UNDERSTANDING OSTEOPOROSIS

Stephen L. Kates, MDHansjӧrg Wyss  Professor of Orthopaedic

SurgeryDepartment of Orthopedics and

RehabilitationAssociate Director, Center for

Musculoskeletal ResearchUniversity of Rochester Medical Center

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

WHAT IS OSTEOPOROSIS?

• Skeletal disorder with: Compromised bone strength Increased risk of fractures Deterioration of microarchitecture

• Most common bone disease

Healthy vertebra

Osteoporotic vertebra

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OSTEOPOROSIS

Normal bone Osteoporosis

Loss of critical bony interconnections

Thinner internal support

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OSTEOPOROSIS OF THE HIP

Loss of critical bony trabeculae occurs with osteoporosis

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BONY ANATOMYCHANGES WITH AGE

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WHAT ARE BONES MADE OF?

• Minerals bound to proteins

• Calcium

• Hydroxyapatite

• Organized collagen fibers

• Cells — osteocytes, osteoblasts, osteoclasts

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BONE REMODELING

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BONES CHANGE DURING LIFE

• Modeling as a child and adolescent

• Remodeling throughout life

• Peak bone mass reached in your 20s

• Remodeling allows bones to heal

• Resorption in later years

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WHAT KEEPSNORMAL BONES HEALTHY?

• Genetic factors

• Moderate physical activity

• Calcium

• Vitamin D

• Hormones Parathyroid hormone Calcitonin Estrogen Testosterone

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CAUSES OF OSTEOPOROSIS

• Primary

• Secondary

• Nutrition

• Lifestyle (Exercise, smoking, alcohol)

• Hormonal problems

• Age

• Medications (steroids, seizure meds)

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FRAGILITY FRACTURE

• Caused by a fall from a standing height or less

• Osteoporosis is the cause

• 33%50% of women will develop a fragility fracture

• 15%33% of men get a fragility fracture

• Likelihood increases with age

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• With fracture

• Without fracture

OSTEOPOROSIS: A 2-STAGE DISEASE

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HIP FRACTURELifetime Incidence in Women 1:6

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ANNUAL INCIDENCE OFOSTEOPOROTIC FRACTURES (USA)

Fracture TypeFracture Type

Hip

350,000+

Vertebral

(Morphometric)

750,000

300,000+

Wrist0

250,000

500,000

750,000

200,000

Other

Only 30% of morphometric vertebral fractures are “clinically apparent”

Clinically apparent

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DIAGNOSIS OF OSTEOPOROSIS

• DEXA scan is best at present

• T score Compares density relative to peak bone mass

(normal healthy 25-year-old)Matched to sex and race

• Z score compares density to peers

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X-RAY TECHNIQUES

DEXA

pDXA

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Slide Slide 1818

T scoreNormal > 1Osteopenia < 1 and > 2.5Osteoporosis 2.5Severe osteoporosis 2.5 with fracture

Mainly for spine and hip in women

WHO DEFINITIONS

WHO SHOULD BE TESTED?

• All women aged 65 and older regardless of risk factors

• Younger postmenopausal women with 1 or more risk factors (other than being white, postmenopausal, and female)

• Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity)

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CASES IN WHICH MEDICARE COVERS DEXA EVERY 2 YEARS

• Estrogen-deficient women at clinical risk of 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

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WHAT ABOUT MEN?

• Fragility fracture

• Steroid use

• Forearm fracture

• Vertebral fracture

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OSTEOPOROSIS IS TREATABLE

• Nutrition

• Exercise

• Lifestyle changes

• Medications

• Fall prevention

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CALCIUM

• RequirementsYoung 1000 mg/day in 2 dosesOlder 1500 mg/day in 3 doses

• Calcium gluconate

• Calcium citrate

• Calcium carbonate

• Whatever you can tolerate

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BODY WEIGHT

• Very low weight is a risk factor (<127 lb)

• Normal weight is best

• Obesity may predispose to falls

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VITAMIN D3 (1 of 2)

• Deficiency is common with age

• Lack of sunlight

• Deficiency = osteomalacia

• Very common in nursing homes

• May cause fractured bones not to heal

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VITAMIN D3 (2 of 2)

• Vitamin D3 — not D2 — is best

• Dose Young 400 units/day Older 600 to 800 units/day — maintenance If deficient, 50,000 units/day

• A blood test is needed to determine deficiency

• Sunlight helps — we have very little

• Essential for bone health!!!!!!

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EXERCISE

• Weight-bearing exercise is best

• Low-impact exercise can help prevent falls

• Weight training

• Tai Chi

• Exercise helps other body systems too

• You have control over this!

• Helps to start young

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FALL PREVENTION

• Medications can cause falls

• Poor lighting

• Throw rugs

• Fall-proofing the home

• Exercise, balance, and strength training

• Correct your vision

• Pets

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CAUSES OF FALLS AT HOME

• Tripping

• Slipping

• Pets

• Ladders

• Stairs

• Poor lighting

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LIFESTYLE

• Alcohol in moderation only

• Alcohol can cause osteoporosis

• Alcohol can cause falls

• Cigarette smoking causes osteoporosisMakes bones heal poorlySmoking cessation is the best plan

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MEDICATIONS

• Many medications can hurt your bonesSteroids (prednisone)Seizure drugsElevated thyroid hormoneCancer drugs (Lupron)

• Avoid these if possible

• DEXA scans necessary with these

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OSTEOPOROSIS MEDICATIONS

• Antiresorptive drugs

• Anabolic therapies

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ANTI-RESORPTIVE THERAPIES: BISPHOSPHONATES

• Nonhormone compounds

• Bind to hydroxyapatite crystals in bone

• Inhibit the osteoclasts that resorb bone

• Cause osteoclasts to die prematurely

• Half-life 6 to 10 years in bone

• Can be taken by mouth or IV

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ORAL BISPHOSPHONATES

• Alendronate (Fosamax)

• Risedronate (Actonel)

• Ibandronate (Boniva)

• IV bisphosphonates are used when oral medications are not tolerated

• Work for men and women

• Best treatment for steroid osteoporosis

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Fra

ctu

re

Ris

k R

edu

ctio

n (

%)

Fra

ctu

re

Ris

k R

edu

ctio

n (

%)

Anysymptomatic

WristVertebral (radiographic)

Multiple vertebral

54%

27%

45%

87%

48%

30%

Non-vertebral

HipPainful vertebral

31%36%

Non-vertebral osteoporotic*

*Fracture of the clavicle, humerus, pelvis, hip, or leg

Black DM et al. JCEM. 2000;85:4118-4124. Slide Slide 3636

ALENDRONATEReduced the risk of fracture at all key sites in women with osteoporosis

BISPHOSPHONATES: PROBLEMS

• Reflux

• Must be upright for 1 hour

• Mostly GI symptoms

• Rare: osteonecrosis of jaw

• Long-term effects not known

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ANTI-RESORPTIVE THERAPIES:SERMs

• Raloxifene and tamoxifen

• Bind to estrogen receptor

• Have a good effect on bone density

• For women only

• Should be used with calcium, vitamin D

• Reduce risk of breast cancer

• Increase risk of a blood clot

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CALCITONIN

• Hormone that regulates calcium, bone

• Synthetic salmon calcitonin

• Decreases bone resorption

• Reduces pain from vertebral fractures

• Nasal spray or injection

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TERIPARATIDE (FORTEO)(1 of 3)

• Synthetic hormone like human parathyroid hormone

• Builds bone mass

• Improves bone quality

• Increases the life span of osteoblasts

• Injection for 2 to 3 years

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TERIPARATIDE (FORTEO)(2 of 3)

• FDA-approved for women with:High fracture riskMultiple fracturesFailure of other therapies

• FDA-approved for men with:Hypogonadal osteoporosisHigh fracture risk

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TERIPARATIDE (FORTEO)(3 of 3)

• Contraindications• Previous radiation therapy• Paget’s disease• Young patients still growing

• Very expensive

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