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Osteoporosis

Osteoporosis. Elizabeth Ryan, MD Geriatric Fellow in Family Medicine Jan 22, 2013. What’s osteoporosis?. Loss of bone mineral density and destruction of bone matrix micro-architecture Clinically important disease that increases risk of fracture. What about “osteopenia”?

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Osteoporosis

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  1. Osteoporosis Elizabeth Ryan, MD Geriatric Fellow in Family Medicine Jan 22, 2013

  2. What’s osteoporosis? • Loss of bone mineral density and destruction of bone matrix micro-architecture • Clinically important disease that increases risk of fracture • What about “osteopenia”? • Old term for “low bone mineral density” • Not technically a disease

  3. Breaking news: • We’re getting old! • 1 in 2 white* women and 1 in 5 men will have an osteoporotic fracture • It costs a ton! • 432,000 hospital admissions • 180,000 nursing home admissions • $17 billion in cost • We can prevent and treat it!

  4. Tell your friends: We need geriatricians!

  5. In 40 minutes you’ll know how to: • Recommend prevention measures • Screen appropriately with DXA • Use FRAX to decide whom to treat • Use bisphosphonates as 1st line • Consider 2nd line treatments if needed • Think through a few controversies…

  6. Inpatient Case • 78yo woman, resident of Merrill Gardens (ALF) admitted through ER after a mechanical fall from standing, found to have a comminuted right intra-trochanteric femur fracture. She went to the OR on HD#2 and is recovering well in SOI (with the expected delirium) and plans to d/c to SNF tomorrow. • Should she get a DXA? • Should you start a bisphosphonate?

  7. Outpt Case #1 • A 65yo woman with a history of hypertension, and periodic bouts of moderate depression has not been to clinic in a year. She received your letter suggesting a “Welcome to Medicare” visit and wonders what you want to talk about. • Will you recommend screening for osteoporosis? • If she gets a DXA how will you decide whether to treat her?

  8. Outpt Case #2 • A 58yo woman with a history of smoking and moderate persistent asthma is here for refills. • Should she get a DXA?

  9. Break into 3 groups Scribble some answers; don’t obsess. We’ll go through them at the end.

  10. GOOD • Sun • Wt-bearing exercise • Vitamin D and Calcium

  11. Bad • Cigarettes • Excessive alcohol • Bone-leeching meds • Sedentary skinniness • Menopause • Falling down • Chronic disease • Space travel

  12. Whom should we screen? • USPSTF and NOF disagree somewhat. (National Osteoporosis Foundation) • Guess which is more conservative? 

  13. USPSTF • Women age ≥65 USPSTF B • Women <65 years whose 10-year fracture risk ≥ 65yo white woman USPSTF B • Men USPSTF I

  14. Thanks, NOF! National Osteoporosis Foundation Screen with DXA: • Women 65 and older, men 70 and older • Anyone 50-69 whose profile increases risk

  15. How do we screen? • DXA! – dual energy x-ray absorptiometry

  16. How are results reported?

  17. Who needs treatment? • Anyone with diagnosed osteoporosis • T-score at hip ≤ -2.5 (ignore Z score) • Fragility fracture (what’s this?!) • NOF recommends treating in LBMD if high FRAX risk of fracture: • 3% for hip OR • 20% major osteoporosis-related fracture.* FRAX tool

  18. What do you prescribe? • Bisphosphonates • Which one? • Alendronate • Daily PO • Generic • Good long-term safety data • Zoledronate if not an option • Annual

  19. Why all the weird instructions? • Take drug holidays • Make sure they’re on Vit D and Calcium • Take pill upside down with star fruit juice • Esophagitis, esophageal ulcers, strictures. • Jaw osteonecrosis • Weird femur fractures

  20. Bisphosphonates Inhibit Osteoclasts

  21. When is 2nd line indicated? • Bisphosphonates not tolerated, possible • Bisphosphonates contraindicated • Denosumab (RANKL inhibitor, inhibits osteoclasts) • Raloxifene (SERM, activates estrogen pathways) • Strontium (previously for bone mets) • Recombinant PTH (most expensive, anabolic effect) • HRT (BMD effect doesn’t last but the neuro deficits do...)

  22. Inpatient Case • 78yo woman, resident of Merrill Gardens (ALF) admitted through ER after a mechanical fall from standing, found to have a comminuted right intra-trochanteric femur fracture. She went to the OR on HD#2 and is recovering well in SOI (with the expected delirium) and plans to d/c to SNF tomorrow. • Should she get a DXA? • Should you start a bisphosphonate?

  23. Inpt Case • 78yo woman, resident of Merrill Gardens (ALF) admitted through ER after a mechanical fall, found to have a comminuted right intra-trochanteric femur fracture. • She goes to the OR on HD#2 and is recovering well in SOI (with the expected delirium) and plans to d/c to SNF tomorrow. • Should she get a DXA? No. This is a fragility fracture (doesn’t have the mechanism to cause fx in healthy bones) and this diagnoses her with OP. No DXA need. • Should you start a bisphosphonate? Now? In 6 weeks?

  24. Outpt Case #1 • A 65yo woman with a history of hypertension, and periodic bouts of moderate depression has not been to clinic in a year. She received your letter suggesting a “Welcome to Medicare” visit and wonders what you want to talk about. • Will you recommend screening for osteoporosis? • If she gets a DXA how will you decide whether to treat her?

  25. Outpt Case #1 • A 65yo woman with a history of hypertension, and periodic bouts of moderate depression has not been to clinic in a year. She received your letter suggesting a “Welcome to Medicare” visit and wonders what you want to talk about. • Will you recommend screening for osteoporosis? Yup; she’s 65. That’s all it takes. • If she gets a DXA how will you decide whether to treat her? Either -2.5 or, if following NOF, high FRAX.

  26. Her results… Oh jeez… • Her T-score is -2.7 at the hip • You start her on alendronate PO daily How long should she be on it? • 5 years then holiday When should you repeat her DXA? • Never because 5 years is all she’s gonna get? • After 5 years and then 2 years later? • “Evidence is lacking...”

  27. When would you repeat if her DXA were -1.7? 2012 NEJM: • Normal BMD --> osteoporosis longer than we thought • Low BMD --> osteoporosis can progress quickly NEJM Repeating DXA Recs: • Normal, mild osteopenia (T-score ≥ -1.5): 15y • Moderate osteopenia(-1.5 to -2): 5y • Advanced osteopenia (-2 to -2.5): 1y

  28. Outpt Case #2 • A 58yo woman with a history of smoking, obesity (180#, 5’3”), and moderate persistent asthma is here for refills. • Should she get a DXA?

  29. DXA in women <65? USPSTF B • Women <65 years whose 10-year fracture risk ≥ 65yo white woman • How do we figure that out? • http://www.shef.ac.uk/FRAX/ • But we don’t know a T-score! • For 50-64yo can use BMI only in FRAX OR • Can use your judgment...

  30. Outpt Case #2 • A 58yo woman with a history of smoking, obesity (180#, 5’3”) and moderate persistent asthma is here for refills. • Should she get a DXA? • Yes. This is based on her FRAX score incorporating BMI in place of T-score which gives 10y risk of osteoporotic fracture at 9.6% (>9.3% risk of baseline 65yo woman).

  31. Now you know: • Prevention measures • Screen with DXA • FRAX shows whom to treat • Bisphosphonates are 1st line • 2nd line treatments are many and expensive • Controversies • Repeating DXA • Screening men • Treating based on FRAX before osteoporosis • Length of bisphosphonate treatment • Starting post-fx bisphosphonates in-house • Use of second-line treatments

  32. References... • Can be found on the geri blog!

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