Sara Schoenfeld, MD Division of Rheumatology Massachusetts General Hospital

Size: px

Start display at page:

Download "Sara Schoenfeld, MD Division of Rheumatology Massachusetts General Hospital"

Lydia Wright
7 years ago
Views:

1 Sara Schoenfeld, MD Division of Rheumatology Massachusetts General Hospital

2 Oral bisphosphonates FRAX DXA Anabolic agents Denosumab Risk factors Exercise Calcium/Vitamin D IV bisphosphonates

3 What is Osteoporosis? Osteoporosis causes bones to lose density, become weak, and fracture easily Osteoporosis affects the entire skeleton Osteoporosis predicts fracture risk

4 Osteoporosis Normal Spine Source: National Osteoporosis Foundation, 2000 Osteoporotic Spine

$Facts about fractures Most osteoporotic fractures occur in the spine, hip, and wrist 2/3 of spine fractures are asymptomatic$

5 Facts about fractures Most osteoporotic fractures occur in the spine, hip, and wrist 2/3 of spine fractures are asymptomatic Fractures lead to disability and increased risk of death Up to 20% increase of mortality as early as one year after fracture

$Osteoporosis is common - 44 million Americans have either osteoporosis or low bone mineral density Osteoporosis is serious - Osteoporotic fractures cause disability and increased risk of death$

6 Why Do We Care About Bone Density? Osteoporosis is common - 44 million Americans have either osteoporosis or low bone mineral density Osteoporosis is serious - Osteoporotic fractures cause disability and increased risk of death Osteoporosis is easy to diagnose - Bone density testing can detect osteoporosis before the first fracture occurs Good treatments are available- Fracture risk can be reduced by 50-70%

7 Impact of Osteoporosis 40% of women over 50 will suffer an osteoporosis-related fracture in their lifetimes Each year, the risk of suffering a fracture from osteoporosis is greater than the combined risk of suffering a heart attack, stroke, or breast cancer in women

8 Who is at risk for developing osteoporosis? Post-menopausal women; increasing age Caucasian or Asian Small body stature Family history and/or personal history of fractures as an adult (non-traumatic) Inactive lifestyle Cigarette smoking Alcohol use (> 3 drinks/day) Inadequate calcium intake Rheumatoid arthritis Medications: prednisone, breast cancer chemotherapy, progesterone birth control

10 Diagnosis: Bone Densitometry

11 How to Detect Osteoporosis DXA (dual-energy x-ray absorptiometry) Gold standard Measures hip and spine (sometimes forearm) Compares bone mineral density to that of a young adult (T-score) Peripheral measures (ankle, hand, finger) A screening tool Indicate possible risk of future fracture Do not confirm the presence of osteoporosis Not approved to make the diagnosis

12 Who Should Get a Baseline Bone Density Test (DXA)? All women 65 years or older Men 70 years or older All adults with a history of a fragility fracture All postmenopausal women with at least one risk factor Adults with a disease or medication history associated with bone loss Rheumatoid Arthritis Prednisone

13 Interpretation: T-score is key The most clinically relevant value on the bone density report The T-score compares the bone density of the patient to that of peak bone density (approximately age 30)

14 WHO defined The T-Score Normal: > -1.0 Osteopenia: -1.0 to -2.5 Osteoporosis: -2.5 or lower The lower the T-score, the higher the risk of fracture

15 Fracture Risk Doubles With Every SD Decrease in BMD Relative Risk of Fracture T-score

$What About Osteopenia 50% of fractures occur in patients with osteopenia T-score between -1.0 and -2.5-2.$

16 What About Osteopenia 50% of fractures occur in patients with osteopenia T-score between -1.0 and How do we determine which patients with osteopenia are at increased risk for fracture? FRAX score

$FRAX Tool to help determine fracture risk in people who have untreated osteopenia Takes into account bone density and risk factors Identifies$

17 FRAX Tool to help determine fracture risk in people who have untreated osteopenia Takes into account bone density and risk factors Identifies high risk individuals who could benefit from treatment Recommends treatment based on 10 year fracture risk: Hip > 3% Osteoporotic fracture > 20%

18 Hip > 3% Osteoporotic fracture > 20% (or Google FRAX!)

19 Treatments Exercise Modification of environment for safety Medications

20 Weight-Bearing Exercise Consult your doctor first

21 Role of Exercise in Prevention and Treatment Decreased risk of falling Improved bone mass and strength Enhanced muscle strength Improved balance, better posture Increased flexibility of soft tissues Improved cardiovascular fitness Improved depression

Fall prevention in the home Use handrails on stairs, bathroom Keep rooms free of clutter Keep floors clean but not slippery Wear supportive, low-heeled shoes.

22 Fall prevention in the home Use handrails on stairs, bathroom Keep rooms free of clutter Keep floors clean but not slippery Wear supportive, low-heeled shoes. Don t walk in socks; floppy slippers Use 100 watt bulbs in all rooms Install ceiling lighting in bedrooms Use rubber mat in shower/tub Keep a flashlight at bedside Check posture in mirror often

Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax )

23 Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Intravenous yearly Zoledronic Acid (Reclast ) Subcutaneous injection Teriparatide (Forteo ) daily Denosumab (Prolia ) twice yearly

24 Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Intravenous yearly Zoledronic Acid (Reclast ) Subcutaneous injection Teriparatide (Forteo ) daily Denosumab (Prolia ) twice yearly

25 How Much Calcium is Enough? Varies for age 1,200-1,500 mg every day after age 50 From diet or supplement or both It is ideal to obtain calcium from diet as much as possible Good Sources of Calcium Milk-300 mg/glass Yogurt-400 mg/cup Broccoli-172 mg/cup

26 How Much Vitamin D? IU every day From fortified foods or supplements or both Higher doses if Vitamin D deficient Good sources of Vitamin D Milk (100 IU per glass) Multivitamins (most have 400 IU) Over the counter vitamin D tablets

27 Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Intravenous yearly Zoledronic Acid (Reclast ) Subcutaneous injection Teriparatide (Forteo ) daily Denosumab (Prolia ) twice yearly

28 Bisphosphonates Works on a bone cell called the osteoclast Well tolerated Treatment is often for 3-6 years, but discuss with your doctor 50-70% reduction in fracture risk 3-5% increased bone mineral density

29 Concerns about Bisphosphonate-Related Adverse Events Esophageal discomfort Osteonecrosis of the jaw (presence of exposed bone in jaw region that does not heal, can be associated with infected bone) Atypical femur fractures

Rare Osteonecrosis of the Jaw Most cases associated with treatment of metastatic cancer Risk factors Intravenous bisphosphonates Dosage used (up to

30 Rare Osteonecrosis of the Jaw Most cases associated with treatment of metastatic cancer Risk factors Intravenous bisphosphonates Dosage used (up to 12x dosage used for osteoporosis) History of dental trauma or surgery Includes dentures History of dental infection Woo S-B, et al, Ann Intern Med, 2006

31 Osteonecrosis of the Jaw Recommendations Complete all dental invasive work prior to or within 1-2 months of initiating IV bisphosphonate treatment Once on IV bisphosphonates maintain good dental care If already on treatment then seek conservative procedure management Appropriate timing of dosing and procedures if possible If ONJ develops treat conservatively Antibiotics, oral rinses Woo S-B et al, Ann Intern Med, 2006

32 Atypical Femur Fractures Fragility of thigh bone (femur) Association with (but not causal) long term bisphosphonate use Important to consider how long a course of therapy should be Studies show benefit with 3-6 years of treatment (depends on which medication) Some patients at very high risk warrant a longer treatment course

33 Bisphosphonates Despite these rare risks, these medications are generally very safe and well tolerated

34 Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Intravenous yearly Zoledronic Acid (Reclast ) Subcutaneous injection Teriparatide (Forteo ) daily Denosumab (Prolia ) twice yearly

35 Teriparatide and Denosumab Most patients won t need these medications because the bisphosphonates are very effective and well tolerated Certain situations where these medications may be indicated Discuss with your osteoporosis doctor Also very effective and well tolerated

36 Concerns about Medication-Related Adverse Events Teriparatide (Forteo ) Black box warning Denosumab (Prolia ) Eczema

37 The Osteoporosis Challenge To educate all patients on measures to maintain good bone health To identify patients at high risk for osteoporosis To use bone densitometry to detect low bone density BEFORE a fracture occurs To educate patients about treatment options To use risk factor reduction, medications and exercise to treat patients for osteoporosis

38 Oral bisphosphonates FRAX DXA Anabolic agents Denosumab Risk factors Exercise Calcium/Vitamin D IV bisphosphonates

Osteoporosis Medications

Osteoporosis Medications When does a doctor prescribe osteoporosis medications? Healthcare providers look at several pieces of information before prescribing a bone- preserving or bone- building medication.