Alimohammad Fatemi Assistant Professor of Rheumatology 1

OSTEOPOROSIS A skeletal Disorder: – Compromised Bone Strength – Increased Risk of Fracture 2 Adams, Nat Rev Endocrinol. 2013

Bone Quality Bone Mineral Bone Material 3 BONE STRENGTH Adams, Nat Rev Endocrinol. 2013

Vertebra Body 4 NormalOsteoporosis

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Epidemiology 200 million women worldwide 1/3 women aged /3 women aged >80 6 IOF, 2015 (

Epidemiology 7 IOF, 2015 (

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Diagnosis 9 Comparison to Young-Adult Mean BMD

WHO CLASSIFICATION Superior to Normal Normal Osteopenia Osteoporosis T

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FRACTURE RISK 50 YEARS AND OVER WOMEN MEN Femur22.9% 10.7% Spine Wrist Any Fracture Kanis JA et al, Osteoporos Int, 2000:11:

Vertebrae Hip Wrist Age (Years) Annual incidence per 1000 women Incidence of Osteoporotic Fractures in Women Wasnich RD, Osteoporos Int 1997;7 Suppl 3:68-72

Incidence of Osteoporotic Fractures in Men Age (Years) Vertebrae Hip Wrist Annual incidence per 100,000 men Wasnich RD, Osteoporos Int 1997;7 Suppl 3:68-72

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Cooper C, Am J Med, 1997;103(2A):12S-17S 80% One year after a hip fracture: Patients (%) Unable to carry out at least one independent activity of daily living All Fractures Are Associated With Morbidity

40% Unable to walk independently 80% One year after a hip fracture: Patients (%) Unable to carry out at least one independent activity of daily living Cooper C, Am J Med, 1997;103(2A):12S-17S

All Fractures Are Associated With Morbidity 40% Unable to walk independently 30% Permanent disability 80% One year after a hip fracture: Patients (%) Unable to carry out at least one independent activity of daily living Cooper C, Am J Med, 1997;103(2A):12S-17S

All Fractures Are Associated With Morbidity 40% Unable to walk independently 30% Permanent disability 20% Death within one year 80% One year after a hip fracture: Patients (%) Unable to carry out at least one independent activity of daily living Cooper C, Am J Med, 1997;103(2A):12S-17S

Survival After Hip Fracture Trombetti A et al, Osteoporos Int, 2002;13: Hip fractured Women Hip fractured Men Women Men Expected Survival In The General Population Survival probability Time after hip fracture (years) 0

LIFE STYLE DIET Dairy Products SPORT Walking Aerobic WRONG HABITS Smoking Alcohol Excess Coffee Excess Protein

CALCIUM Need – 1000 mg Men, Women before Menopause – 1500 mgWomen after Menopause

CALCIUM Need – 1000 mg Men, Women before Menopause – 1500 mgWomen after Menopause Source – Dairy ProductsMilk, Yoghourt, Cheese

CALCIUM Need – 1000 mg Men, Women before Menopause – 1500 mgWomen after Menopause Source – Dairy ProductsMilk, Yoghourt, Cheese  Milk 300 mg/cup  Cheese 300 mg/Oz  Yogurt 300 mg/cup

CALCIUM Need – 1000 mg Men, Women before Menopause – 1500 mgWomen after Menopause Source – Dairy ProductsMilk, Yoghourt, Cheese – VegetablesBroccoli

CALCIUM Need – 1000 mg Men, Women before Menopause – 1500 mgWomen after Menopause Source – Dairy ProductsMilk, Yoghourt, Cheese – VegetablesBroccoli – TabletsCalcium Carbonate, Citrate

CALCIUM Are Calcium Tab safe? – Risk of Cardiovascular event 29 BMJ 336, 262–266 (2008) JAMA Intern. Med.

Patients should be encouraged to obtain 500– 1,000 mg of calcium from their daily diet 30 CALCIUM Nat. Rev. Endocrinol. 9, 255–256 (2013)

VITAMIN D Need – 50 to 70 years400 units – > 70 years600 units

WHO? History of hip or vertebral fracture T-score ≤-2.5

WHO? History of hip or vertebral fracture T-score ≤-2.5 T-score between -1 and -2.5

CLINICAL RISK FACTORS for FRACTURE Age Sex Weight Height History of Fracture Parental History of Fracture Current Smoking Steroid Use Alcohol Use RA Secondary Osteoporosis 36

FRAX 37

WHO? History of hip or vertebral fracture T-score ≤-2.5 T-score between -1 and -2.5 AND: – 10-year probability of hip fracture ≥3 percent or – 10-year probability of any major osteoporosis-related fracture ≥20 percent

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Drugs Used In Osteoporosis Treatment HRT SERM/Raloxifene Calcitonin Bisphosphonates - Alendronate - Zoledronate - Ibandronate  Parathyroid Hormone (PTH) Denosumab Strontium Ranelate

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ESRTROGEN Antiresorptive Fracture Risk Its effect lost 1 year after stop it 42

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SERM Raloxifene 60 mg – Vertebral Fracture – Breast Cancer – DVT 44

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Calcitonin Nasal Spray (200 unit/day) – Vertebral Fracture – No effect on Hip fracture – Minimal effect on Bone Density 46

Calcitonin Safe? 47

Calcitonin Safe? – May Increase Skin Cancer 48

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BISPHOSPHONATES Fracture Risk – Vertebral – Non Vertebral Bone Density 50

BISPHOSPHONATES Adverse Effects: – Atypical fracture of Femur – Osteonecrosis of Jaw – Esophageal Cancer? 51

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PTH Anabolic Agent 20 μg Daily SC (18-24 months) 53

Indications: – Vertebral Compression Fracture – Other Osteoporotic-Fracture with Low BMD – T-score < PTH

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DENOSUMAB An antiresorptive Suppress Osteoclasts 60 mg every 6 months (SC) Injection site reaction 56

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STRONTIUM RANLEATE Bone Formation Bone Resorption 58

STRONTIUM RANLEATE Bone Formation Bone Resorption Powder 2g/ Day 59

STRONTIUM RANLEATE Bone Formation Bone Resorption Powder 2g/ Day But, Increases DVT 60

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Menopause Prevention HRTif no contraindication (WHI)

Menopause Prevention HRTif no contraindication (WHI) Anti-Resorptive Agents Alendronate 70 1 /week

Menopause Prevention HRTif no contraindication (WHI) Anti-Resorptive Agents Alendronate 70 1 /week Calcium + Vitamin D

FOLLOW-UP Every 6 Months Ca, P, Alkaline Phosphatase, 24 h Calciuria Every 1.5 to 3 Years BMD Change of Treatment Strategy Side Effects Non-Responsive

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