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Osteoporosis Guidelines Review

Osteoporosis Guidelines Review. Dr. Karen Schultz April 2010 http://www.cmaj.ca/cgi/reprint/167/10_suppl/s1.pdf. The definition of osteoporosis is a low BMD. True False. FALSE…OP is oh so much more than BMD!.

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Osteoporosis Guidelines Review

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  1. Osteoporosis Guidelines Review Dr. Karen Schultz April 2010 http://www.cmaj.ca/cgi/reprint/167/10_suppl/s1.pdf

  2. The definition of osteoporosis is a low BMD • True • False

  3. FALSE…OP is oh so much more than BMD! • Osteoporosis=“a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength reflects the integration of 2 main features: bone density and bone quality.”

  4. Decreased Quantity= Low BMD Impaired bone quality = +

  5. Who would you investigate for osteoporosis? • Someone with rheumatoid arthritis • A postmenopausal 56 year old woman • Someone whose CXR incidentally noted osteopenia • Someone complaining that they are 3 inches shorter than they remembered • An alcoholic

  6. How do you assess risk for OP, i.e. low BMD and/or poor quality bone? • Risk Factors—those majors and minors

  7. Table 3: Factors that identify people who should be assessed for osteoporosis Major risk factorsMinor risk factors • Age > 65 years* • Rheumatoid arthritis • Vertebral compression fracture* • Past history of clinical hyperthyroidism • Fragility fracture after age 40* • Chronic anticonvulsant therapy • Family history of osteoporotic fracture* (especially maternal hip fracture) • Low dietary calcium intake • Systemic glucocorticoid therapy* of > 3 months duration • Smoker • Excessive alcohol intake • Malabsorption syndrome • Excessive caffeine intake • Primary hyperparathyroidism • Weight < 57 kg • Propensity to fall • Weight loss > 10% of weight at age 25 • Osteopenia apparent on x-ray film • Chronic heparin therapy • Hypogonadism • Early menopause (before age 45) *=markers for impaired bone quality

  8. Who would you investigate for osteoporosis? • Someone with rheumatoid arthritis (minor)-what if they were also on steroids? • A postmenopausal 56 year old woman • Someone whose CXR incidentally noted osteopenia (major) • Someone complaining that they are 3 inches shorter than they remembered (stay tuned….) • An alcoholic (minor…but what if they fell a lot in their drunken stupour?....)

  9. How would you investigate for osteoporosis? • Calcaneal USS • Bone turnover markers (i.e. alk phos, osteocalcin, etc) • Single photon absorptiometry (SPA) • Dual-energy xray absorptiometry (DXA) • Lateral thoracic xray

  10. What is the WHO definition of OP on DEXA? • T score of -1.0 • Z score of -2.5 • Z score of -1.0 • T score of -2.5

  11. Table 11.6. Ten-year fracture risk for women Lowest T-Score Lumbar spine, total hip, femoral neck, trochanter Age (years) Low risk Moderate risk High risk <10% 10%–20% >20% 50 >–2.3 –2.3 to –3.9 <–3.9 55 >–1.9 –1.9 to –3.4 <–3.4 60 >–1.4 –1.4 to –3.0 <– 3.0 65 >–1.0 –1.0 to –2.6 <–2.6 70 >–0.8 –0.8 to –2.2 <–2.2 75 >–0.7 –0.7 to –2.1 <–2.1 80 >–0.6 –0.6 to –2.0 <–2.0 85 >–0.7 –0.7 to –2.2 <–2.2 A new way of reporting: fracture risk

  12. Using Fracture Risk to decide about treatments • If also using steroids or fragility fracture bump up one risk category • If both, bump up 2 (i.e. automatically highest risk) • If risk <10% (low risk): healthy lifestyle • If risk >20% (high risk):HLS + medications • If risk 10-20% (moderate risk): HLS + personalize treatment

  13. NEWS FLASH:The 3C’s, an A and an S • If you dx OP the following Lab tests are recommended in all patients to exclude secondary causes: CBC Ca Cr Alk Phos SPE

  14. All patients should have adequate calcium and vitamin D. For patients over 50 adequate is: • 1000 mg elemental calcium and 400 IU Vit D • 1000 mg calcium carbonate and 400 IU Vit D • 1500 mg elemental calcium and 1000 IU Vit D • 1500 mg calcium carbonate and 1000 IU Vit D • 1500 mg elemental calcium and 800 IU Vit D

  15. ….and they should be physically active. For OP prevention purposes physically active is: • Weight lifting at least 4 times a week • Swimming >/= 30 minutes at least 3 times a week • Aerobic activity x 30 minutes most days of the week • Weight bearing exercise >/=30 minutes at least 3 times a week

  16. A 55 year old male has a 23% risk of fracture. Best management would be: • Advise about exercise, ca and Vit D and redo BMD in 1-3 years • Calcitonin • Alendronate • Risedronate • Testosterone

  17. A 55 post menopausal woman with a BMD of -2.6 would best be treated with: • Raloxifene • Estrogen and progesterone • Etidronate • Risedronate • Alendronate

  18. A 55 year old woman with a BMD of -1.5 who fractured her wrist after tripping over a telephone cord and falling would best be treated with: • Estrogen and progesterone • Calcitonin • Alendronate • Risedronate • Etidronate • Raloxifene

  19. A 67 year old male with a BMD of -2.6 in his hip and -1.9 in his spine would best be treated with: • Testosterone • Etidronate • Risedronate • Alendronate • Raloxifene

  20. Good Luck May they ask you all the right questions

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