UNDERSTANDING OSTEOPOROSIS Stephen L. Kates, MD Hansj ӧ rg Wyss Professor of Orthopaedic Surgery Department of Orthopedics and Rehabilitation Associate Director, Center for Musculoskeletal Research University of Rochester Medical Center THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

WHAT IS OSTEOPOROSIS? Skeletal disorder with:  Compromised bone strength  Increased risk of fractures  Deterioration of microarchitecture Most common bone disease

Healthy vertebra Osteoporotic vertebra Slide 3

OSTEOPOROSIS Normal bone Osteoporosis Loss of critical bony interconnections Thinner internal support Slide 4

OSTEOPOROSIS OF THE HIP Loss of critical bony trabeculae occurs with osteoporosis Slide 5

BONY ANATOMY CHANGES WITH AGE Slide 6

WHAT ARE BONES MADE OF? Minerals bound to proteins Calcium Hydroxyapatite Organized collagen fibers Cells — osteocytes, osteoblasts, osteoclasts Slide 7

BONE REMODELING Slide 8

BONES CHANGE DURING LIFE Modeling as a child and adolescent Remodeling throughout life Peak bone mass reached in your 20s Remodeling allows bones to heal Resorption in later years Slide 9

WHAT KEEPS NORMAL BONES HEALTHY? Genetic factors Moderate physical activity Calcium Vitamin D Hormones  Parathyroid hormone  Calcitonin  Estrogen  Testosterone Slide 10

CAUSES OF OSTEOPOROSIS Primary Secondary Nutrition Lifestyle (Exercise, smoking, alcohol) Hormonal problems Age Medications (steroids, seizure meds) Slide 11

FRAGILITY FRACTURE Caused by a fall from a standing height or less Osteoporosis is the cause 33%  50% of women will develop a fragility fracture 15%  33% of men get a fragility fracture Likelihood increases with age Slide 12

With fracture Without fracture OSTEOPOROSIS: A 2-STAGE DISEASE Slide 13

HIP FRACTURE Lifetime Incidence in Women 1:6 Slide 14

ANNUAL INCIDENCE OF OSTEOPOROTIC FRACTURES (USA) Fracture Type Hip 350,000+ Vertebral (Morphometric) 750, ,000+ Wrist 0 250, , , ,000 Other Only 30% of morphometric vertebral fractures are “clinically apparent” Clinically apparent Slide 15

DIAGNOSIS OF OSTEOPOROSIS DEXA scan is best at present T score  Compares density relative to peak bone mass (normal healthy 25-year-old)  Matched to sex and race Z score compares density to peers Slide 16

X-RAY TECHNIQUES DEXA pDXA Slide 17

Slide 18 T score Normal>  1 Osteopenia  2.5 Osteoporosis   2.5 Severe osteoporosis   2.5 with fracture Mainly for spine and hip in women WHO DEFINITIONS

WHO SHOULD BE TESTED? All women aged 65 and older regardless of risk factors Younger postmenopausal women with 1 or more risk factors (other than being white, postmenopausal, and female) Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity) Slide 19

CASES IN WHICH MEDICARE COVERS DEXA EVERY 2 YEARS Estrogen-deficient women at clinical risk of osteoporosis Individuals with vertebral abnormalities Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy Individuals with primary hyperparathyroidism Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy Slide 20

WHAT ABOUT MEN? Fragility fracture Steroid use Forearm fracture Vertebral fracture Slide 21

OSTEOPOROSIS IS TREATABLE Nutrition Exercise Lifestyle changes Medications Fall prevention Slide 22

CALCIUM Requirements  Young 1000 mg/day in 2 doses  Older 1500 mg/day in 3 doses Calcium gluconate Calcium citrate Calcium carbonate Whatever you can tolerate Slide 23

BODY WEIGHT Very low weight is a risk factor (<127 lb) Normal weight is best Obesity may predispose to falls Slide 24

VITAMIN D3 (1 of 2) Deficiency is common with age Lack of sunlight Deficiency = osteomalacia Very common in nursing homes May cause fractured bones not to heal Slide 25

VITAMIN D3 (2 of 2) Vitamin D3 — not D2 — is best Dose  Young 400 units/day  Older 600 to 800 units/day — maintenance  If deficient, 50,000 units/day A blood test is needed to determine deficiency Sunlight helps — we have very little Essential for bone health!!!!!! Slide 26

EXERCISE Weight-bearing exercise is best Low-impact exercise can help prevent falls Weight training Tai Chi Exercise helps other body systems too You have control over this! Helps to start young Slide 27

FALL PREVENTION Medications can cause falls Poor lighting Throw rugs Fall-proofing the home Exercise, balance, and strength training Correct your vision Pets Slide 28

CAUSES OF FALLS AT HOME Tripping Slipping Pets Ladders Stairs Poor lighting Slide 29

LIFESTYLE Alcohol in moderation only Alcohol can cause osteoporosis Alcohol can cause falls Cigarette smoking causes osteoporosis  Makes bones heal poorly  Smoking cessation is the best plan Slide 30

MEDICATIONS Many medications can hurt your bones  Steroids (prednisone)  Seizure drugs  Elevated thyroid hormone  Cancer drugs (Lupron) Avoid these if possible DEXA scans necessary with these Slide 31

OSTEOPOROSIS MEDICATIONS Antiresorptive drugs Anabolic therapies Slide 32

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ANTI-RESORPTIVE THERAPIES: BISPHOSPHONATES Non  hormone compounds Bind to hydroxyapatite crystals in bone Inhibit the osteoclasts that resorb bone Cause osteoclasts to die prematurely Half-life 6 to 10 years in bone Can be taken by mouth or IV Slide 34

ORAL BISPHOSPHONATES Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Boniva) IV bisphosphonates are used when oral medications are not tolerated Work for men and women Best treatment for steroid osteoporosis Slide 35

Fracture Risk Reduction (%) Any symptomatic Wrist Vertebral (radiographic) Multiple vertebral 54% 27% 45% 87% 48% 30% Non- vertebral Hip Painful vertebral 31% 36% Non-vertebral osteoporotic* *Fracture of the clavicle, humerus, pelvis, hip, or leg Black DM et al. JCEM. 2000;85: Slide 36 ALENDRONATE Reduced the risk of fracture at all key sites in women with osteoporosis

BISPHOSPHONATES: PROBLEMS Reflux Must be upright for 1 hour Mostly GI symptoms Rare: osteonecrosis of jaw Long-term effects not known Slide 37

ANTI-RESORPTIVE THERAPIES: SERMs Raloxifene and tamoxifen Bind to estrogen receptor Have a good effect on bone density For women only Should be used with calcium, vitamin D Reduce risk of breast cancer Increase risk of a blood clot Slide 38

CALCITONIN Hormone that regulates calcium, bone Synthetic salmon calcitonin Decreases bone resorption Reduces pain from vertebral fractures Nasal spray or injection Slide 39

TERIPARATIDE (FORTEO) (1 of 3) Synthetic hormone like human parathyroid hormone Builds bone mass Improves bone quality Increases the life span of osteoblasts Injection for 2 to 3 years Slide 40

TERIPARATIDE (FORTEO) (2 of 3) FDA-approved for women with:  High fracture risk  Multiple fractures  Failure of other therapies FDA-approved for men with:  Hypogonadal osteoporosis  High fracture risk Slide 41

TERIPARATIDE (FORTEO) (3 of 3) Contraindications Previous radiation therapy Paget’s disease Young patients still growing Very expensive Slide 42

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