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Management of Osteoporosis in a 94-Year-Old Female: Evidence-Based Therapeutic Options

This presentation highlights the comprehensive management plan for a 94-year-old female with osteoporosis. It covers objectives, patient background, therapeutic recommendations, and monitoring guidelines. Key therapeutic agents like teriparatide and zoledronic acid are discussed, along with evidence supporting their use. Special attention is given to the patient's history of fractures, current medications, potential drug interactions, and living situation. The goal is to prevent further fractures, manage pain, and promote independent living while evaluating the cost-effectiveness and feasibility of treatments.

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Management of Osteoporosis in a 94-Year-Old Female: Evidence-Based Therapeutic Options

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Presentation Transcript

  1. Achy Breaky Bones Hilary Rowe, BScPharm VIHA Pharmacy Resident 2009-10 Geriatrics Rotation Sept 30, 2009

  2. Outline • Objectives • Introduction to the Patient • Review of Systems • DRP’s • Osteoporosis • Evidence • Recommendation • Monitoring

  3. Objectives • Review pathophysiology & diagnostic criteria for osteoporosis • Review Evidence of teriparatide & zoledronic acid • Discuss therapeutic options for a 94 yo osteoporotic female • Discuss decision & monitoring

  4. Mrs. FT • ID: 94 yo female • Admitted: • urinary retention from a UTI (resolved) • Allergies: • Sulpha (reaction unknown) • SH: • Lives alone, medications in vials, Pharmanet regular, no Hx smoking, alcohol 2 oz drink before dinner

  5. Mrs. FT • Discharge Plan: • Return home to independent living • PMHx: • Oophorectomy, hysterectomy, fractures, HTN, GERD • Meds PTA: • Felodipine, Cilazapril, Rabeprazole, Calcitonin, Tramadol/Acetaminophen, Alendronate, Acetaminophen, Calcium, Vitamin D

  6. Review of Systems

  7. Review of Systems

  8. Review of Systems

  9. Review of Systems

  10. Review of Systems

  11. DRP’s • Mrs. T requires continued assessment of pain on transfer and with physio despite present therapy of tramadol/Acetaminophen, calcitonin, and prn hydromorphone • Mrs. T is at risk of unsteadiness and falls secondary to low Na and would benefit from monitoring and continued re-assessment of her fluid and salt intake

  12. DRP’s • Mrs. T is at risk of falls secondary to experiencing a drug-drug interaction with mirtazapine and alcohol causing drowsiness and a hangover effect and would benefit from counseling in regards to alcohol intake • Mrs. T continues to experience multiple painful fractures despite standard therapy of Alendronate, Ca and Vit D and may benefit from consideration of additional therapies.

  13. Osteoporosis • Osteoclasts - ion channels that pump protons into extracellular space, ↓ in pH dissolves bone • Osteoblasts deposit new bone • Balance between these cells determines if bone is made, maintained, or lost

  14. Osteoporosis • Low bone mass and fragility due to: • peak bone mass is low • bone resorption is excessive • trabecular bone loss and increased porosity in compact bone • bone formation during remodeling is decreased • Diagnosed by fragility fracture or T score <-2.5

  15. Mrs. FT • Patient is on Calcium, Vit D, Calcitonin, Alendronate • Fracture right hip healing (March 09) • Compression Fractures of the spine: recent Sept 18th bone scan T12 & T3 • Lives alone • Cognitively intact and no compliance issues

  16. Goals of Therapy • Reduce hip and vertebral fractures • Prevent hospitalizations • Control Pain • Reduce side effects • Keep patient living independently (quality of life) • Limit financial burden

  17. Therapeutic Options • Alendronate 70mg weekly • Zoledronic acid 5mg infusion yearly • Teriparatide 20 mcg subcutaneous injection daily

  18. Studies to Discuss • Alendronate vs Teriparatide • Alendronate: Decreases the rate of bone resorption by blocking osteoclasts • Zoledronic acid vs Placebo • Zoledronic Acid: Inhibits osteoclast resorption, reducing bone turnover • Teriparatide vs Placebo • Forteo: acts on osteoblasts to stimulate new bone growth and improve bone density

  19. Body et al. J Clin Endocrinol Metab 2002

  20. Black et al. New Engl J Med 2007

  21. Black et al. New Engl J Med 2007

  22. Neer et al. New Engl J Med 2001

  23. Neer et al. New Engl J Med 2001

  24. Patient Considerations • Cost $15,000 per 18 months • Need to apply to Forteo Customer Care • Can patient do injections? • Can patient remember daily regimen? • Benefit to patient? • Drug interactions?

  25. Recommendation • Teriparatide 20mcg subcutaneous daily for 18 mo • Have Forteo nurse teach patient in hospital • Calcium carbonate 500mg elemental BID • Vitamin D 2000 units daily • Continue to mobilize with walker

  26. Monitoring

  27. Monitoring

  28. References • Neer RM, Arnaud CD, Zanchetta JR et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. New Engl J Med 2001;344:1434-41. • Black et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. New Engl J Med 2007;356:1809-22. • Body JJ, Gaich GA, Scheele WH et al. A randomized double-blind trial to compare the efficacy of teriparatide [Recombinant Human Parathyroid Hormone (1–34)] with alendronate in postmenopausal women with osteoporosis. The Journal of Clinical Endocrinology and Metabolism 2002; 87(10):4528–4535.

  29. Questions?

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