallow tablet with a full glass of water (8 oz) and remain upright for at least 30 minutes (60 minutes for monthly ibandronate).
  • Supplement with calcium/vitamin D if dietary intake is inadequate.
• Adverse effects of bisphosphonates:
  • Hypocalcemia
  • Hypophosphatemia
  • Musculoskeletal pain, cramps (FDA warning)
  • Gastrointestinal:
    • Abdominal pain
    • Acid reflux
    • Dyspepsia
    • Esophageal ulcer
    • Gastritis
  • Osteonecrosis of the jaw (IV bisphosphonates)
  • Visual disturbances (rare)
• Zolendronic Acid (Reclast, Aclasta):
  • Approved for treatment of osteoporosis in postmenopausal women.
  • Single 5 mg IV infusion given over 15 minutes once yearly.
  • Supplement with calcium/vitamin D.
  • May be an alternative for individuals with gastrointestinal contraindications to oral formulations.
• Duration of bisphosphonate treatment:
  • Bisphosphonates have a long residence time in bone.
  • Long-term treatment may raise safety concerns.
  • 5-10 years of treatment appears safe for most patients.
  • Assess for risk factors:
    • Lower risk: Drug holiday after 3-5 years
    • Higher risk: Drug holiday after 10 years

Bone Mineral Density (BMD)

• Measured by dual-energy x-ray absorptiometry (DEXA) scan
• DEXA scan measures BMD at the hip and lumbar spine

Investigations for Bone Health

• Blood Tests
  • Full blood count for anemia
  • Bone profile including calcium and alkaline phosphatase
  • Vitamin D levels
  • Parathyroid hormone levels - important for bone turnover
  • Thyroid function tests - hyperthyroidism can cause osteoporosis
  • Cortisol - low cortisol might be a sign of exogenous steroids
• Plain film x-rays of lumbar spine
  • Assess for thoracic and lumbar vertebral fractures

Who Needs a Bone Density Test?

• Women aged 65 and older
• Men aged 70 and older
• Younger postmenopausal women and men aged 50-69 with clinical risk factors
• Adults who have had a fracture after age 50

Fracture Prediction Tools

• Fracture Risk Assessment Tool (FRAX)
  • Calculates the 10-year probability of a major osteoporotic fracture and the 10-year probability of a hip fracture
  • Treatment becomes cost-effective when the 10-year fracture risk is over 4%

WHO Criteria for Postmenopausal Osteoporosis

• T-score compares an individual's BMD to the mean value for young adults (expressed as standard deviations)
• Normal: T-score above -1.0
• Low bone mass (osteopenia): T-score between -1.0 and -2.5
• Osteoporosis: T-score below -2.5

Patient Care Goals for Osteoporosis

• Identify patients at risk of fractures
• Reduce incidence of fractures
• Maintain quality of life
  • Activity levels
  • Independence
  • Health

Simple Prevention Steps for Osteoporosis

• Step 1: Get daily recommended amount of calcium and vitamin D
• Step 2: Be physically active every day
  • Improve strength and balance
  • Regular weight-bearing exercise
  • Includes walking, jogging, stair climbing, dancing, tennis, yoga
  • Can increase bone density modestly and reduce fall risk
• Step 3: Avoid smoking and excessive alcohol
• Step 4: Talk to your doctor about bone health
• Step 5: Have a bone density test and take medication when appropriate
  • Simple and painless procedure

Nutrition for Bone Health

• Calcium
  • Recommendation for those over 50 years old: 1,200 mg
• Vitamin D
  • Recommended intake: 800-1000 IU per day, supplemented if necessary
  • Main dietary sources: fortified milk, some fortified cereals, cold saltwater fish (salmon, halibut, herring, tuna, oysters, and shrimp), and some calcium and vitamin/mineral supplements
  • Vitamin D is manufactured in the skin by direct sunlight exposure
    • 10-15 minutes of exposure 2-3 times per week can be sufficient (depending on skin sensitivity)
    • Clothing, sunscreen, window glass, and pollution reduce the amount of vitamin D produced
  • Important for calcium absorption - choose a supplement with vitamin D unless obtaining it from other sources
  • Avoid going over a daily combined total of 2,000 IU or 50 mcg from food and supplements
• Calcium Supplements
  • Calcium carbonate: needs stomach acid to dissolve and absorb
  • Calcium Citrate: doesn't require stomach acid for absorption
    • May be taken anytime (consult healthcare provider)
    • May cost more
• Vitamin D and Fall Risk
  • Contributes to reduction in fracture risk
    • Improved muscle function
    • Reduced risk of falls
  • Meta-analyses of 5 clinical trials (over 60 years old) showed significant reduction in falling risk in those taking vitamin D plus calcium versus placebo
  • Vitamin D deficiency prevalent in older adults
    • Maintain 25-hydroxyvitamin D3 at least greater than 40 ng/mL
    • Treatment: 50,000 IU vitamin D weekly for 6-8 weeks, then assess need for chronic monthly therapy

Medications for Osteoporosis

• FDA Approved Medications
  • Bisphosphonates
    • Alendronate (Fosamax, Fosamax Plus D)
    • Risedronate (Actonel)
    • Ibandoronate (Boniva)
  • Calcitonin (Miacalcin, Fortical, Calcimar)
  • Parathyroid Hormone (PTH) [PTH (1-34), teriparatide]: Forteo
  • Selective Estrogen Receptor Modulators (SERMs)
    • Raloxifene (Evista)
  • Estrogen/Hormone Therapy (ET/HT)
    • Premarin, Estrace, Prempro
• Choice of treatment is made on an individual basis
• Bisphosphonates
  • Antiresorptive agents
  • FDA approved for:
    • Prevention and treatment of osteoporosis in postmenopausal women
    • Treatment to increase bone mass in men with osteoporosis
    • Treatment of glucocorticoid-induced osteoporosis in men and women
    • Treatment of Paget's disease of bone in men and women
  • Reduce osteoclastic activity and bone resorption by binding bone mineral, being absorbed by mature osteoclasts, inducing osteoclast apoptosis, and suppressing resorption
• Denosumab
  • Human monoclonal antibody to RANKL
  • Decreases osteoclast number and function
  • Reduces risk of spine, hip, and non-vertebral fractures
  • Subcutaneous dose every 6 months
  • No dose adjustment for decreased kidney function
  • Effect is reversible within 6-12 months of stopping
  • Mode of Action: fully human monoclonal antibody that binds the cytokine RANKL (receptor activator of NFkB ligand)
  • RANKL inhibition blocks osteoclast maturation, function, and survival, thus reducing bone resorption
• Teriparatide
  • Recombinant human PTH (1-34)
  • Mechanism of action different from other agents (anabolic)
  • Daily subcutaneous injection
  • Indicated for patients at high risk for fracture:
    • Postmenopausal women with osteoporosis
    • Men with primary or hypogonadal osteoporosis
    • Men and women with osteoporosis associated with sustained systemic glucocorticoid therapy
  • Treatment limited to 2 years, followed by an antiresorptive agent
• PTH (1-34) Adverse Effects:
  • Most common: dizziness, rash, nausea, headache, leg cramps, arthralgia, rhinitis, transient hypercalcemia
  • Symptoms of hypercalcemia: nausea, vomiting, constipation, low energy, or muscle weakness
  • Most adverse effects in clinical trials were mild and generally did not lead to discontinuation of the drug
  • Osteosarcoma risk in animals (lead to black box warning by FDA)
  • Treatment should be limited to those most severely affected and for a maximum of two years
  • Combination therapy with a bisphosphonate not recommended as effects do not appear additive
  • Cost, daily SQ injections may be prohibitive for some patients

Monitoring Bone Health

• Monitor with DXA every 1-2 years
  • Do not "over-interpret" change
  • Be happy when BMD is stable OR increasing
• Why do some patients lose BMD on treatment?

Test your knowledge on bone health and fracture statistics. This quiz covers common bone breaks, risk factors, and the impact of aging on bone density. Learn about modifiable and non-modifiable risk factors that can affect your bone health.