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Osteoporosis Case Studies March 2012 Ronald C. Hamdy, MD, FRCP, FACP Professor of Medicine

Osteoporosis Case Studies March 2012 Ronald C. Hamdy, MD, FRCP, FACP Professor of Medicine Director, Osteoporosis Center Professor/Chair, Geriatric Medicine East Tennessee State University Editor-in-Chief, Journal of Clinical Densitometry.

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Osteoporosis Case Studies March 2012 Ronald C. Hamdy, MD, FRCP, FACP Professor of Medicine

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  1. Osteoporosis Case Studies March 2012 Ronald C. Hamdy, MD, FRCP, FACP Professor of Medicine Director, Osteoporosis Center Professor/Chair, Geriatric Medicine East Tennessee State University Editor-in-Chief, Journal of Clinical Densitometry

  2. Mrs. MB, 51 years old WW, Concerned about Osteoporosis • Asymptomatic • Natural menopause 2 years ago • Exercises regularly – strenuous routine • Good dietary calcium and vitamin D intake • Family history: negative for osteoporosis • No prescribed medications • OsCal 500 mg + Vitamin D twice daily • Multivitamins once a day • Weight 121 pounds; height 64”

  3. Mrs. MB, 51 years old WW, Concerned about Osteoporosis • Asymptomatic • Natural menopause 2 years ago • Exercises regularly – strenuous routine • Good dietary calcium and vitamin D intake • Family history: negative for osteoporosis • No prescribed medications • OsCal 500 mg + Vitamin D twice daily • Multivitamins once a day • Weight 121 pounds; height 64”

  4. Mrs. MB, 51 years old WW, Concerned about Osteoporosis Area BMD T-score L1 9.9 1.419 + 2.4 L2 11.4 1.445 + 2.9 L3 13.9 1.483 + 2.4 L4 14.1 1.494 + 1.7 L1-4 48.8 1.463 + 2.6

  5. Mrs. MB, 51 years old WW, Concerned about Osteoporosis RIGHT HIP BMD T-score Femoral Neck 1.081 + 0.8 Trochanter 0.773 - 0.2 Total Hip 1.047 + 0.4 LEFT HIP Femoral Neck 1.016 + 0.3 Trochanter 0.818 + 0.3 Total Hip 1.047 + 0.4 Area BMD T-score L1 9.9 1.419 + 2.4 L2 11.4 1.445 + 2.9 L3 13.9 1.483 + 2.4 L4 14.1 1.494 + 1.7 L1-4 48.8 1.463 + 2.6 Lunar, Prodigy

  6. Mrs. MB, 51 years old WW, Concerned about Osteoporosis • Diagnosis: Normal bone density (WHO criteria)

  7. Mrs. MB, 51 years old WW, Concerned about Osteoporosis • Diagnosis: Normal bone density (WHO criteria) • Management recommendations: Maintain Bone Mass – Healthy lifestyle Repeat DXA scan 2 years

  8. Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSC RIGHT Fem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034 Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053 Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.40.078 0.050 LEFT Fem Neck 1.016 + 0.3 0.945 - 0.3 - 7.00.071 0.031 Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.30.068 0.042 Total Hip1.047 + 0.4 0.966 - 0.3- 7.7 0.081 0.022 L1-L41.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028

  9. Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSC RIGHT Fem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034 Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053 Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.40.078 0.050 LEFT Fem Neck 1.016 + 0.3 0.945 - 0.3 - 7.00.071 0.031 Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.30.068 0.042 Total Hip1.047 + 0.4 0.966 - 0.3- 7.7 0.081 0.022 L1-L41.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028 Laboratory investigations: Blood Chemistry profile, Vit. D, PTH: Within normal limits.

  10. Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis Normal BMD

  11. Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis Normal BMD Bone loss sustained: Expected Post-menopausal loss Management recommendation: Maintain Bone mass Repeat DXA scan 1 year

  12. Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis

  13. Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis VERY VERY

  14. Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis Base 2-yrs % 1-yr BMD change 04-05 Region BMD BMD Diff. BMD T-score % Abs LSC RIGHT Fem Neck 1.081 0.985 - 8.9 0.977- 0.1- 0.8 0.008 0.034 Trochanter 0.773 0.732 - 5.3 0.713 - 0.5 - 0.3 0.019 0.053 Total Hip 1.047 0.969 - 7.4 0.958- 0.3- 0.80.0110.050 LEFT Fem Neck 1.016 0.945 - 7.0 0.938- 0.3- 0.70.0070.031 Trochanter 0.818 0.750 - 8.3 0.739- 0.1- 1.50.0110.042 Total Hip1.047 0.966 - 7.70.948- 0.3- 1.80.0180.022 L1-L41.463 1.394 - 5.0 1.374+ 1.7- 1.40.0200.028

  15. Age-associated Changes in Bone Mass Peak Bone Mass 1- 5% annually 1- 2% annually MENOPAUSE Bone Mass ActiveGrowth SlowLoss RapidLoss ContinuingLoss 10 20 30 40 50 60 70 80 90 Age in Years

  16. Mrs. MRW, 76 years WW • Low back pain , gradually worsening • Episode of very severe pain, incapacitating, 3 weeks ago • Positive family history; Sister 85 yrs, died after hip fracture • Daily calcium intake: about 1500 mg • CBC, CMP, TSH; within normal limits • Meds: NSAID, calcium supplements • Weight 130 pounds, height 64” • X-ray evidence of vertebral compression fracture

  17. Mrs. MRW, 76 years WW • Low back pain , gradually worsening • Episode of very severe pain, incapacitating, 3 weeks ago • Positive family history; Sister 85 yrs, died after hip fracture • Daily calcium intake: about 1500 mg • CBC, CMP, TSH; within normal limits • Meds: NSAID, calcium supplements • Weight 130 pounds, height 64” • X-ray evidence of vertebral compression fracture

  18. Mrs. MRW, 76 years WW • Low back pain , gradually worsening • Episode of very severe pain, incapacitating, 3 weeks ago • Positive family history; Sister 85 yrs, died after hip fracture • Daily calcium intake: about 1500 mg • CBC, CMP, TSH; within normal limits • Meds: NSAID, calcium supplements • Weight 130 pounds, height 64” • X-ray evidence of vertebral compression fracture

  19. Mrs. MRW, 76 years WW Area BMD T-score L1 12.65 0.849 - 0.69 L2 11.80 1.012 - 0.15 L3 15.55 0.920 - 1.49 L4 11.61 1.123 + 0.06 L1-4 51.61 0.969 - 0.71

  20. Mrs. MRW, 76 years WW Area BMD T-score L1 12.65 0.849 - 0.69 L2 11.80 1.012 - 0.15 L3 15.55 0.920 - 1.49 L4 11.61 1.123 + 0.06 L1-4 51.61 0.969 - 0.71 Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8

  21. Mrs. MRW, 76 years WW Diagnosis: Osteoporosis 10-years % # probability: Hip # 33 Other # 50 Area BMD T-score L1 12.65 0.849 - 0.69 L2 11.80 1.012 - 0.15 L3 15.55 0.920 - 1.49 L4 11.61 1.123 + 0.06 L1-4 51.61 0.969 - 0.71 Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8

  22. Mrs. MRW, 76 years WW Area BMD T-score L1 12.65 0.849 - 0.69 L2 11.80 1.012 - 0.15 L3 15.55 0.920 - 1.49 L4 11.61 1.123 + 0.06 L1-4 51.61 0.969 - 0.71 Diagnosis: Osteoporosis Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8 Goal: Reduce Fracture Risk especially hip

  23. Mrs. MRW, 76 years WW • Bisphosphonates: Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, BonivaZoledronate, Reclast • Raloxifene, Evista • Calcitonin, Miacalcin • Teriparatide, Forteo • Denosumab, Prolia Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8 Goal: Reduce Fracture Risk especially hip

  24. Risk for hip fractures relative to placebo for participants who are at high risk for fracture, by agent MacLean, C. et. al. Ann Intern Med 2008;148:197-213

  25. FDA Approved Medication –Hip Fractures * Study aborted 18 months

  26. Mrs. MRW, 76 years WW • Bisphosphonates: Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, BonivaZoledronate, Reclast • Raloxifene, Evista • Calcitonin, Miacalcin • Teriparatide, Forteo • Denosumab, Prolia Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8 Diagnosis: Osteoporosis Goal: Reduce Fracture Risk especially hip

  27. Mrs. MRW, 76 years WW • Bisphosphonates: Alendronate, Fosamax, generics Risedronate, Actonel, AtelviaIbandronate, BonivaZoledronate, Reclast • Raloxifene, Evista • Calcitonin, Miacalcin • Teriparatide, Forteo • Denosumab, Prolia Vertebral compression fractures RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6 Trochanter 0.535 - 1.7 Total Hip 0.736 - 1.7 LEFT HIP Femoral Neck 0.554 - 2.7 Trochanter 0.516 - 1.8 Total Hip 0.724 - 1.8 Diagnosis: Osteoporosis Goal: Reduce Fracture Risk especially hip

  28. Mrs. MRW, 76 years WW • CONCERNED ABOUT: • OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES

  29. Mrs. MRW, 76 years WW • CONCERNED ABOUT: • OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES Probability: 1:10,000 to 1:100,000

  30. Mrs. MRW, 76 years WW • CONCERNED ABOUT: • OSTEONECROSIS OF THE JAW (ONJ) • ATYPICAL FEMORAL SHAFT FRACTURES (AFSF) Probability#: Hip #33 % 1:3 Other # 50 % 1:2 Probability: 1:10,000 to 1:100,000

  31. Atypical femoral shaft fracturesProdromal symptoms/signs • Clinical: Pain, localised tenderness • Imaging: X-rays, technetium scan, MRI, CT-scans, MRI • Laboratory: Bone turnover markers: N-TX, C-TX

  32. 54%* Prevention of Hip fracture with Hip Protectors 1801 elderly men and women in long stay or supported home care Cumulative Hazard of Hip Fractures *P=0.008 Months Kannus P, et al. N Engl J Med 2000; 343:1506-1513

  33. Mrs. MRW, 76 years WW • Bisphosphonates: alendronate, risedronate, ibandronate zoledronate • Raloxifene • Calcitonin • Teriparatide • Denosumab ? Kyphoplasty ?? Vertebroplasty

  34. Mrs. MRW, 76 years WW • Bisphosphonates: alendronate, risedronate, ibandronate zoledronate • Raloxifene • Calcitonin • Teriparatide • Denosumab ? Kyphoplasty ?? Vertebroplasty Calcium/vitamin D

  35. DAILY CALCIUM INTAKE Elemental Calcium (mg) • Postmenopausal: 1,500 • Premenopausal: 1,000 • Pregnant/nursing: 1,200 - 1,500 • Men < 65 years: 1,000 • Men > 65 years: 1,500

  36. Mrs. IB, WW, 56 years • Asymptomatic • Surgical menopause when 41 years • Exercises regularly • Good dietary calcium and vitamin D intake • Family history: positive for osteoporosis • No prescribed medications • CitraCal 500 mg + Vitamin D twice daily • Multivitamins once a day • Weight 175 pounds; height 64” – No height loss

  37. Mrs. IB, WW, 56 years • Asymptomatic • Surgical menopause when 41 years • Exercises regularly • Good dietary calcium and vitamin D intake • Family history: positive for osteoporosis • No prescribed medications • CitraCal 500 mg + Vitamin D twice daily • Multivitamins once a day • Weight 175 pounds; height 64” – No height loss

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