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* For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. in the clinic Osteoporosis © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Who should be screened for osteoporosis? Those with clinical risk factors for osteoporosis or fracture Advanced age; female sex Poor health/frailty; falls Estrogen deficiency Poor eyesight (despite correction) Hx fracture as adult Dementia; cognitive impairment Hx fragility fracture in 1° relative Impaired neuromuscular fxn Current cigarette smoking Alcoholism Low body weight (<127 lbs) White race or Asian race Low calcium intake Residence in nursing home Hx glucocorticoids >3 mos Long-term heparin therapy Anticonvulsant therapy Aromatase-inhibitor therapy Androgen-deprivation therapy Low physical activity © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Indications for Bone Mineral Density Testing All women ≥65 and men ≥70 Postmenopausal women & men aged 50-69 based on clinical risk profile Women in menopausal transition w/ increased fracture risk Adults ≥50 who have a fracture Adults with a condition or taking a medication associated with low bone mass or bone loss If pharmacologic Rx for osteoporosis considered To monitor effect of pharmacologic Rx for osteoporosis Postmenopausal women discontinuing estrogen © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. How should screening be done, and how are the results interpreted? Measure BMD with DXA To screen for and diagnose osteoporosis To assess fracture risk To monitor changes in BMD over time Use fracture risk assessment tool (FRAX) Estimates 10-yr probability of hip fracture & major osteoporotic fracture in untreated men & women aged 40-90 Greater clinical utility than relative risk Uses limited number easily obtainable clinical risk factors Can be used with or without BMD © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What lifestyle measures are recommended for prevention? Regular moderate physical activity (especially resistance) Good nutrition, adequate calcium, vitamin D Smoking cessation Reduced alcohol consumption Avoid or minimize medications with harmful skeletal effects Prevent falls in frail, elderly © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What is the role of calcium and vitamin D in the prevention of osteoporosis? Essential for maintenance of bone mass in adulthood Calcium RDI: ≥1200mg with diet + supplements if ≥50 yrs Tolerable upper limit intake 2500mg/d Calcium carbonate: take with meals to optimize absorption Calcium citrate: Take with or without food Monitor with 24-hr urinary calcium measurement Vitamin D RDI for vitamin D3: 800-1000 IU/d if ≥50yrs Minimum blood level serum 25-hydroxyvitamin D: ≈75 nmol/L (30 ng/mL) Suggest fortified food products plus modest sun exposure © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. When should pharmacologic treatment be considered for prevention? If bone loss is rapid or if risk for osteoporosis is high Such as during early postmenopausal years May prevent or reverse bone loss May maintain trabecular microarchitecture May reduce fracture risk Base decision on expected benefit, potential risks © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. CLINICAL BOTTOM LINE: Screening and prevention… Fundamental components of prevention Healthy lifestyle and good nutrition Avoidance of medications known to be harmful to bone Pharmacologic Rx to reduce fracture risk is indicated when: Patients with osteopenia are at high fracture risk Patients are anticipated to have rapid bone loss that could soon result in osteoporosis and high fracture risk © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. How should osteoporosis be diagnosed? Postmenopausal women & men ≥50—WHO diagnostic criteria • Low bone mass (osteopenia): T-score ≤–1.0 and ≥–2.5 • Osteoporosis: T-score ≤–2.5 • Severe osteoporosis: T-score ≤–2.5 + Hx fragility fracture Premenopausal women & men <50—don’t use WHO criteria • Use Z-scores, not T-scores • Z-score ≤–2.0: below expected range for age Also: diagnose if fragility (low-trauma) fracture occurs Regardless BMD © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What should the initial evaluation of a patient with osteoporosis include? History Diet Lifestyle Medications Family history Falls, fractures Focused review of systems © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Physical: Potentially helpful findings for osteoporosis Loss of height ? vertebral fracture Low body weight risk for fracture Weight loss ? hyperthyroidism or malnutrition Fast heart rate ? hyperthyroidism or anemia Fast respiratory rate ? asthma Poor gait ? muscle strength, balance Paralysis or immobility bone loss, increased fall risk Joint laxity ? osteogenesis imperfecta, Ehlers-Danlos, Marfan Inflammatory arthritis glucocorticoid use OA or lower limb injury reduced load-bearing, bone loss © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Physical: Potentially helpful findings for osteoporosis Blue sclera, poor tooth development, hearing loss, fracture deformities ? osteogenesis imperfecta Poor dental hygiene ? jaw osteonecrosis w/ bisphosphonates Thyromegaly, thyroid nodules, proptosis ? hyperthyroidism Urticaria pigmentosa ? sytemic mastocytosis Kyphosis, short distance ribs to iliac crest ? vertebral fractures Abdominal tenderness ? inflammatory bowel disease Stretch marks, buffalo hump, bruising ? glucocorticoid excess Venous thrombosis ? may contraindicate estrogen or raloxifene Small testicles ? hypogonadism © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Lab studies Essential tests Complete blood count Serum calcium Serum phosphorus Serum creatinine Serum TSH Serum liver enzymes Serum alkaline phosphatase Serum total/free testosterone (men) 24-hr urinary calcium Optional tests* Serum 25-hydroxyvitamin D Serum PTH Serum/urine protein electrophoresis, κ/λ light chains Serum celiac antibodies 24-hr urinary free cortisol or overnight dexamethasone suppression test Serum tryptase *based on clinical circumstance © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Imaging studies Appropriate for carefully selected patients: Spine imaging: height loss or kyphosis (? unrecognized vertebral fractures) Nuclear bone scan or x-ray: unexplained increase in alkaline phosphatase Barium swallow: swallowing difficulties (? stricture) © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. When should consultation be considered? Osteoporosis & metabolic bone disease specialist Non-traumatic fracture with normal BMD Recurrent fracture or bone loss despite therapy Unexpectedly severe or unusual features Complex management / comorbidites: renal failure, hyperparathyroidism, malabsorption Suspect 2° causes Discordant clinical and lab findings Gastroenterologist Small bowel biopsy if celiac disease suspected Oncologist Labs suggest multiple myeloma, other forms of cancer © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. CLINICAL BOTTOM LINE: Diagnosis… History and physical Lab tests CBC + serum calcium, phosphorus, creatinine, aspartate & alanine transaminase, alkaline phosphatase, and TSH and 24h urinary calcium levels (plus testosterone for men) Additional lab or imaging tests Depending on clinical circumstances Refer to osteoporosis specialist When complex or unusual diagnostic issues arise © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What are the goals of treatment? Improve bone strength With regular physical activity, calcium & vitamin D, pharmacologic agents Surrogate markers of bone strength: BMD / markers of bone Measure at baseline and 1 to 2 yrs after starting therapy Prevent falls With quadriceps strengthening, balance training Assess in office (observe; ? can patient walk in straight line, balance on 1 foot) Reevaluate periodically risk may increase with age © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What lifestyle measures are recommended? Smoking cessation Reduced alcohol use Weight-bearing and muscle-strengthening exercise Adequate calcium and vitamin D intake Home safety evaluation (to reduce risk from falls) Minimize mind-altering medications Sedatives, hypnotics, narcotic analgesics © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What pharmacologic interventions are effective for treatment? IV bisphosphonates (zoledronate, ibandronate) Oral bisphosphonates (alendronate, risedronate, ibandronate) Increase bone mass; decrease fractures IV SEs: flu-like symptoms after first dose Oral SEs: esophageal irritation; discontinue if musculoskeletal pain occurs; jaw osteonecrosis & atypical femur fractures Raloxifene Increases BMD; decreases fractures; reduces risk for invasive breast cancer SEs: thromboembolic risk; vasomotor symptoms; fatal stroke © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. Teriparatide Increases BMD; decreases fractures SEs: Dizziness, nausea Contraindicated with osteosarcoma, Paget disease, unexplained Alk Phos elevation, open epiphyses, Hx skeletal radiation Denosumab Increases bone mass; decreases fractures SEs: cellulitis, eczema, and flatulence Calcitonin Slightly increases BMD; decreases vertebral fractures; may decrease pain from acute or subacute vertebral fractures SEs: Rhinitis, irritation of nasal mucosa Estrogen (with or without medroxyprogesterone) Improves BMD and reduces the risk for fracture Not approved for osteoporosis Rx — risks outweigh benefits, even in women at high risk for fracture © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. How should they be chosen? Oral bisphosphonates alendronate, risedronate, ibandronate 1st-line therapy Injectable denosumab, ibandronate, zoledronate If oral bisphosphonates ineffective or contraindicated Raloxifene Early postmenopausal women with high breast cancer risk + no thromboembolic disease + low risk stroke, hip fracture Nasal salmon calcitonin For women ≥5y postmenopausal unable to take other agents Teriparatide If multiple risk factors for osteoporotic fracture + failure/ intolerance other therapy © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. How should patients be monitored? Measure BMD to assess changes Measure bone turnover marker to monitor therapy Untreated patients Significant bone loss may influence decision to start treatment Treated patients Significant decrease in BMD usually = nonresponse or suboptimum response to therapy Reevaluate treatment + evaluate secondary causes Consider contributing factors: ? medication compliance; ? sufficient calcium and vitamin D intake © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. When should consultation be considered for management? When expertise needed for associated disorders Hyperparathyroidism, hyperthyroidism Vitamin D deficiency, hypercalciuria, osteomalacia Cushing syndrome, glucocorticoid-induced osteoporosis Hypopituitarism or hypogonadism (males) Elevated alkaline phosphatase levels or bone turnover When routine therapy is not possible or effective Significant bone loss after ≥1y Rx or combination Rx considered Standard therapies not tolerated or patients have fractures Vertebroplasty or kyphoplasty needed © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. CLINICAL BOTTOM LINE: Treatment… Those at high risk for fracture most likely to benefit from Rx Individualize drug selection according to… Clinical circumstances Magnitude of fracture risk Comorbid conditions Patient preference Encourage a healthy lifestyle, adequate calcium & vitamin D Monitor Rx effect using BMD testing or bone turnover markers © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. What should patients be taught? The association between low BMD and fracture risk Importance of adequate calcium & vitamin D intake Weight-bearing exercise to maintain bone mass To avoid: smoking, excess alcohol consumption Benefits and potential risks of pharmacologic agents for osteoporosis © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. How can falls and bone fractures be prevented? Comprehensive fall-reduction program Home safety evaluation To identify potential physical or structural problems at home (slippery floors, impeded pathways) Exercises that improve strength and balance Reduction in use of drugs that impair cognitive abilities Patient education One-on-one instruction and community resources Consultation with nutritionist, PT, & exercise physiologist Regular contact with health care professional improves therapy adherence (BMD increases > with no monitoring) © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1. CLINICAL BOTTOM LINE: Treatment… Keep patient well-informed Can lead to improved clinical outcomes Equip patient to make appropriate decisions on lifestyle and nutrition to optimize skeletal health Inform patient on benefits and risks of pharmacologic therapy Monitor patient regularly © Copyright Annals of Internal Medicine, 2011 Ann Int Med. 155 (1): ITC1-1.