Osteoporosis Yr. 1 PDF

Osteoporosis Dr. Maged Mostafa, MD Consultant Orthopedic Surgeon KHUH  What is osteoporosis? Why we should care? Whom to test and how? Whom to treat and how?  Osteoporosis Characterized by low bone mass and deterioration of bone structure Not a natural part o...

Osteoporosis Dr. Maged Mostafa, MD Consultant Orthopedic Surgeon KHUH  What is osteoporosis? Why we should care? Whom to test and how? Whom to treat and how?  Osteoporosis Characterized by low bone mass and deterioration of bone structure Not a natural part of aging Increased risk for women, post- menopausal, over age 65 All races, sexes, and ages are susceptible Preventable and treatable! Osteoporosis is a disorder of the bones in which the bones become brittle, weak, and easily broken. A decrease in the mineralization and strength of the bones over time causes osteoporosis  Pathophysiology – bone remodelling.Bone is constantly being remodelled It is a coupled process of new bone formation by the osteoblasts.and bone resorption by the osteoclasts.This process is normally equal, to keep the skeletal integrity After menopause, due to lack of oestrogen, osteoblast under fill.areas of resorption resulting in thinning of the bone Electron microscopy of the osteoporotic bone ”The “silent disease - “Silent disease” until complicated by fractures Bone loss occurs without symptoms – First sign may be a fracture due to weakened bones – A sudden strain or bump can break a bone  osteoporosis is painless unless a fracture occurs A fracture following a fall or minor trauma suggests that the bones may be fragile Significant height loss and curvature of the spine may indicate compression fractures have occurred in the spine although other conditions including spinal arthritis can also cause these symptoms.  Why Are Healthy Bones ?Important Strong bones support us and allow us to move Bones are a storehouse for vital minerals Strong bones protect our heart, lungs, brain and other organs  Why we Should Care?  Osteoporosis Is a Serious Public Health Problem Affects 10 million Americans (80% women) 2 million fractures yearly Direct cost $17 billion Distribution of Fractures Hip fractures account for 300,000 hospitalizations.annually People who break a hip might not recover for months or even years. Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth  in 5 people with a 1 hip fracture end up in a nursing home.within a year Some people never walk again. Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth The most common breaks in weak bones are in the wrist, spine and.hip Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth  After mid-30’s, we begin to slowly lose bone mass. Women lose bone mass faster after menopause. Men lose bone mass too.  Risk factors If you have any of these “red flags,” you could be at high risk for weak bones. Talk to your health.care professional Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth Fracture after age 50  Family history osteoporosis  Poor health  smoking  Small body built Age > 65 Eating disorder Early menopause before age 45  never gotten enough calcium  Drinking more than two drinks of alcohol.several times a week  frequent fall  no physical activity ‘sedentary life’ Suffering of any of these medical conditions:  Hyperthyroidism  Chronic lung disease  Cancer  Inflammatory bowel disease  Chronic liver or kidney disease  Hyperparathyroidism  Vitamin D deficiency  Cushing's disease  Multiple sclerosis  Rheumatoid arthritis Taking any of these medications:  Oral glucocorticoids (steroids)  Cancer treatments (radiation, chemotherapy)  Thyroid medicine  Antiepileptic medications  Gonadal hormone suppression  Immunosuppressive agent Aluminum Heparin Modifiable risk factors NON-MODIFIABLE RISK FACTORS Diagnosis  Assessment (symptoms / history).Ask about symptoms of back pain Any history of fragility fractures (A fracture resulting from a fall from standing height or.less) Assessment (signs).Loss of height.Kyphosis (Dowager's hump).Back pain on palpation  Diagnosis / investigations Osteoporosis is diagnosed by 2 main methods: – By bone mineral density measurement. – By history of fragility fracture regardless of bone mineral density. Bone Mineral Density is measured by dual-energy x-ray absorptiometry (DEXA) scan. – DEXA scan measures the bone mineral density at hip and in the lumbar spine.  INVESTIGATIONS CONTINUED – LOOKING FOR OTHER CAUSES Bloods: – Full blood count (Anaemia). – Bone profile (Calcium and alkaline phosphate). – Vitamin D levels. – Other causes: 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: – Assessment for thoracic and lumbar vertebral fractures.  Who Should Have a Bone Density Test )BMD( Women age 65 and older and men age 70 and older Younger postmenopausal women and men ages 50–69 with clinical risk factors Adults who have a fracture after age 50 1. Sweet MG, et al. Am Fam Physician. 2009;79(3):193-200. 2. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. www.nof.org. Accessed February 2013. Dual-energy X-ray absorptiometry  FRACTURE PREDICTION TOOLS Treatment initiation can be guided by the 10-year probability of a fracture. This is calculated using the Fracture Risk Assessment Tool (FRAX). – Gives the % chance of a major osteoporotic fracture and the % chance of a hip fracture within the next 10 years. Treatment becomes cost-effective when 10-year fracture risk is over ~4%.  WHO Criteria for Postmenopausal Osteoporosis The T-score compares an individual’s BMD with the mean value for young adults and expresses the difference as a standard deviation score Category T-score Normal and above 1.0- Low bone mass (osteopenia) to -2.5 1.0- Osteoporosis and below 2.5- http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed August 2014. WHO Study Group. World Health Organ Tech Rep Ser. 1994;843:1-129. Shortening and external rotation of the fractured hip. WRIST FRACTURES VERTEBRAL FRACTURES  Patient Care Goals Identify patients at risk of fractures Reduce incidence of fractures Maintain quality of life – Activity – Independence – Health Simple Prevention Steps Five simple steps to bone health and osteoporosis prevention …  Step 1 Get your daily recommended amount of calcium and vitamin D  Step 2 Be physically active everyday Improve strength and balance Even simple activities such as walking, stair climbing and dancing can strengthen bones.  Regular Weight-Bearing Exercise Defined as those in which bones and muscles work against gravity as feet and legs bear the body’s weight Include walking, jogging, stair climbing, dancing, tennis, yoga Improve muscle strength, balance May increase bone density modestly, reduce fall risk.  Step 3 Avoid smoking and.excessive alcohol 12 oz. 5 oz. 1.5 oz. Step 4 Talk to your doctor.about bone health  Step 5 Have a bone density test and take medication.when appropriate Testing is a simple, painless procedure.  Food and supplement labels Assess calcium and vitamin D intake by using food and supplement labels.  Vitamin D and Fall Risk In addition to its effect on BMD, may contribute to reduction in fracture risk – Improved muscle function – Reduction in risk for falls Meta-analyses of 5 clinical trials (> 60 YOA) showed significant reduction in risk for falling in those taking vitamin D plus calcium versus those taking placebo Vitamin D deficiency prevalent in older adult population – Maintain 25-hydroxyvitamin D3 at least > 40 ng/mL – Treatment: 50,000 IU vitD weekly x 6-8 weeks, then assess need for chronic monthly therapy ?What about Vitamin D from food Main dietary sources of vitamin D are: Fortified milk (400 IU per quart) Some fortified cereals Cold saltwater fish (Example: salmon, halibut, herring, tuna, oysters and shrimp) Some calcium and vitamin/mineral supplements  Vitamin D from sunlight exposure Vitamin D is manufactured in our skin following direct exposure to sun. Amount varies with time of day, season, latitude and skin pigmentation. 10–15 minutes exposure of hands, arms and face 2–3 times/week may be sufficient (depending on skin sensitivity). Clothing, sunscreen, window glass and pollution reduce amount produced. Source: National Osteoporosis Foundation Web site; retrieved July 2005 at http://www.nof.org  Vitamin D intake should be 800-1000 IU per day, supplemented if necessary (age ≥50) Calcium Requirements for 50+ Years Over 50 years mg 1,200 Goal Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth Calcium supplement considerations  Calcium carbonate vs. citrate Calcium carbonate Calcium citrate Needs acid to Doesn’t require dissolve and for stomach acid for absorption absorption Less stomach acid May be taken as we age anytime—check with your healthcare Often taken at provider meals when more stomach acid May cost more  Vitamin D necessary for calcium absorption Choose a supplement with vitamin D unless obtaining vitamin D from other sources. Follow age group recommendation. Avoid going over a daily combined total of 2,000 IU or 50 mcg from food and supplements. Vitamin D is like a key that unlocks the door It’s not necessary to consume and lets calcium calcium and vitamin D at the into the body. same time to get the benefit of enhanced calcium absorption. Medications  Choice of treatment should be made on an individual basis after discussion between the responsible clinician and the patient/carer.  FDA-Approved Drugs for Osteoporosis Bisphosphonates Calcitonin (Miacalcin , ® – Alendronate, Alendronate Fortical , Calcimar ) ® ® plus D (Fosamax®, Fosamax Plus D®) – Risedronate, Risedronate Parathyroid Hormone with Calcium (Actonel®) [PTH (1-34), teriparatide] – Ibandronate (Boniva®) – Forteo® Selective Estrogen Estrogen/Hormone Receptor Modulators Therapy (ET/HT) (SERMs) – Premarin®, Estrace®, – Raloxifene (Evista®) Prempro®  Bisphosphonates – Antiresorptive Agents 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 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  Clinical Benefit of Bisphosphonates Relative risk reduction for fractures Postmenopausal women with osteoporosis 3 years bisphosphonate treatment Vertebrae Hip hosla S, et al. J Clin Endocrinol Metab. 2012;97(7):2272-2282.  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 for the day Tablet should be swallowed with a full glass of water (8 oz) and patients should remain upright, walking, standing, or sitting for at least 30 minutes (60 minutes for monthly ibandronate) Should supplement with calcium/vitamin D if dietary intake inadequate  Bisphosphonates – Adverse Effects Hypocalcemia (18%) Gastrointestinal – Abdominal pain Hypophosphatemia – Acid reflux (10%) – Dypepsia – Esophageal ulcer Musculoskeletal pain, – Gastritis cramps – FDA warning Osteonecrosis of the jaw (IV bisphosphonates) Visual disturbances (rare)  Zolendronic Acid (Reclast®) Aclasta Approved for treatment of osteoporosis in postmenopausal women in August 2007 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  How Long Should ?Bisphosphonate Treatment Last Bisphosphonates have a long residence time in bone – Does long-term treatment create safety concerns that limit the duration of treatment? Given the long retention in bone, with release and possibly recycling of drug, does cumulative exposure lead to a reservoir in bone, so that after therapy is stopped, sufficient drug will be released to exert a continuing benefit? Porras AG, et al. Clin Pharmacokinet. 1999;36(5):315-328. Watts NB, et al. J Clin Endocrinol Metab. 2010;95(4):1555-1565.  How Long to Treat with ?Bisphosphonates 5–10 years appears to be safe for most patients Assess for risk: Lower Higher Risk Risk Drug Holiday Drug Holiday After 3-5 years After 10 years NB and Diab D. J Clin Endocrinol Metab. 2010;95(4):1555-1565.  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 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 different 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, follow with antiresorptive agent  PTH (1-34) – Adverse Effects Most common – Dizziness, rash, nausea, headache, leg cramps, arthralgia, rhinitis, transient hypercalcemia S/s of hypercalcemia: nausea, vomiting, constipation, low energy, or muscle weakness Most adverse effects in the clinical trials were mild and generally did not lead to the discontinuation of the drug Osteosarcoma risk in animals – Lead to black box warning by FDA  PTH (1-34) 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 not recommended as effects do not appear additive Cost, daily SQ injection may be prohibitive for some patients  Monitoring 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? – Adherence – Drug pharmacokinetics – Underlying disorders that need to be addressed Patients on treatment whose BMD remains low are at high risk of fracture and may benefit from longer treatment  Secondary Fracture Prevention A 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 the next 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 can affect alertness and balance Assistive device evaluation and training Sweet MG, et al. Am Fam Physician. 2009;79(3):193-200. Take home message  Take home message Improve the ability to assess risk factors for osteoporosis and apply evidence-based screening recommendations to these at-risk patients within one’s practice Develop strategies to improve the treatment of patients with osteoporosis Utilize the tools and other information in this initiative, including patient education tools and systems-based approaches, to facilitate improving the assessment and care being provided to patients with osteoporosis Bone Health Building Blocks