Osteoporosis Definition A condition of skeletal fragility characterized

Osteoporosis: Definition A condition of skeletal fragility characterized by compromised bone strength predisposing to an increased risk of fracture Normal Bone Osteoporosis NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000. Source: Dempster DW, et al. J Bone Miner Res. 1986: 1: 15 -21; Reprinted with permission from the American Society of Bone and Mineral Research

Annual incidence of common diseases Frequency of Common Medical Events in Women 2, 000 1, 500, 000 1, 000 * 250, 000 hip 250, 000 forearm 250, 000 other sites 513, 000 ** 500, 000 228, 000† 750, 000 vertebral 0 Osteoporotic Fractures incidence all ages estimate women 29+ †annual estimate women 30+ ‡ 1996 new cases, women all ages Heart Attack Stroke 184, 300‡ Breast Cancer *annual **annual 1. Riggs, B. L. , and Melton, L. J. III, Bone 17(5)(Suppl. ): 505 S-511 S, 1995 2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart Association 3. Cancer Facts & Figures— 1996, American Cancer Society

Prevalence • Osteoporosis is a health threat for an estimated 44 million Americans. • Of that 44 million : • 10 million individuals already have the disease • 80% of these are women • 34 million more are estimated to have low bone mass and increased risk for osteoporosis. • Osteoporosis affect people of all ethnic backgrounds. • While osteoporosis is often thought of as an older person's disease, it can strike at any age.

Cost • The estimated national direct expenditures for osteoporotic hip fractures was $18 billion dollars in 2002. • Office visits have increased five-fold (from 1. 3 to 6. 3 million) in the past 10 years. • In 2001, about 315, 000 Americans age 45 and over were admitted to hospitals with hip fractures. Osteoporosis is highly preventable. However, if the toll of osteoporosis is to be reduced, the commitment to osteoporosis research must be significantly increased. It is reasonable to project that with increased research, the future for definitive treatment and prevention of osteoporosis is very bright.

Fractures • An average of 24 percent of hip fracture patients aged 50 and over die in the year following their fracture. • Only 15 percent of hip fracture patients can walk across a room unaided 6 months later. • Hip fractures AND vertebral fractures are linked with an increased risk of death. • One in five hip fracture patients ends up in a nursing home, a situation that participants in one study described as less desirable than death.

Fractures • Hip fracture risk is increasing most rapidly among Hispanic women. • Women with a hip fracture at a four-fold greater risk of a second one. • Osteoporotic fractures lower a patient’s quality of life. Annually, 1. 5 million osteoporotic fractures occur: 300, 000 hip fractures 700, 000 vertebral fractures 250, 000 wrist fractures 300, 000 fractures elsewhere One in two women and one in four men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime.

Estimates of Osteoporosis in Women >50 yr old Non-Hispanic white and Asian women: • 20% have osteoporosis; 52% have low bone mass. Non-Hispanic black women: • 5% have osteoporosis; 35% have low bone mass Hispanic women: • 10% have osteoporosis; 49% have low bone mass. Osteoporosis is under-recognized and under-treated not only in Caucasian women, but in African-American women as well.

Shrinking is NOT an Inevitability of Aging and IS NOT normal!! • White women ≥ 65 year old have twice the fracture incidence versus African-American women. • Women have a hip fracture rate two to three times higher than men. • A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer. Osteoporosis and Women Bone loss during breastfeeding? Bone density can be temporarily lost during breastfeeding. Several studies have shown that recovering full bone density occurs within six months after weaning.

Etiology Rheumatologic disorders • rheumatoid arthritis, • ankylosing spondylitis • Marfan syndrome • hemochromatosis • Hypophosphatasia • epidermolysis bullosa INHERITED DISORDERS • homocystinuria • osteogenesis imperfecta • porphyria • Ehlers-Danlos syndrome • Menkes' syndrome • glycogen storage diseases OTHER DISORDERS • immobilization, • amyloidosis • pregnancy and lactation • use of glucocorticoids • scoliosis • Iatrogenic osteoporosis • chronic obstructive caused by therapeutic pulmonary disease

Nutritional and gastrointestinal disorders • malnutrition, • parenteral nutrition, • malabsorption syndromes, • gastrectomy, • severe liver disease (especially biliary cirrhosis), • pernicious anemia. Etiology Endocrine disorders • Cushing's Hematologic syndrome, Hypogonadal states disorders/malignancy • hyperparathyroidism • Turner syndrome, • multiple myeloma, • thyrotoxicosis, • Klinefelter syndrome, • lymphoma and • insulin-dependent • Kallmann Syndrome, leukemia, diabetes mellitus, • anorexia nervosa, • mastocytosis, • acromegaly, • hypothalamic • hemophilia, • adrenal insufficiency amenorrhea, • thalassemia. • hyperprolactinemia.

Symptoms • Osteoporosis, the "silent disease, " has bone loss without symptoms. • Onset only occurs with sudden strains, bumps, or fall causes a fracture or a vertebra to collapse. • Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis or stooped posture.

Bone Mineral Density Values World Health Organization (WHO) Osteoporosis Guidelines BMD Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s Life T-Score WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998. 1. 4 1. 3 1. 2 1. 1 1. 0 0. 9 0. 8 0. 7 0. 6 0. 5 0. 4 0. 3 Mean – 2 SD Consider preventive intervention Consider therapeutic intervention 20 30 40 50 60 70 80 Age Adapted from AACE Guidelines. Endocr Pract. 2001; 7: 293 -312.

DEXA scan: Hip T-Score

Who Should Be Tested? • All women aged 65 and older. * • Younger postmenopausal women with multiple risk factors • Postmenopausal women who present with fractures • Estrogen deficient women at clinical risk for 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. *Medicare covers BMD testing for the following individuals age 65 and older. Medicare permits individuals to repeat BMD testing every two years.

Risk Factors for Hip Fracture Skeletal Risk Non-Skeletal Risk Factors for Fx Factors for Falls/Fx -Age (>80 yr) -Poor balance/gait -Low BMD (T< -2. 5) -Previous Fx -Family history Fx -Smoking Fx Risk -Impaired eyesight -Meds that increase risk of falling -Loss of soft tissue hip padding -History of falls -Fall-related injury -Smoking Risk of Hip Fx =

Detection: Bone Mineral Density Tests Type of Test Area tested DXA (Dual Energy X-ray Absorptiometry) spine, hip or total body p. DXA (Peripheral Dual Energy X-ray Absorptiometry) wrist, heel or finger SXA (single Energy X-ray Absorptiometry) wrist or heel QUS (Quantitative Ultrasound) heel, shin bone and kneecap QCT (Quantitative Computed Tomography) spine p. QCT (Peripheral Quantitative Computed Tomography) wrist RA (Radiographic Absorptiometry) hand DPA (Dual Photon Absorptiometry) spine, hip or total body SPA (Single Photon Absorptiometry) wrist

Therapeutic Agents Used in Osteoporosis • Inhibitors of bone resorption: – Calcium – Estrogens +/- progest – SERMs – Bisphonates – Calcitonin • Stimulators of bone formation – PTH – Fluoride A. Normal Spine B. B. Moderately Osteoporotic Spine C. C. Severely Osteoporotic Spine

Bisphonates 1. Alendronate and alendronate plus vitamin D (brand name Fosamax® and Fosamax® plus D) 2. Ibandronate (brand name Boniva®) 3. Risedronate and risedronate with calcium (brand name Actonel® and Actonel® with Calcium) 4. Calcitonin (brand name Miacalcin®) Rodan, G. A. et al. J. Clin. Invest. 1996; 97: 2692 -2696 Copyright © 1996 American Society for Clinical Investigation Mechanism of Action: • inhibition of the production of essential lipid compounds inside osteoclasts • decreased osteoclast activity • induction of cell death. • decreases bone turnover • slowing the rate at which new bone remodeling units are formed • reducing the depth of resorption. • increase in bone mass over time.

Estrogen/Hormone Therapy Women's Health Initiative Trial • Hip and vertebral fractures decreased by at least one-third in both of the trials and total fractures decreased by 24%-30%. • The clear fracture benefits of postmenopausal hormone therapy (HT) are offset by the adverse effects: – increased risk of stroke, –cognitive impairment, and –deep vein thrombosis • HT provided no cardioprotective benefit, and increased the risk of breast cancer. (AMA) 1. Estrogens (brand names, such as Climara®, Estrace®, Estraderm®, Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle® and others) 2. Estrogens and Progestins (brand names, such as Activella™, Fem. Hrt®, Premphase®, Prempro® and others) 3. Parathyroid Hormone – Teriparatide (PTH (1 -34) (brand name Fortéo®)

Combination therapy • The use of an anabolic and antiresorptive agent is less effective than an anabolic agent alone. • Since the effects of antiresorptive therapy with bisphonates are long-lasting, until more is known, bisphonate use should be discontinued before initiating PTH. • Combination therapy with two antiresorptive agents is generally reserved for those who: • have experienced a fracture while on therapy with a single drug • start out with a very low BMD and a history of multiple fractures • have a very low BMD and lose more bone mass on therapy with a single drug

Algorithm for women Older than 80 Discuss calcium, vitamin D, nutrition, exercise. • Older women do not convert vitamin D in the skin & should be on an oral supplement Discuss fall prevention Consider hip pads • Check sedative use, vision, muscle weakness, balance, environmental problems (cords, rugs, poor lighting). Hip padding for thin women. Already Fx? yes no Height loss >4 cm? no Taking estrogen? Rx Fx yes Xray • Raloxifene, calcitonin, or lowdose bisphonate. Do not start hormones. BMD not needed to decide treatment. No Fx yes no Hip DEXA or heel ultrasound No further work-up

Counsel All Women on: • Risk factors for osteoporosis • Adequate calcium and vitamin D intake • The need for weight bearing exercise • Fall prevention strategies • Avoidance of tobacco and moderate use of alcohol Consider Bone Mineral Density Screening for: • Women over 65 years of age • Women 50 to 64 with one or more of the following clinical risk factors • Any fracture after age 40 • Family history of osteoporosis • Current smoking • Weight <127 lbs. • Post-menopausal women who present with a fracture Consider Treatment of Post-menopausal Women with: T-score of < 2. 5 or less T-score of - 2. 0 or less in the presence of one or more risk factors listed Any vertebral or hip fractures Web Resources Compiled by Judith Chilcot School of Nursing University of Washington Medical Center http: //www. osteoed. org/ Check out Osteo. Ed, an educational web site, for quick answers to osteoporosis questions. *Guidelines from pamphlet for providers by the National Osteoporosis Foundation. http: //www. nof. org/physguide/impact_and_overview. htm#synopsis

Five Steps Toward Prevention 98% of a woman’s skeletal mass is acquired by age 20 Optimal strategies for building strong bones occurs during childhood and adolescence 1. A balanced diet rich in calcium and vitamin D 2. Weight-bearing and resistancetraining exercises 3. A healthy lifestyle with no smoking or excessive alcohol intake 4. Talking to one’s healthcare professional about bone health 5. Bone density testing and medication when appropriate A study of disease management in a rural healthcare population demonstrated that a preventive program was able to reduce hip fractures and save money.

Prognosis • The best predictor of fracture is a previous fracture. • Treatment can improve fracture risk considerably. • Fractures can lead to decreased mobility and an additional risk of deep venous thrombosis and/or pulmonary embolism. • Vertebral fractures can lead to severe chronic pain of neurogenic origin, which can be hard to control. Although osteoporosis patients have an increased mortality rate due to the complications of fracture, most patients die with the disease rather than of it.