AGS OSTEOPOROSIS WORK-UP. Joseph M. Lane, MD Hospital for Special Surgery New York, NY

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1 OSTEOPOROSIS WORK-UP AGS Joseph M. Lane, MD Hospital for Special Surgery New York, NY THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2 Types of financial relationships and the companies with whom I have relationships are as follows: Consulting Fees: Amgen, Arthrocare, Biomimetics, D Fine, Innovative Clinical Solutions, Kuros Biosurgery AG, Osteotech, Orthovita, Soteira, Zelos, Zimmer Speakers Bureaus: Eli Lilly, Novartis, Orthovita, Proctor & Gamble, Roche, Sonofi Aventis

3 OSTEOPOROSIS Decreased bone mass Microarchitectural deterioration Altered quality (mineral, collagen) Fragility fracture Slide 3

4 Low bone mass is the single most accurate predictor of increased fracture risk Slide 4

5 WORLD HEALTH ORGANIZATION CRITERIA Normal Osteopenia Osteoporosis Severe osteoporosis 1 SD 1 SD to 2.4 SD 2.5 SD 2.5 SD and fracture Slide 5

6 BIOCHEMICAL MARKERS Bone resorption Collagen breakdown products: n-telo and c- telo peptides, pyridinoline Bone formation Bone alkaline phosphatase Osteocalcin Slide 6

7 OSTEOPOROSIS RISK FACTORS INDEPENDENT OF BONE MASS Low body weight (<127 pounds) Recent loss of body weight Personal history of fragility fracture Maternal history of fragility fracture Smoking Slide 7

8 HIP FRACTURE RISK AND AGE 10-year hip fracture risk with 3 SD DXA 50-year-old 2% 3% 80-year-old 16% 18% Slide 8

9 FRAX FRAX is a sophisticated risk assessment instrument, developed by the University of Sheffield in association with the World Health Organization. It uses risk factors in addition to DXA measurements for improved fracture risk estimation. It is a useful tool to aid clinical decision making about the use of pharmacologic therapies in patients with low bone mass. The International Osteoporosis Foundation supports the maintenance and development of FRAX. International Osteoporosis Foundation, Reprinted with permission from the IOF. All rights reserved. Slide 9

10 Slide 10

11 R/O MARROW-ETIOLOGY OSTEOPENIA CBC/diff ESR Immunoelectrophoresis Abnl 2% Bone marrow Normal R/O Endocrine Multiple myeloma Slide 11

12 Vertebral fracture (kyphoplasty) 1/82 lymphoma Slide 12

13 R/O ENDOCRINE-ETIOLOGY OSTEOPENIA T3, T4 TSH (IRMA) PTH Glucose Steroid HC Abnl 5% 15% Hyperthyroidism HPT Type 1 diabetes Cushing s disease Normal R/O Osteomalacia Slide 13

14 Insulin is critical to bone health Type 1 diabetes low insulin Slide 14

15 Iatrogenic thyroid increases turnover CHECK TSH Slide 15

16 Dermal Inhaled are steroids steroids Slide 16

17 Slide 17

18 R/O OSTEOMALACIA Alkaline phosphatase PTH Ca PO 4 25(OH) vitamin D 30% 70% hip fracture patients 40% primary total joint arthroplasty Slide 18

19 HOSPITAL FOR SPECIAL SURGERY (HSS) 45% elective surgery <32 ng/ml 25(OH) vitamin D Trauma Professional athletes Slide 19

20 TOTAL HIP ARTHROPLASTY AT HSS <20 ng/ml Walker Distance on discharge Slide 20

21 COMMON CAUSES OF OSTEOMALACIA Nutritional vitamin D deficiency Disorders of intestinal absorption of vitamin D (eg, sprue) Defects of vitamin D metabolism Renal osteodystrophy Renal tubular acidosis Hypophosphatemic (renal tubular) Slide 21

22 Slide 22

23 Slide 23

24 Key 25 (OH) vitamin D Calcium corrected for albumin Slide 24

25 Vitamin D deficiency A common occurrence in both high-energy and low-energy fractures

26 High turnover BONE TURNOVER (1 of 2) Bone collagen breakdown products (NTX, CTX) Low turnover Bone formation Bone-specific alkaline phosphatase Osteocalcin BINP Bone resorption (NTX, CTX) Slide 26

27 High turnover BONE TURNOVER (2 of 2) Onset of menopause Rx: bone resorption Low turnover Genetic Old age Chemotherapy Bisphosphonates Rx: Stop bisphosphonates Anabolic agent Slide 27

28 METABOLIC BONE DISEASE WORK-UP FOR OSTEOPENIA Bone marrow CBC Sed rate Immunoelectrophoresis Endocrinopathy Hyperthyroidism Hyperparathyroidism Cushing s disease Type 1 diabetes Osteomalacia Calcium Phos Alkaline p-tase PTH 25 (OH) vitamin D Osteoporosis High vs. low turnover NTX Slide 28

29 THANK YOU FOR YOUR TIME! Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatricssociety Slide 29

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