Download Recent Advances in the Diagnosis and Treatment of Osteoporosis

ANA Testing
Carrie Marshall
1/18/08
Treatment of
Osteoporosis
Azami Ahad. MD
Rheumatologist
Assistant professor of Ardabil University of Medical
Sciences
1392/7/28
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Preventing Osteoporosis
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Pay attention to your modifiable risk factors –
mainly what you put in your mouth!
Anyone not taking in adequate dietary Calcium
and Vitamin D should get supplements
– Dairy
– Fortified juice or soy milk
Adequate calcium intake
Lowers risk of kidney stone
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Calcium Recommended Intake
Age
0-6 months
210 mg
7-12 months
270 mg
1-3 years
500 mg
4-8 years
800 mg
9-13 years
1,300 mg
14-18 years
1,200 -1500 mg
19-50 years
1,000 mg
50+ years
1,200 -1500 mg
http://ods.od.nih.gov/factsheets/calcium.asp
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Calcium Absorption
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Absorption 6-20%
Food improves absorption by 20-25%
Heaney, RP et al. Am J Clin Nutr. 1989; 49(2): 372-6
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Low stomach acid reduces absorption
(Long term use of PPI correlated to low BMD)
Only a small amount can be absorbed at
one time, so more frequent intake is
better
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Calcium supplements
Preparation
% Elemental
Calcium
Solubility
Calcium
carbonate
40%
Insoluble
(take with food)
Calcium citrate
24%
Soluble
Calcium lactate
13%
Soluble
Calcium
gluconate
9%
Soluble
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Vitamin D & Calcium Supplements
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Vitamin D
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Positive Effects of Vit D
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Increases Calcium absorption
Strengthens Bones
Reduces Falls
- Increases muscle function, decreases muscle
pain, and reduces body sway.
Bischoff-Ferrari 2004 JAMA 291;16:1999-2006
Glerup H, et al. 2000 J Int Med 247:260-8
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Reduces Fractures
– As effective as Alendronate in cardiac transplant patients
– Alendronate 10 mg vs. Calcitriol 0.5 mcg daily
Shane E, et al. N Engl J Med. Feb 19 2004;350(8):767-776
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Vitamin D
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Requirements increase with age
– 600 IU <70 yo
– 800 IU >70 yo
IOM report 11/30/2010
http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calciumand-Vitamin-D.aspx

In Osteoporosis give 1,000 IU daily
http://www.nof.org/prevention/vitaminD.htm
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Exercise
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Back strengthening exercise lead to
fewer vertebral fractures over 10 years
– 1.6% in exercising group
– 4.3% in control group
Sinaki M, et al. Bone 2002;30:836-841

Increased spine BMD over 9 months
3.5% vs. 1.5%
Villareal DT, et al. JAGS 2003;51(7):985-90
Kemmler W, et al. Arch Int Med 2004;164(10):1084-91
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Summary Break
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Osteoporosis is a growing epidemic
Prevention through lifestyle
modification is important
Calcium and vitamin D are key
Exercise
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Causes of Secondary
Osteoporosis
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Tobacco
Alcohol
Vitamin deficiencies
– Vit D, B12, Vit K
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Medications
– Anticonvulsants
– Steroids >5mg/d for
>6 months

Diseases
– Rheumatoid or other
inflammatory arthritis
– Multiple myeloma,
lymphoma
– Hyperthyroidism
– Hyperparathyroidism
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Treatments- Medications
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Anabolic Agents
–
–
–
–
–
Parathyroid hormone
Sodium flouride
Strontium ranelate
Growth hormone
Insulin-like growth
factor-1
– Statins
– RANK-L, Denosumab
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Antiresorptives
– Estrogens
– Selective estrogen
receptor modulators
– Bisphosphonates
– Calcitonin
Others: Calcium, Vitamin D
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Bisphosphonates
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Binds to bone
Inhibits osteoclast activity
Supports osteoblast bone formation
First line treatment for osteoporosis
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Bisphophonates Block
Bone Resorption
Inhibits osteoclasts.
Binds to bone
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Bisphosphonates
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Alendronate (Fosamax) generic
Risedronate (Actonel) better GI profile
Ibandronate (Boniva) no hip protection
Zoledronic Acid (Reclast) once a year
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Unusual Complications
of Bisphosphonates
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Osteonecrosis of jaw– Rare 1/100,000 patient years
– 94% in cancer patients receiving zoledronic acid or
pamidronate
Woo S-B, et al. 2006 Ann Int Med 144(10):753-61
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Unusual Fx in some patients with nl BMD
Neviaser AS, et al. 2008 Journal of Orthopaedic Trauma 22(5):
346-350
Lenart et al. 2008 NJEM 358 (12): 1304
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Estrogen
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ERT increases BMD and reduced bone markers
more than SERM
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Prestwood, KM et al. J Clin Enodocrinol Metab. 2000; 85(6): 2197-2202
WHI raised concerns about CV risks
E2 still approved for hot flashes
Low-dose ERT at menopause will delay
bone thinning (but not recommended as firstline therapy)
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Selective Estrogen Receptor
Blocker (SERM)
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Raloxifene (Evista) preferentially binds to
the alpha estrogen receptor
– fewer estrogen+ breast cancers
– fewer vertebral fractures
– more venous thromboembolism
– more fatal stroke
– No difference in coronary deaths
No difference in: hip fractures
RUTH trial: Barrett-Connor, et al. 2006 NEJM 355(2);125-37
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Calcitonin
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Calcitonin is effective for osteoporosis
fracture pain. Effect takes about 2
weeks.
Silverman, SL. Osteoporos Int. Nov 2002;13(11):858-867.
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No significant effect in the hip
Antalgic
Cost:168000 RL
– Miacalcin® $112
– Fortical® $54
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Parathyroid Hormone
(PTH)
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Parathyroid Hormone
(PTH)
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Forteo (Teriparatide) -20$/d
Daily 20 mcg/d or 0.08ml SQ injection
PTH draws Ca out of cortical bone
– Hip 50% cortical bone
– Spine 10% cortical bone
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Intermittent antiresorptive effect
Preferential anabolic activity
Weak evidence for hip Fx
ACP Practice Guideline. Ann Int Med 2008;149:404-415
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Parathyroid Hormone
(PTH)
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Forteo (Teriparatide)
Approved for use of <2 years
Neer, RM et al. NEJM 2001;344(19):1434-41
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Do not use in combination with
bisphosphoonate- Black et. al. N Engl J Med
2003;349(13):1207-15
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Increases BMD 6%
Not very effective for preventing fractures
Risk of osteosarcoma in animal trials
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Strontium ranelate
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2 g bid
Antiresorptive & anabolic actions
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Denosumab - new kid on the
block (Brand name Prolia)
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Denosumab (formerly AMG-162)
– Monoclonal antibody
– Inhibits bone resorption by blocking
KB-ligand (RANKL)
Bekker et al. 2004 J Bone Miner Res 19:1059-66
– Injected sq twice yearly
– Expensive $1650 per year, 10.000.000RL
– ? Effect on immune system
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Summary of Medications
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Bisphosphonates- First line therapy
– Boniva no hip benefit
– Must have GFR > 30
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Calcitonin only for spine, good for pain
Estrogen good for osteoporosis
SERM need long term data, only spine
PTH <2 yrs, not in combination
Denosumab monoclonal antibody, 2x/yr
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Balloon Kyphoplasty
Stabilizes the Fracture and Corrects Spinal
Deformity caused by one or more VCFs
Indicated for vertebral compression fracture
if pain not controlled with meds
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Conclusion
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Osteoporosis is a growing epidemic
Save yourselves! Preach prevention!
Test all women over 65, and others at
risk for osteoporosis (DEXA)
Treat all elderly, and patients at risk,
with Calcium and Vitamin D
Don’t be afraid of bisphosphonates
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