Download No Bones About It - University of Iowa Hospitals and Clinics

Presented by:
Nicole Nisly, MD
About Today’s Presentation
• I will discuss osteoporosis and focus on causes,
treatment options and prevention
• I will discuss medications and life style choices
that can be of help
• I will discuss some treatments that are not FDA
approved
• I have no conflict of interests to disclose
About Dr. Nisly
• Hello, my name is Dr Nicole Nisly, thank you for
coming today
• I am a Professor of Internal Medicine and work at
the University of Iowa Iowa River Landing Clinic
(319/467-2000)
• My areas of expertise include Internal Medicine
Primary Care, Complementary and Integrative
Medicine, LGBTQ Health and Cultural Diversity in
Health
How do we get osteoporosis?
• We reach our maximum
bone mass normally by
the age of 40
• As we age, we tend to
lose bone mass,
especially after
menopause
• Certain conditions make
that loss happen faster
Risk Factors for Osteoporosis
http://www.shef.ac.UK/FRAX
• Age (most fractures of the
hip occur after age of 80)
• Use of corticosteroids
• Low Body weight
• Smoking
• Excessive alcohol use
• Parental Hip Fx
• Rheumatoid arthritis
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Previous ‘Fragility” fractures
Malabsorption
Early menopause
Hypogonadism
Chronic liver disease
Inflammatory Bowel disease
How do we know if we have osteoporosis?
• For most women, they should be screened with
a DEXA scan at age 65
• Sooner with increased risk factors (FRAX
calculated risk of over 20% over 10 years)
• For men: less certain but around age 70, sooner
if at risk
About DEXA Scan Results
(dual energy xray absorptiometry)
• This test measures bone mineral density (BMD).
• T score compares your BMD to that of a young
women around age 25
• Z score compares your BMD to someone of your
age
• Osteoporosis: T score of 2.5 or less SD
• Osteopenia: T score between 1-2.5 SD
• Z score of 2 or lower SD is abnormal
How often do you test?
• For women at average risk and T score between
2-2.49 SD or any risk factors, repeat every 2
years
• T score between 1.5-1.99 SD, repeat in 3-5 years
• T scores at 1-1.49 SD, repeat in 10-15 years
• Address risk and benefit, including cost. The
purpose of testing is to help decide when to
treat and reduce risks
Should I test early?
• If you have the risk factors indicated previously
or fragility fracture: test women starting at age
50 and men around 70
• Canadian osteoporosis Society recommends
earlier testing for women and men between 5065
How to test?
• DEXA scan of Hip and Lumbar spine preferred
• Peripheral measurements of heel or ultrasound
measurements while more available do not
correlate well with fracture risk
• Bone turnover markers are not cost effective in
guiding evaluation or treatment
Other Tests
• Calcium
• Biochemistry profile including Albumin and
protein and Alkaline Phosphatase
• 25-OH vitamin D
• Complete Blood Count
• Other tests in certain situations:
• Cortisol, parathyroid hormone, celiac disease
screening, 24 hr urinary calcium
Pre-Menopausal Women & Children
• Bone density testing should only be done in
very specific situations of very high risk
• Use Z scores instead of T scores to interpret test
• Usual WHO guidelines apply to post
menopausal women
How about prevention?
• Increase exercise and weight lifting, aim at 3 times
per week for 30 minutes
• Balance and fall prevention is important, exercises
such as Tai-Chi may help
• Gluten Free Diet and Low or High protein diet are
discussed for specific cases
• Vitamin D 3 in gel capsule: 600-4,000 IU daily (most
people 600-1,000)
• Calcium: diet is best source. Supplements
The Issue of Calcium
• Dietary sources: one serving of dairy: 300 mg
1 oz hard cheese, 8 oz of milk, 6 oz of yogurt)
Greens, non dairy drinks
• Supplements: calcium citrate absorbs better if
using certain medications
• Goal: 500-1,000 mg of supplement if needed
Medications
• Biphosphanates such as Alendronate,
Risendronate, Ibandronate and the I.V. form of
Zoledronic Acid increase bone mass and reduce
fracture
• SERM such as Raloxifene can decrease bone loss
and reduce vertebral fracture
• Others: parathyroid hormone shots, Strontium
(not available in the US), Denosumab shots,
calcitonin
Natural Therapies
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Tai chi
Soy protein
Ipriflavone (unproven)
Previously discussed life style changes
Environmental modifications such as night lights,
removing rugs, using walkers, exercising regularly
• QUIT SMOKING!!
• Reduce alcohol
What is CAM anyway?
• A wide range of practices, new and old, at times
safe, other times dangerous, widely used by
patients worldwide, however…
• In general, safety and efficacy are not yet well
established,
• Not commonly taught in medical schools and
• Not commonly utilized in U.S. hospitals
However…
• Integrative Medicine and various
Complementary or Holistic Therapies are
making their way into the health care system in
various formats
• Education: Core Curriculum, Electives, Resident
electives, Fellowships are growing in the U.S.
Selected Alternative Medicine
Systems and Techniques
• Mind-body interventions
• Alternative systems of medical practice
• Biologically based therapies
• Manipulative and body-based methods
• Energy therapies
Mind-body Interventions
• Art therapy
• Biofeedback
• Dance/movement
therapy
• Hypnosis
• Imagery
• Meditation
• Music therapy
• Prayer and mental
healing
• Self-help support
groups
• Yoga
Alternative Systems of Medical Practice
• Acupuncture
• Homeopathy
• Ayurveda
• Naturopathic medicine
• Community-based
• Traditional chinese
medicine
– Latin American community
healthcare
– Native American
healthcare
Why bother telling your doctor or
pharmacist what will they do with that
information?
• Integrated care vs. uncoordinated care
• Potential for:
– Side-effects
– Drug-dietary supplement interactions
– Benefits
Herbal Medicines
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European Botanical Medicines
Latin American Herbal Remedies
Native American Herbal Agents
Ayurvedic Herbal Agents
Oriental Herbal Agents
– Chinese
– Japanese - Kampo
Medicine Derived From Plants
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Aspirin
Atropine
Belladonna
Capsaicin
Cascara
Cocaine
Colchicine
Digoxin
Ephedrine
Ergotamine
Ipecac
Opium
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Physostigmine
Pilocarpine
Podophyllum
Psyllium
Quinidine
Reserpine
Scopolamine
Senna
Taxol
Tubocurarine
Vincristine
Vinblastine
Klepser, 2000
St. John’s Wort
• Drug Interactions (P450 1A2, 2C9, 3A4)
• Activates a receptor, named PXR, in the liver and
intestine, which accelerates drug metabolism.
• It may interact with over 80% of drugs available
in the U.S. market.
I have a cold, allergy or
something…
• Mr. Sneezy comes in for
refill of his allergy
medication.
• Typically he has
symptoms during the
ragweed season.
• I have frequent colds,
can I use Echinacea, he
asks?
Where do I go for reliable
information?
• NCCAM (http://nccam.nih.gov/)
• ODS (http://ods.od.nih.gov/index.aspx)
• NCI/OCCAM (http://www3.cancer.gov/occam/)
– MD Anderson database
(http://www.mdanderson.org/departments/CIMER/)
• Natural Medicine Comprehensive Database
(www.naturaldatabase.com)
• Micromedex
• Consumerlab.com
Talk to your Doctor
• Tell your health care providers about all the
complementary and alternative practices you use.
This will help ensure coordinated and safe care.
• Be proactive. Don't wait for your health care
providers to ask about your CAM use.
• Make the most of the conversation. Bring a list of
everything you use, keep a record of the
information you receive, and ask questions if
something is unclear.
Using Supplements
• Why I want to take the supplement
• How I found out about it
• Is it safe for me to take? Will it interact with any of my
medications?
• Is it likely to help me?
• What else should I know about it? Where can I find
more information?
• Should I try this? If not, why not? Might something
else be better?
Keeping Track of your Intake
Name
and
company
Gingko
Nature
Made
St John’s
wort,
walmart
Dose
Taken
60
mg/day
Dose
Ingredie Why
Recomm nts
ended
120
Gingko
Memory
mg/day
300
mg/day
900
mg/day
SJW,
Kava,
valerian
Mood
In conclusion: be an informed and
empowered consumer: it is your health!
The “best patient” is a
well informed,
interested, responsible
and empowered patient,
who actively and
collaboratively
participates in their
health care.
Final Words & Questions