Management of Osteoporosis

1. Management of Osteoporosis Stephanie Fegley, FNP Department of Orthopaedic Surgery Christiana Care Health Services March 28, 2014

2. Objectives: • Identify populations at risk for low bone density or osteoporosis. • Recognize when it is appropriate to order a Bone Density Scan (DXA) with or without Vertebral Fracture Assessment (VFA). • Select appropriate pharmacologic agent for osteoporosis management based on past medical history and side effect profile. • Utilize “fragility fracture panel” to help rule out secondary causes of osteoporosis.

3. Nearly an epidemic • Reflects the amount of FF per year in the U.S. • More than MI, CVA & breast cancer combined.

4. Cast Mountain

5. Statistics • At least 44 million Americans are affected by osteoporosis or low bone density. • Due to an aging population, the number of Americans with osteoporosis or low bone density is expected to increase significantly. • Up to ½ of all women will suffer a FF during their lifetime • Up to ¼ of all men will suffer a FF during their lifetime

6. NOF 2 Million 2 Many Campaign

7. Cost of Osteoporosis • Direct care expenditure from osteoporosis-related fractures exceeds $19 billion annually. • By 2025, the annual cost of fractures is projected to grow to more than $25 billion, as annual fractures surpass 3 million.

8. Painful, yet undertreated • Approximately 80% of patients do not receive recommended osteoporosis care following a fragility fracture. • Men, who account for 30% of fractures & 25% of cost, are particularly undertreated.

9. “No one’s ever died from osteoporosis” • Nearly 25% of patients who suffer a hip fracture die within a year. • Those who do survive experience significant morbidity, as many experience a loss of independence & may require long-term nursing home care. • Others never return to their baseline mobility, and will have to ambulate with a walker or cane & are at increased risk of future falls & fractures.

10. Provide a “Teachable Moment” • According to AOA, a fragility fracture should be treated as a sentinel event. This will provide opportunities or clinicians to educate patients, fellow physicians & other healthcare providers about the importance of bone health and osteoporosis treatment. • The best time to talk to your patient about a fragility fracture and the likelihood of Osteoporosis is while the fracture is fresh.

11. Fracture Cascade • About 50% of people with one fracture due to Osteoporosis will have a repeat fracture. • The risk of fracture rises with each new fracture, hence the “cascade effect” • Women who have a vertebral fracture are 4x more likely to have another fracture within the next year, compared to women who have never fractured.

12. Pathophysiology • Age-related changes in bone microarchitecture: • Decreased bone volume • Decreased trabecular thickness • Decreased trabecular number • Decreased connectivity • Decreased mechanical strength • Increased cortical porosity

13. Populations at risk… • HIV/AIDS • Ankylosingspondylitis • Blood & bone marrow disorders • Breast cancer • Cushing’s syndrome • Eating disorders • Emphysema • Female athlete triad • Gastrectomy • Gastrointestional bypass procedures • Hyperparathyroidism • Hyperthyroidism • Idiopathic scoliosis • Inflammatory bowel disease • Diabetes mellitus • Kidney disease • Lupus • Lymphoma & leukemia • Malabsorption syndromes (i.e.- Celiac & Crohn’s disease) • Multiple myeloma • Organ transplants • Parkinson’s disease • Poor diet

14. More at Risk Populations… • Post-polio syndrome • Premature menopause • Prostate cancer • Rheumatoid arthritis • Severe liver disease • Spinal cord injuries • Cerebral Vascular Accident • Thalassemia • Thyrotoxicosis • Weight loss

15. Medications that will Increase Risk… • Oral glucocorticoids • Anticonvulsants • PPIs • SSRIs • TZDs • Lithium • Aromatase Inhibitors • Gonadotropin-releasing hormone agonists • Chemotherapy • Heparin • Depo-Provera

16. Other Factors that Increase Risk • Low dietary Calcium intake • Vitamin D Insufficiency or Deficiency • Tobacco use in the past 12 months • Consuming > or = 3 units of alcohol per day • Sedentary lifestyle • 2 or more falls in the past year • Moderate to high caffeine intake

17. Cheap ways to tell if your patient is at an increased risk for fragility fracture: • Prior history of fracture after age 50 or >, at fall from standing height or less • One of the “At risk populations” • Is/has been taking one of the medications that increase risk • Tobacco abuse • Drinks > or = 3 units of alcohol per day • Sedentary lifestyle • History of > or = 2 falls in the past year • Check a FRAX http://www.shef.ac.uk/FRAX/tool.aspx?country=9

18. Fracture Risk Assessment Tool (FRAX) • Tool developed by the World Health Organization (WHO) to calculate fracture risk in patients, by combining clinical risk factors with BMD, to generate a 10 year probability of fracture. • 10 year probability of hip fracture • 10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture)

19. When not to use FRAX: • When the patient has already had a hip fracture • When they have been on treatment for Osteoporosis in the past 2 years • Less than 40 years old • Most DXA reports will include a FRAX score at the end, if not contraindicated. This is to help the provider determine if treatment is necessary.

20. DXA Report with Inappropriate use of FRAX

21. Recommendations for when to order a DXA: • Women age 65 years and older and men age 70 and older. • Women under 65 and men age 50-69 about whom there is concern based on clinical risk factor profile or FRAX score. • Women and men of any age who have suffered a low-impact fracture. • Women and men of any age who are at increased risk as a result of selected medical conditions or treatment with specific medications.

22. DXA Guidelines • DXA should be “Central DXA”, with lumbar spine & hips (preferably both hips) scanned. • DXA should be interpreted in accordance with International Society for Clinical Densitometry (ISCD) • The final diagnosis from DXA is based on the lowest t-scorefrom the spine, proximal femur, or femoral neck, whichever is lowest. • Diagnosis from DXA in premenopausal women and men under age 50 is based on z-scores and is reported as normal or low bone density for age.

23. DXA Guidelines (cont.) • Evaluation of the forearm(s) should be performed if the evaluation of the spine or hip(s) is limited or nondiagnostic. • Absolute fracture risk assessment using FRAX should be included in DXA reports for appropriate patients.

24. Vertebral Fracture Assessment (VFA) • Lateral spine imaging with densitometric VFA is indicated when lowest t-score from DXA is <1.0 and or more of the following is present: • Women age >/= 70 years or man age >/= 80 years • Historical height loss > 4cm (> 1.5 inches) • Self-reported but undocumented prior vertebral fracture • Glucocorticoid therapy equivalent to >/= 5mg prednisone or equivalent per day for >/= 3 months.

25. How should you write your script? • Write to perform a “DXA with VFA” or “DXA with VFA, if indicated” • Things to consider: • The patient has to lay on their side to have the VFA performed, so if they have a recent fracture, this may be too difficult/painful. • Insurance coverage

26. Guidelines for follow-up DXA • Insert Table 1 from CMG

27. Defining Osteoporosis by BMD • Insert table 2 from CMG

28. Deciding when to treat using FRAX: • According to the WHO, you should consider a pharmacologic agent if: • 10 year probability of a hip fracture is > 3% • 10 year probability of major osteoporotic fracture (spine, forearm, or shoulder fracture) is > 20%

29. Important Physical Exam Findings • Eyes- Sclera • Mouth- Teeth~ In OI can be normal or soft & translucent. Also if you are considering bisphosphonate or Prolia therapy you want to evaluate their dentition to determine increased risk for ONJ. • Musculoskeletal- Postural changes such as kyphosis, “lengthening of the arm-trunk axis” (describes shortening of the trunk w/ comparatively long extremities) & tenderness of the spinous processes • Gait- Try and sneak a peek at them walking in or out of the exam room. Can they get up from a chair without using their hands? • Scars- Fracture repairs they have forgotten about • BMI < 18 increases risk • Height at every office visit!

30. Determining the cause… • Once you make the diagnosis, don’t forget to rule out secondary causes! • Fragility Fracture Panel: • Serum Creatinine • Calcium • Albumin • Phosphorus • Alkaline phosphatase (ALP) • Thyroid Stimulating Hormone (TSH) • Vitamin D 25-OH • Intact Parathyroid Hormone (iPTH)

31. Vertebral Compression Fractures • Approximately two-thirds are never diagnosed, because they are written off as pain associated with aging or arthritis. • Think about the cascade • Loss of height (more than 3cm/just over 1 inch) • Sudden severe back pain in the mid & lower spine • Increased stoop or ‘dowager’s hump’

32. Conservative Treatment for Compression Fxs • Self-Care at home: • Rest • Pain relief with NSAIDs • May also need muscle relaxants • Ice for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better. • Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.

33. Conservative Treatment for Compression Fxs • Hospital Admission: • Inpatient treatment dependant upon pain control, weakness, ambulatory dysfunction, urinary retention, & caudaequina syndrome. • TLSO (ThoracolumbosacralOrthosis) brace as needed, when out of bed for comfort. • Rest • Pain relief with opiates (usually hydrocodone or oxycodone) • May also need muscle relaxants • Ice for 20 minutes every 60 minutes for the first week, then can do heat or ice, which ever feels better. • Physical therapy, when permitted~ with emphasis on stretching & strengthening program to decrease risk for further osteoporosis and strengthen muscles supporting the back.

34. Kyphoplasty

35. Vertebral Compression Fracture Posture

36. Consequences of Vertebral Compression Fractures • Kyphosis • Loss of height • Bulging abdomen • Acute & chronic back pain • Breathing difficulties • Depression • Reflux & other GI symptoms • Limitation of spine mobility (affecting ADL & ambulation) • Need to use walking aid

37. Own the Bone • Launched by the American Orthopaedic Association (AOA), to help providers drastically improve efforts of fracture prevention. • Christiana Care Health System have been participating in the Own the Bone Registry since January 1, 2012. • OTB focuses on 10 measures for the patient with a history of a fragility fracture

38. 10 Own the Bone Measures • Calcium supplementation • Vitamin D supplementation • Weight-bearing & muscle-strengthening exercise • Fall prevention education • Smoking cessation • Limiting excessive alcohol intake • Pharmacotherapy • Ordering DXA • Physician referral letter to report the patient’s fragility fracture, risk factors, & recommendations for treatment. • Patient education latter to explain bone health risk factors & recommendations for treatment.

39. Which is the best Calcium? • The majority of these patients should be told to consume 1200mg of calcium per day between diet and supplement combined. • Dietary intake of calcium from food sources should be encouraged as much as realistically possible & fill the gap with a Ca supplement when necessary.

40. Food Sources of Calcium • Lowfat & non-fat dairy products are high in calcium while certain green vegetables and other foods contain calcium in smaller amounts. • Calcium fortified foods- Orange juice, cereals, soymilk, English muffins, waffles, breads, snacks, & bottled water.

41. Foods that Reduce the Absorption of Calcium • Foods with high amounts oxalate & phytate reduce the absorption of Ca contained in those foods. • Foods high in oxalate= spinach, rhubarb & beet greens • Foods high in phytate= legumes (pinto beans, navy beans, peas), 100% wheat bran* (*space >/= 2 hours after eating foods that contain bran) • You can reduce the phytate level to get more Ca from legumes by soaking them in water for several hours, discarding the water, & then cooking them in fresh water.

42. Calcium Side Effects • Gas or constipation may occur from Ca supplements • Some patients complain of nausea • Patient’s should increase fluids & fiber in their diet, but if that does not help, they should try another type or brand of Ca. • When starting a new Ca supplement, start with smaller amounts & drink an extra 6-8 ounces of water with it, then gradually add more Ca each week.

43. Calcium Supplementation • There are many different types of calcium salts (i.e. glubionate, gluconate, lactate, citrate, acetate, phosphate, & carbonate) • Calcium Carbonate (40% elemental Ca) • Viactiv, Caltrate, Oscal, Tums, numerous store brands • 300-600mg of calcium per pill • Requires hydrochloric acid for best absorption, therefore remind patients to take with meals. • Calcium Citrate (21% elemental Ca) **May need 2 pills per dose • Citracal, some store brands • 200-300mg of calcium per pill • Does not requires hydrochloric acid for absorption, so it can be taken with or without food. • Calcium Phosphate (39% elemental Ca) • Posture • Absorption is very similar to Calcium Carbonate

44. Is There a “Best” Calcium Salt? • The data suggests that both Calcium carbonate & Calcium citrate, taken with meals, have equivalent bioavailability. • If you have a patient on a H2 blocker, PPI, or you know has achlorhydria and supplements won’t be taken with meals, Calcium citrate is a better choice. • Calcium carbonate is cheaper • Calcium phosphate is equivalent to Calcium carbonate in supporting bone building. • Study suggests that Calcium citrate has better availability than Calcium carbonate after roux-en-Y gastric bypass.

45. Calcium Supplements • Most important factors are those predicting long-term use: palatability, cost, tolerance • Advertised “differences” more apparent than real • Magnesium may be helpful with constipation • Calcium chews contain Vitamin K- ** Caution in patients taking Coumadin

46. Why is Vitamin D so Important? • Vitamin D is essential for adequate gastrointestinal absorption of calcium. • Insufficient amounts of vitamin D over time reduces serum calcium levels and can trigger a compensatory release of parathyroid hormone. • This may produce secondary hyperparathyroidism, resulting in mobilization of calcium from the bone and a reduction in bone mineral density.

47. What is the Best Level to Check for Vitamin D Status? • 25-OH Vitamin D level is best • 1,25 OH2 Vitamin D levels are useful in chronic kidney disease, primary hyperparathyroidism, sarcoidosis, oncogenic osteomalacia, vitamin D-resistant rickets, pseudo- vitamin D deficiency rickets, and hypophosphatemic rickets

48. What Do the Results Mean? • <10ng/mL Severe Vitamin D Deficiency • 10-19ng/mL Vitamin D Deficiency • 20-29ng/mL Vitamin D Insufficiency • 30ng/mL Normal • 40-60ng/mL Target range for someone with history of Osteoporosis with or without fracture

49. Health Risk Associated with Vitamin D Deficiency • Ricketts • Osteomalacia • Precipitates & exacerbates Osteoporosis • Increased risk of: deadly cancers, cardiovascular disease, Multiple Sclerosis, Rheumatoid Arthritis, & Type I DM • Can also cause muscle weakness & increased risk for falls

50. Sources of Vitamin D • Sunlight • Food • Supplements & Medications • NOF recommendations: • Adults < 50 years old: 400-800IU/day • Adults >/= 50 years old: 800-1,000IU/day