1. Aging Q3 ACOVE #9 Osteoporosis Jay Brzezinski, MD Medical University of South Carolina 2011

2. Osteoporosis ACOVE Work Group Dr. Jay Brzezinski, Chair Dr. Bill Moran Dr. Pam Pride Dr. Leonard Lichtenstein Dr. Amy Thompson Dr. Brad Keith Dr. Lara Hourani Tamela Sill, RN

3. 25 million Americans have osteoporosis ½ of all post-menopausal women will have an OP related fracture Up to 20% of hip fracture patients die in one year Usually asymptomatic until fracture occurs Burden

4. Trabecular bone Also called Cancellous bone Vertebral body bone Bone near joint lines Has bone marrow Light weight Has spiculated pattern BONE

5. Cortical bone Compact bone Long bones Dense Stiff hard heavy BONE

6. Trabecular bone, 25% replaced per year Cortical bone, 3% replaced per year Osteoporosis occurs in both It makes sense that trabecullar bone fractures easier? BONE

7. Age Gender Prior fracture Family history Exercise Smoking RA ETOH Drugs….steroids RISK FACTORS

8. Obesity? Athletic childhood? Osteoarthritis? Diet?? Family history? NON-RISK FACTORS??

9. All women at age 65 Women under 65 with FRAX score >9.3% 9.3% is risk of asymptomatic woman age 65 A previous fracture? We are not screening now! SCREENING( i.e. asymptomatic)

10. DEXA is best Heel quantitative ultrasound?? How to Screen

11. Dual energy x-ray absortiometry One x-ray beam is absorbed by soft tissue One x-ray is absorbed by everything Subtract the two and get bone Problem with ordering a screening BMD on PP??? – Diagnosis: “Pre Menopausal” DEXA

12. -1.0 or better is normal Lower than -2.5 is osteoporosis -1.0 to -2.4 is osteopenia What if I have had a compression fracture? What if I had a hip replaced? T-SCORE

13. www.sheffield.ac.uk/FRAX/tool.jsp FRAX

14. Calcium Vitamin D Should I measure What does it mean Will replacement help Exercise?? Treatment

15. alendronate (Fosamax ® ) 70 mg qweek Ibandronate (Boniva ® ) 150 mg qmonth risedronate (Actonel ® ) 5 qday,35 qweek, 150 qmonth Zoledronic acid (Reclast ® ) qyear IV Bisphosphonates

16. Teriparitide sq qday times 2 years Risk…osteosarcoma Used to treat osteoporosis with prior fracture or high risk who cannot take bisphosphonates Forteo ®

17. 5 years? 7 years? Life? Until BMD better? Bisphosphonates accumulate in bone and after stopping leach out over 1-2 years How long to Treat?

18. Mild risk: rx 5 years and follow BMD High risk: rx 10 years and do 1-2 year drug holiday Expert Opinion

19. Normal with no risks: 3-5 year Risk factors that persist: 2 years High risk after menopause: 2 years Treated patients: 2 years than less if responding When to rescan

20. Osteonecrosis of jaw=>60,000 and most occurred in cancer patients treated with very high dose zoledronic acid Atypical femur fracture=? 25,000? Risks NNH

21. Benefits NNT Prior FractureNo Prior Fracture Any Fracture = 21 Vertebral Fracture = 8 Hip Fracture = 35 - 46 Other Fracture = 21 - 43 100 29 4.5 - 66 35 – 66

22. Osteoporosis Blue Sheet

23. Osteoporosis Detailing Sheet

24. If patient is age 65 or over and female, has the patient ever had a DXA scan? If patient is 65 or over and female, has the patient’s risk of fracture (FRAX) been calculated? Does the patient report ever having a fractured bone? Practice Partner Template Progress Notes

25. Osteoporosis ACOVE begins in clinic Thursday, July 21, 2011 Thanks for supporting Aging Q 3