1. Osteoporosis Update DR. SYLVIE OUELLETTE RHEUMATOLOGIST

2. Disclosures  Speaker programs  AbbVie, Amgen  Research  Amgen, Novartis  Education/ conference support  Amgen, Roche  Advisory Boards  AbbVie, Amgen, UCB, Roche

3. Objectives  By the end of this presentation, you will be able to:  Effectively counsel patients regarding Calcium and Vitamin D supplementation  Counsel patients regarding risk of atypical femoral fractures with osteoporosis therapy  Have a plan for when and how to consider treatment interruption for patients who have received anti-resorptives for osteoporosis

5. Key Changes from 2002 1 to 2010 2 – Osteoporosis Canada  Higher daily vitamin D supplementation (D3) 3  400 – 1000 IU for individuals < 50 years  800 – 2000 IU for individuals > 50 years  Lower daily calcium intake (from all sources): 1200 mg  Updated evidence-based approach to therapies 1. Brown JP, Josse RG. CMAJ 2002; 167(10 Suppl):S1-34. 2. Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print]. 3. Hanley DA, et al. CMAJ 2010; 182: E610-E618.

6. Calcium - What I used to do  Concerns of calcium supplement  Kidney stones  Cardiovascular events  GI intolerance  Favour dietary Calcium (3-4/d)  Milk  Yogurt/ cottage cheese  Block cheese  Calcium fortified orange juice, soy milk, almond milk

8. Calcium - What I do now  Community dwelling individuals  No demonstrated benefit to promoting dietary Calcium or supplements  Benefits likely = harm  Frail, institutionalized patients  Encourage Calcium to 1000 mg/d  Diet first  Then supplement  Supported by  Weaver CM et al, OI 2016, 27:367  Chapuy MC et al, NEJM 327(23):1637

9. Vitamin D  Essential for Calcium homeostasis  Vitamin D receptors in muscle  Vitamin D deficiency associated with muscle weakness  Studies suggested  Decreased incidence of falls, fractures  Improved lower extremity function in high risk seniors

10. Vitamin D – Hansen KE JAMA Int Med 2015;175(10): 1612-21  3 year DBRCT of 230 post-menopausal women less than 75 yo  Vitamin D 800 IU daily + twice monthly placebo  Daily placebo and twice monthly Vitamin D 50 000 IU  No difference in:  BMD  Muscle mass  Timed Up and Go  Number of falls  Functional status

11. Vitamin D – Bischoff-Ferrari HA, JAMA Int Med 2016;176(2):175-183  1 year, DBRCT  200 men and women over 70 yo with prior fall (community-dwelling)  Low-dose control group – Vitamin D3 24 000 IU monthly  Vitamin D3 60 000 IU monthly  Vitamin D3 24 000 IU + 300 mcg of calcifediol monthly  Despite improved Vitamin D levels,  No benefit on lower extremity function  INCREASED falls with higher doses

12. Vitamin D – what I do now  Community-dwelling adults (with no other health issues)  No benefit to greater than 800-1000 IU/d Vitamin D3  Institutionalized patients  Consider supplement 1000-2000 IU/d  Can consider pooled weekly dose, but not monthly or greater interval

14. Drug holiday

15. Risk of Fractures Adler et al JBMR, 31(1), 16-35

16. Fracture risk of bisphosphonates N Engl J Med 2016;374:254-62. DOI: 10.1056/NEJMcp151 3724

17. NNT 90 NNH 800 Weighing the risks and benefits of bisphosphonate treatment Based on treatment for 3 years - Black DM, Rosen CJ. N Engl J Med 2016;374:254-262.

18. Drug Holiday  Task Force of the American Society for Bone and Mineral Research  JBMR 2016, 31(1): 16-35  Treatment decisions MUST be individualized

19. Drug holiday - Exclusions  2014, Epidemiology/Quality of Life Working Group of the International Osteoporosis Foundation  HIGH risk patients  Lowest T-score < -3.5  Glucocorticoids >5 mg/d  History of multiple fractures

20. Adler et al JBMR, 31(1), 16-35

21. Summary  In high risk patients, treatment with bisphosophonates out-weighs risks of atypical femoral fractures  May consider halting therapy with bisphosphonates after 5 years (3 yrs if IV)  Community-dwelling individuals probably don’t need Calcium supplements or advice about dairy  High dose Vitamin D is unlikely to confer much benefit

22. How much Calcium supplement would you recommend to a 65 yo woman?  A- 1500 mg/d as supplement  B- 1200 mg/d (including her diet AND supplement)  C- none, if she is community dwelling

23. How much Calcium supplement would you recommend to a 65 yo woman?  A- 1500 mg/d as supplement  B- 1200 mg/d (including her diet AND supplement)  C- none, if she is community dwelling

24. How long should patients continue on anti- resorptive therapy?  A – it depends on fracture risk  B – 5 to 10 years  C – indefinitely

25. How long should patients continue on anti- resorptive therapy?  A – it depends on fracture risk  B – 5 to 10 years  C – indefinitely

26. Questions?