Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Aging Q3 ACOVE #9 Osteoporosis Jay Brzezinski, MD Medical University of South Carolina 2011 Osteoporosis ACOVE Work Group Dr. Jay Brzezinski, Chair Dr. Bill Moran Dr. Pam Pride Dr. Leonard Lichtenstein Dr. Amy Thompson Dr. Brad Keith Dr. Lara Hourani Tamela Sill, RN Burden 25 million Americans have osteoporosis ½ of all post-menopausal women will have an OP related fracture Up to 20% of hip fracture patients die in one year Usually asymptomatic until fracture occurs BONE Trabecular bone Also called Cancellous bone Vertebral body bone Bone near joint lines Has bone marrow Light weight Has spiculated pattern BONE Cortical bone Compact bone Long bones Dense Stiff hard heavy BONE Trabecular bone, 25% replaced per year Cortical bone, 3% replaced per year Osteoporosis occurs in both It makes sense that trabecullar bone fractures easier? RISK FACTORS Age Gender Prior fracture Family history Exercise Smoking RA ETOH Drugs….steroids NON-RISK FACTORS?? Obesity? Athletic childhood? Osteoarthritis? Diet?? Family history? SCREENING( i.e. asymptomatic) All women at age 65 Women under 65 with FRAX score >9.3% 9.3% is risk of asymptomatic woman age 65 A previous fracture? We are not screening now! How to Screen DEXA is best Heel quantitative ultrasound?? DEXA Dual energy x-ray absortiometry One x-ray beam is absorbed by soft tissue One x-ray is absorbed by everything Subtract the two and get bone Problem with ordering a screening BMD on PP??? – Diagnosis: “Pre Menopausal” T-SCORE -1.0 or better is normal Lower than -2.5 is osteoporosis -1.0 to -2.4 is osteopenia What if I have had a compression fracture? What if I had a hip replaced? FRAX www.sheffield.ac.uk/FRAX/tool.jsp Treatment Calcium Vitamin D Should I measure What does it mean Will replacement help Exercise?? Bisphosphonates alendronate (Fosamax®) 70 mg qweek Ibandronate (Boniva®) 150 mg qmonth risedronate (Actonel®) 5 qday,35 qweek, 150 qmonth Zoledronic acid (Reclast®) qyear IV Forteo® Teriparitide sq qday times 2 years Risk…osteosarcoma Used to treat osteoporosis with prior fracture or high risk who cannot take bisphosphonates How long to Treat? 5 years? 7 years? Life? Until BMD better? Bisphosphonates accumulate in bone and after stopping leach out over 1-2 years Expert Opinion Mild risk: rx 5 years and follow BMD High risk: rx 10 years and do 1-2 year drug holiday When to rescan Normal with no risks: 3-5 year Risk factors that persist: 2 years High risk after menopause: 2 years Treated patients: 2 years than less if responding Risks NNH Osteonecrosis of jaw=>60,000 and most occurred in cancer patients treated with very high dose zoledronic acid Atypical femur fracture=? 25,000? Benefits NNT Prior Fracture No Prior Fracture Any Fracture = 21 100 Vertebral Fracture = 8 29 Hip Fracture = 35 - 46 4.5 - 66 Other Fracture = 21 - 43 35 – 66 Osteoporosis Blue Sheet Osteoporosis Aging Q3 ACOVE # 9 PCT Ask: PCT CIRCLE: MD ACTION: YES or NO 1. Have you ever had a DXA scan (bone density) for osteoporosis? YES YES 1a. If YES, Is the DXA documented in Practice Partner? NO 1b. If NO, Was the patient referred for a DXA? 2. Was the patient’s risk of fracture (FRAX) calculated? 3. Did the patient’s FRAX score influence any clinical decisions in today’s visit? 4. Have you ever had a fractured bone? YES MD CHECK: 4. If YES, 4a. Did you do a fracture history? 4b. Did the fracture history indicate any need for change in medications or further treatment? NO If NO – No further action needed NO o s Osteoporosis Detailing Sheet Aging Q3 Osteoporosis and Aging ACOVE #9 An estimated 25million Americans have osteoporosis. It affects elderly people of all races and ethnicities. 20-25% of persons with a hip fracture are unable to return to independent living and 12-20% die within 1 year. Risk Factors Screening DXA for all Women 65+ years Diagnosis T-Score Osteoporosis ≤ -2.5 Osteopenia -1.0 to - 2.4 Normal > -1.0 Age Gender Previous fracture Family history Low BMI Physical activity Currently smoking Rheumatoid arthritis Alcohol use Steroid use * False Positives with Compression Fractures *Note: If patient uses >5 mg/day Prednisone or equivalent < 3 months: Warning > 3 months: Rx Bisphosphonate 65+ Female Fracture (Major trauma NA) DXA (Baseline) No Fracture DXA and FRAX Treat >-1.0 DXA No Treatment < -2.5 Treat -1.0 to - 2.4 DXA Look for the FRAX at: http://www.shef.ac.uk/FRAX/tool.jsp?country=9 ≥ 3% FRAX (Hip Fracture) Treat ≥ 20% FRAX (Osteoporotic Related Fracture) FRAX should not be used with persons on treatment for osteoporosis. Treat Practice Partner Template Progress Notes If patient is age 65 or over and female, has the patient ever had a DXA scan? If patient is 65 or over and female, has the patient’s risk of fracture (FRAX) been calculated? Does the patient report ever having a fractured bone? Osteoporosis ACOVE begins in clinic Thursday, July 21, 2011 Thanks for supporting Aging Q3