1. Osteoporosis: The silent killer
Michele T. Glasgow, MD
Midwest Orthopaedic Institute
Bone Health Center
2111 Midlands Court
Sycamore, Illinois

2. What is osteoporosis? Means “porous bone.”
Skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture

4. Osteoporosis is Common
9 million Americans have osteoporosis (~80% women)
200 million people worldwide
1 in 2 women and 1 in 4 men >50yo will have an osteoporosis fracture in their lifetime
By 2020, it is projected that there will be ~14 million Americans with osteoporosis.

5. Osteoporosis is Costly
Responsible for 2 million fractures annually
$19 billion in related costs per year
By 2025, experts estimate osteoporosis will be responsible for ~3 million fractures and $25.3 billion in costs each year

6. Osteoporosis is Serious
20% of hip fractures die within one year REGARDLESS OF REPAIR from complications related to surgery or other co-morbidities
~50% of hip fracture survivors require long term nursing home care and have some degree of permanent disability

7. Osteoporosis is “Silent”
Bone loss occurs without symptoms
Often it is not detected until a fracture occurs
Compression fractures of the spine often occur without trauma and may present with back pain, kyphosis, or simple height loss

8. Osteoporosis = TICKING TIME BOMB!!

9. Bone Composition Bone Matrix 90% collagen and 10% other proteins
Bone mineral
Hydroxyapatite (calcium and phosphorus)
Bone cells
Osteoclasts, osteoblasts, osteocytes

10. Bone Basics
Cancellous Bone Cortical Bone

11. Bone science
Bone is constantly remodeling in a coordinated sequence of resorption (osteoclasts) and formation (osteoblasts).
Peak bone mass occurs between ages
Bone loss occurs when resorption > formation.
Age related bone loss occurs at a rate of ~ % per year.
Bone loss accelerates with menopause (early and surgically induced) at an estimated rate of 1-2% per year.
Women can lose up to 20% of bone mass in 5-7 years after menopause.

13. Fracture Rates Displayed by Age and Gender

14. Who needs to be screened?
ASK YOUR DOCTOR!!

15. Osteoporosis Risk Factors
Female
Thin, petite frame
Post menopausal
Age (>50 for women, >70 for men)
Race (Caucasian or Asian)
Family history
Hx of fracture or height loss
Poor calcium and vitamin D diet
Smoking
Excessive alcohol
Inactive lifestyle
Excessive caffeine intake

16. Diseases that cause bone loss
Autoimmune Disorders - RA, MS, Lupus Digestive and GI Disorders - IBD, Celiac Disease, Wt loss surgery Endocrine/Hormonal Disorders –DM, Hyperparathyroidism, Hyperthyroid, Low estrogen or testosterone Hematologic/ Oncology - Cancer, Leukemia, Lymphoma, MM, Sickle Cell Disease Neurological Disorders - PD, Stroke, MS Mental Illness - Eating Disorders, Depression Other - AIDS/HIV, Kidney/Liver Disease, COPD

17. Medications that cause bone loss
Medroxyprogesterone acetate (Depo provera)
Methotrexate
PPIs (Nexium, Prevacid, Prilosec)
SSRIs (Lexapro, Prozac, Zoloft)
Steroids (glucocorticosteroids IE prednisone)
Tamoxifen (pre-menopausal use)
Thiazolidinediones (Actos, Avandia)
Anticonvulsants (Dilantin, Phenobarbital)
Aromatase inhibitors (Arimidex, Aromasin, Femara)
Chemotherapy/XRT
Cyclosporine/Tacrolimus
GnRH (Lupron, Zoladex)
Heparin
Lithium
Thyroid Hormones (In excess)

18. Fractures Most typical osteoporosis sites: Hip, Spine and Wrist
Disease is systemic – occurs throughout the body
Fall from a standing height or low trauma resulting in a fracture IS by definition an osteoporotic fracture (aka fragility fracture)

19. Prevention Balanced diet of calcium and vitamin D
Regular weight bearing and muscle strengthening exercise
Healthy lifestyle, avoid excess alcohol, caffeine, soda
Bone density testing and medication when appropriate
Fall prevention

20. Detection DXA or bone density scan can:
Detect osteoporosis before a fracture occurs
Predict your chances of fracturing in the future
Determine your rate of bone loss and/or monitor the effects of treatment if the test is conducted at intervals of a year or more
Paid for by Medicare every two years

21. Diagnosis Central dual-energy DXA (GOLD STANDARD)
In the absence of a fracture, T-score > -2.5 in the spine, femoral neck or total hip.
Fracture of the hip or spine
AACE American Association of Clinical Endocrinologists) Guidelines for Diagnosis and Treatment of Osteoporosis 2010

23. Limitations of World Health Organization Definition
Established in post-menopausal osteoporosis
Does not recognize fragility fractures and therefore may have a “normal result” in patients with osteoporotic fractures
Only for central DXA and forearm
REMEMBER: This is a SCREENING TOOL!! It is in conjunction with clinical information and judgement

24. Alternative Tools: Peripheral DXA
Should NOT be used for monitoring patient’s response to therapy
Ease and availability
Often used as a screening tool

25. Central DXA Capable of measuring the spine and hip “Gold Standard”
Used in most epidemiologic studies and clinical trials
Diagnosis is based on the lowest site

26. Contraindications for central DXA
Pregnancy
Recent contrast study or nuclear medicine scan (wait 72 hours)
Calcium supplements taken day of the study
Extensive orthopaedic instrumentation
Severe obesity

27. Lumbar Bone Mineral Density
Use L1-L4
Often falsely elevated due to osteoarthritis
May need to exclude arthritic segments, or, the entire study if necessary

28. Femoral (Hip) Bone Mineral Density
Use total hip or femoral neck, whichever is the lowest.
Do NOT use Ward’s area for diagnosis
Mean hip BMD can be used for monitoring (Total hip is preferred as ROI)

29. Medical Evaluation: Osteoporosis Labs
Intact PTH
Ionized calcium
SPEP/UPEP
Testosterone
24 hour creatine clearance
Bone turnover markers
CBC
CMP
TSH
Magnesium
Vitamin D 25-OH

30. Bone Turnover Markers Product of bone remodeling
Noninvasive, easily repeated
Cannot be used to diagnose 733.0
Can be used to monitor response to treatment
Expensive $$$$
Bone resorption markers
NTX
CTX
Alkaline phosphatase
Bone formation marker
Procollagen 1-N terminal S

31. FRAX Developed by WHO in 2008
Prediction tool to assess an individual’s fracture risk
Risk factors + BMD (femoral neck only) = probability of osteoporosis fx in 10 yrs in untreated patients ages
Indication for treatment: Use clinical judgement!!
Low bone mass and a 10 year probability of a hip fx >3% or a 10 year probability of a major osteoporosis-related fx >20% (US-adapted WHO algorithm).

33. DXA, labs, FRAX, clinical judgement
Osteoporosis Tools:
DXA, labs, FRAX, clinical judgement

34. AACE Guidelines for treatment 2010
Patients with a history of spine or hip fracture
Patients without a history of fractures but with a T-score of less than -2.5
Patients with a T-score between -1.0 and -2.5 if FRAX suggests a 10 year probability for major osteoporotic fracture is >20% or hip fracture > 3%.

35. “The skinny” on Calcium
Food is the best source! Read the label.
Food labels list calcium as a % of the DV (or 1000mg)
i.e. 30% DV of calcium equals 300mg
Supplement ONLY if needed.
Calcium is absorbed best when taken in amounts of mg or less.
Calcium carbonate is best absorbed with food
Calcium citrate is absorbed +/- food

36. The Sunshine Vitamin: Vitamin D
3 Sources: Sunlight, Food, Supplements
Promotes calcium absorption
Maintains serum Ca and PO4 (bone mineralization)
Needed for bone growth and remodeling

37. National Osteoporosis Foundation Calcium/Vit D recommendations
VITAMIN D
Women and Men
<50 = IU
>50 = IU
CALCIUM
Women
<50 = 1000mg
>50 = 1200mg
Men
<70 = 1000mg
>70 = 1200mg

38. Supplements Caltrate 600 + D: one tablet BID dosing w/ food
Citracal + D: 2 tablets BID dosing
Citracal Slow Release 1200: once daily
Citracal Petites

39. AACE 2010 Medication Recommendations
Use alendronate, risedronate, zoledronic acid or denosumab as first line therapy.
Use ibandronate as a second line agent.
Use raloxifene as a second or third line agent.
Use calcitonin as the last line of therapy.
Use teriparatide for patients with very high fracture risk or in patients who have failed bisphosphonate therapy.
Combination therapy is not advised.

40. Estrogen Replacement Class: Hormone
MOA: anticatabolic (antiresorptive)
FDA approved for prevention of PMO
**NIH Recommendations 2002**
**Women should consult their doctor and weigh the benefits of HT against the risks for stroke, heart attack, blood clots, breast and colon cancer (WHI).

41. Calcitonin Nasal Spray
Class: Biologic agent
MOA: anticatabolic (antiresoprtive)
Administration: Nasal spray (Miacalcin)
FDA: Approved for women with 5+ yrs PMO
Side effects: Nasal irritation, possible analgesic effect, no known drug interactions.
Minimal increase spine BMD. No increase hip BMD.
Calcitonin Nasal Spray

42. Bisphosphonates MOA: anticatabolic (antiresorptive)
Administration: Oral, IV (Boniva and Reclast)
Side effects:
Avoid in renal patients (GFR <30ml/min)
Osteonecrosis of the jaw (rare)
15 min IV infusion may have an acute phase reaction (30-40% have fever, myalgias)

43. Bisphosphonates Fosamax (Alendronate) Actonel (Risedronate)
Boniva (Ibandronate)
Reclast (Zolendronic Acid)
Fosamax
(Alendronate)
Actonel
(Risedronate)
Boniva
(Ibandronate)
Reclast
(Zolendronic Acid)
FDA approved for prevention and tx of PMO, GIO and osteoporosis in men
FDA approved for prevention and tx in PMO
FDA approved for tx of PMO and men with osteoporosis
Reduces spine, hip and non vertebral fractures
Reduces spine fractures
**Effect on hip and non vertebral fractures is unknown**
Increases BMD in spine and hip

45. AACE Stance on Bisphosphonates 2010
Consider a drug holiday after 4-5 years of stability on bisphosphonate therapy.
Follow BMD and bone turnover markers during a drug holiday.
Reinitiate therapy if bone declines sustantially, bone turnover markers increase or fracture occurs.

46. Evista (Raloxifene)
Class: SERM (selective estrogen receptor modulator)
MOA: anticatabolic (antiresorptive)
FDA approved for prevention and tx of PMO
FDA approved as an agent to reduce breast cancer
Reduces spine fractures **hip and non vertebral fractures not proven** (2nd or 3rd line agent)
Side effects: Increased risk of DVT, does not alleviate hot flashes

47. PROLIA (denosumab) Class: anticatabolic (antiresorptive)
MOA: RANK ligand inhibitor
Administration: 60mg SQ every 6 months
FDA approved for prevention and tx of osteoporosis in PMO and osteoporosis tx in men.
Good option in pts who have failed or are intolerant to other available osteoporosis therapy
Side effects: hypocalcemia, infection, dermatologic rxn, ONJ

49. Forteo (teriparatide)
Class: Biologic agent
MOA: anabolic
Administration: 20mcg injection SQ daily for max 2 years
FDA: approved for PMO women with osteoporosis at high risk of fracture and men with primary or hypogonadal osteoporosis at high risk of fracture
BLACK BOX WARNING: Osteosarcoma
DO NOT USE in pts with Paget’s, unexplained increase in alk phosphatase, kids, or prior skeletal XRT

50. Forteo Mechanism of Action

51. How is treatment monitored?
Baseline DXA with repeat DXA every 1-2 years until findings are stable. Then repeat every 2 years.
Monitor changes in BMD of spine or total hip.
F/U patients should repeat DXA same facility, same machine.
Bone turnover markers

52. Defining successful treatment
BMD is stable or increasing and no fractures are present.
For patients on antiresorptive agents, bone turnover markers at or below the median value.
One fracture is NOT a sign of failure!! Consider alternate therapy, compliance, and reassess.
Defining successful treatment

53. +Men >70

54. When to see the Bone Expert
Patient with normal BMD sustains a fracture without trauma.
Patients with recurrent fractures or continued bone loss despite therapy.
Severe osteoporosis.
When a patient has a condition that complicates management (ie. renal failure, hyperparathyroidism, malabsorption).

55. Midwest Orthopaedic Institute
Thank you!
Midwest Orthopaedic Institute
Bone Health Center
Michele T. Glasgow, MD
Marie Rivers, PA-C