the top 10 questions about osteoporosis - … • 69 yo w ♀ • age 26- tah, bso; ... living or...

Osteoporosis & The Transplant Patient Top 10 Questions

Bobo Tanner MD Director, Osteoporosis Clinic

Marni Groves, NP Division of Rheumatology & Allergy

Vanderbilt University Nashville TN

Sept. 22nd , 2016

Disclosures

Research ,advisory panel and /or speakers

bureau: Pfizer, BMS,,GSK, AMGEN, Merck, Novartis

Case • 69 yo w ♀ • Age 26- TAH, BSO; Rx HT “few years” • Age 33- DXA Bone Density test= “low” • Failed treatments:

– SQ calcitonin-GI – alendronate -GI – raloxifene–Hot flashes

• Age 50: Ischemic heart dz • Age 55- DXA hip T-score= -3.5

– Rx risedronate x 2yrs

• Age 57: Cardiomyopathy • T’plant list

#1. Why Are You Concerned About this

Patient's Bone Density?

•60

•70

•80

•90

•100

•30 •40 •50 •60 •70 •80 •90

•Age

•Rel

ativ

e BM

D (%

) •Forearm •Spine

•Hip and Heel

•0

•1000

•2000

•3000

•4000

•35- •39

•85+

•Colles' •Vertebrae •Hip

•Age

•Ann

ual F

ract

ure

Inci

denc

e

•Cooper C. Baillières Clin Rheumatol. 1993;7:459–477. •Faulkner KG. J Clin Densitom. 1998;1:279–285.

As BMD Decreases Fracture Risk Increases

•* Remember: Only ~1/3 of spine fractures are acutely painful

Presenter

Presentation Notes

BMD and Fracture Risk Are Inversely Related Significant bone loss at all skeletal sites occurs as women age with an increased rate of loss after menopause.1 Up to one third of bone mass is lost in the first 5 years after menopause.1 There is a dramatic increase in the incidence of fracture as women �grow older.2,3 Women over 50 years of age have a 40% chance of suffering an osteoporotic fracture in their remaining years.4 References: 1. Faulkner KG. Bone densitometry: choosing the proper skeletal site to measure. �J Clin Densitom. 1998;1:279–285. 2. Cooper C. Epidemiology and public health impact of osteoporosis. Baillières Clin Rheumatol.1993;7:459–477. 3. Cooper C, Atkinson EJ, O’Fallon WM, et al. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res. 1992;7:221–227. 4. Kanis JA. Osteoporosis and its consequences. In: Osteoporosis. Cambridge, MA: Blackwell Science, Ltd; 1994:1–21.

The Osteoporotic Event: Hip Fracture

Hip Fracture: Devastating Event

• Mortality rate same as breast cancer

• 20% excess mortality in the first year

• 50% incapacitation

• 20% of females need assisted living or nursing home

• 80% of 75 yo preferred death to hip fx & nsg hm

• Cooper C, et al. Am J Epidemiol. 1993;137:1001

Awaiting Solid Organ Transplant: Low Bone Mineral Density

• Low BMD common in these pts. • 2 yrs or more waiting t’plant • Long term survival after t’plant • BMD affected by:

– Organ disease: kidney, liver, lung – Treatment: steroids, heparin, loop diuretics

• Negative calcium balance & bone loss

Opportunity: prevent bone loss or restore before transplant

2. Questions about Osteoporosis When should DXA Bone Density testing be performed?

Bone Mass Measurement Act Federal Register 1997 for HCFA/CMS

Medicare Osteoporosis Measurement Act 2003

1. Women with estrogen deficiency 2. Spine x-ray evidence of fracture or OP 3. Glucocorticoid therapy (3mos, 5 mg/d) 4. Primary Hyper-PTH 5. Follow-up treatment (23 months unless

medical reason for sooner e.g. steroids)

3.How Do You Interpret a DXA Scan?

• T-score: BMD compared to young adult reference – Used for OSTEOPOROSIS diagnosis

– Post menopausal women, men >50

• Z-score: BMD compared to age-matched reference Descriptive, especially children, premenopausal women and men <50;

–Z-score Not used for diagnosis

T- and Z-scores

Presenter

Presentation Notes

The diagnosis of OP is based upon the 1994, the World Health Organizations’ endorsement of T scores. WHO used T scores to provide quantitative diagnostic criteria for osteoporosis. T scores represent the number of standard deviations (SD) a patients BMD is above or below average BMD of a young-adult reference population. T scores are used for the diagnosis of OP. Note the above WHO criteria apply to Caucasian females. Z scores represent the number of SD a patient’s BMD is above or below average BMD of a age matched reference population. Not used for diagnosis, but serve as an indicator to aggressively look for secondary causes. Z-score may suggest further evaluation, but no clear data on a cut-off that is of concern.

T- & Z- scores & Osteoporosis World Health Organization (WHO) & ISCD

DXA Criteria T-score Classification________

Postmenopausal women, men>50

> -1 Normal < -1 and > -2.5 Osteopenia < -2.5 Osteoporosis < -2.5 & fracture Severe Osteoporosis

Z-score Classification_______ Premenopausal women, men<50

< -2 “low bone density for age” WHO Study Group JBMR 1994,1997; ISCD PDC www.ISCD.org 2013

Presenter

Presentation Notes

Developed by a study group of the WHO in 1994 to help epidemiologists compare data from different countries and regions. Has been applied to clinical practice of bone densitometry, in particular to central DXA. Note that osteopenia does NOT include either –1 or -2.5 (-1 is normal; -2.5 is osteoporosis). NOTE: A FRAGILITY FRACTURE WITH ANY T-SCORE=OSTEOPOROSIS Not because this was part of WHO definition, but because this is a standard practice. Just because we have a densitometric definition does not mean that the clinical definition (fragility fracture) should be discarded.

http://www.iscd.org/

Spine Bone Density Report

Case (cont’d)

• Age 59- cardiac transplant • prednisone 5mg/day • re-start risedronate => ibandronate • Age 64 DXA FN = -2.4

4. When Do You Treat Osteopenia?

Using FRAX ®

WHO Fracture Risk Prediction

Example of Applying the FRAX Tool

Which Woman is at Higher Fracture Risk?

54 year old smoker with a T-score of -2.0 or

81 year old with no prior fracture with a T-score of -1.4

•10 year risk of hip fracture = 2.5%; major osteoporotic fracture = 10%

•10 year risk of hip fracture = 3.2%; major osteoporotic fracture = 26%

Presenter

Presentation Notes

Initiate Pharmacologic Treatment: FRAX® and NOF Guidelines

1. Patients w/ hip or vertebral fractures

2. PM women, men > 50 ,T-scores ≤−2.5 femoral neck, total hip, lumbar spine ,33% radius

3. Patients w/ Osteopenia (T-score < −1.0 & > −2.5)

and FRAX® = major fx risk ≥20 % or Hip fx risk ≥3 % Clinician’s judgment and/or patient preferences may indicate treatment for people with 10-year fracture

probabilities below these levels. www.NOF.org and www.shef.ac.uk/FRAX

http://www.nof.org/

http://www.shef.ac.uk/FRAX

5. What are The Treatment Choices For Osteoporosis?

Normal Bone Remodeling: A Coupled Homeostatic Process

2–4 weeks 3–4 months

Resting Stage

Reversal Phase Formation Remodeling

Completed Activation Resorption

Lining cells Osteoclast precursors Activated

Osteoclasts Osteoblasts

Bone remodeling unit

1. Marcus R. In: Hardman JG et al. Goodman & Gillman’s The Pharmacologic Basis of Therapeutics. 10th ed. McGraw-Hill; 2001:1715–1743. 2. Tanaka Y et al. Curr Drug Targets Inflamm Allergy. 2005;4:325–328. 3. Rosen CJ. Available at: http://www.endotext.org/parathyroid/index.htm. Accessed March 15, 2006.

Lining cells

Presenter

Presentation Notes

Normal Bone Remodeling: A Coupled Homeostatic Process Normal bone remodeling is a homeostatic, coupled process comprised of bone resorption by osteoclasts and bone formation by osteoblasts.1–3 Sequence and timing At any time, most bone surface is inactive, and lining cells cover the surface during the resting stage. The first step in remodeling is activation of resorption; the lining cells retreat, and osteoclasts resorb the exposed mineralized tissue. Resorption proceeds for about 2 to 4 weeks at each remodeling site. Once the resorption phase is completed, osteoblasts migrate to the resorption pit and refill it with new osteoid matrix in the formation phase. The process of formation with complete secondary mineralization of the new matrix takes about 3 to 4 months.1–3 As the initiator of the bone remodeling process, the osteoclast is a key target of osteoporosis prevention and treatment The life span of an osteoclast in vivo is about 2 weeks, with a half-life of 6 to 10 days. New osteoclasts continually develop from precursor cells of the hematopoietic system to replenish senescent cells.4 Therapies that target osteoclasts therefore must be available on a constant basis to interrupt bone resorption by mature and newly formed osteoclasts. Bone remodeling rate and the concept of activation frequency Initiation of new remodeling sites by osteoclasts occurs continuously and asynchronously throughout the skeleton. There are remodeling sites at various stages of bone resorption and formation at any time.1 Activation frequency is a direct, tissue-level measure of the rate of bone remodeling. It is the number of times per year you can expect a new bone remodeling site to be activated on any trabecular surface.5 References: 1. Marcus R. Agents affecting calcification and bone turnover. In: Hardman JG, Limberd LE, Gilman AG, eds. Goodman & Gilman’s The Pharmacologic Basis of Therapeutics. 10th ed. New York, NY: McGraw-Hill;2001:1715– 1743. 2. Tanaka Y, Nakayamada S, Okada Y. Osteoblasts and osteoclasts in bone remodeling and inflammation. Curr Drug Targets Inflamm Allergy. 2005;4:325–328. 3. Rosen CJ. The epidemiology and pathogenesis of osteoporosis. 2004. Available at: http://www.endotext.org/parathyroid/index.htm. Accessed March 15, 2006. 4. Chambers TJ. Regulation of osteoclast development and function. In: Rifkin BR, Gay CV, eds.. Biology and Physiology of the Osteoclast. Boca Raton, Florida: CRC Press; 1992:105–128. 5. Recker R, Lappe J, Davies, KM, Heaney R. Bone remodeling increases substantially in the years after menopause and remains increased in older osteoporosis patients. J Bone Miner Res. 2004;19:1628–1633.

http://www.endotext.org/parathyroid/index.htm

FDA Approved Osteoporosis Medications Drug Post Menopausal OP Steroid OP Male OP

Prevention Treatment Prevention Treatment

Alendronate Risedronate Ibandronate Zoledronate Raloxifene Estrogen Calcitonin * Denosumab Teriparatide

Questions about Osteoporosis

6. Are Bisphosphonates safe? -Renal Excretion -Esophageal irritation - ONJ -Atypical fractures

#6. What is the Clinical Presentation of Osteonecrosis of the Jaw (ONJ)?

• Signs &Symptoms:1 – Asymptomatic or – Facial pain, jaw pain – Soft-tissue swelling,drainage – Exposed,necrotic bone

• Cultures: actinomyces2

• Risk factors – Cancer & concomitant therapies – Poor oral hygiene – Smoking – Pre-existing dental disease, anemia, coagulopathy, and

infection • Management

– Povidone-iodine & 0.12% chlorhexidine mouthwash

– Oral antibiotics and anti-inflammatory drugs – Conservative debridement for necrotic tissue

Ruggiero SL, Hehrotra B, Rosenberg TJ, et al. J Oral Maxillofac Surg. 2004;62:527-34.

1. Expert Panel Recommendations for the Prevention, Diagnosis, and Treatment of Osteonecrosis of the Jaws: June 2004

2. Naveau A. Joint Bone Spine 2005.

Melo MD, Obeid G. J Can Dent Assoc 2005;71: 11-3.

Presenter

Presentation Notes

Pts can be asx for weeks or months before presentation. Pain during chewing or brushing Symptoms: some pts may complain of unusual sx of heavy jaw or numbness. Sx: Exposed jaw, Purulent drainage or extension to a sinus Symptoms: inflammation- swelling, loosen teeth. Lesions in anterior portion of mandible. Mucosal surface here is the thinnest. When have secondary healing after extraction can be effected Histological: Condyle marrow: edema and sclerosis Sequestration suggested Necrotic Bone: Suppuration evident Epithelial proliferation in medullary spaces Decrease bone density and patchy sclerosis4 Cultures: Osteomyelitis

ONJ Comparative Risks

•Kanis JA et al. Osteoporos Int. 2001;12:417-427. Pharmcoepidemiol Drug Saf. 2003;12:195-202. National Center for Health Statistics. JADA. 2006;137:1144-1150. www.nssl.noaa.gov/papers/techmemos/NWS-SR-193/techmemo-sr193-4.html

•(1) Women age 65-69 (from Swedish National Bureau of Statistics and database of Olmsted County, MN, USA.)

•0.6

•0.7

•6

•11

•32

•387

•2668

•0 •10 •20 •30 •40 •50 •60 •70 •80 •90 •100

•Death by Lighting Strike

•ONJ- Osteoporosis Patient

•Death by Murder

•Death by MVA

•Anaphylaxis from Penicillin Shot

•Hip Fracture (1)

•Any Fragility Fracture (1)

•Risk per 100,000 People per Year

American Dental Association Recommendations 2011

• Dentists generally should not modify routine dental treatment solely because of the use of anti-resorptive agents

• All patients should receive routine dental examinations • Patients for whom anti-resorptive agents have been

prescribed likely would benefit from a comprehensive oral examination before or early in their treatment

• Anti-resorptive therapy places them at low risk of developing ARONJ (the highest prevalence estimate in a large sample is about 0.10 percent)

Hellstein, et al., JADA 2011; 142: 1243-1251

#6. Can Bisphosphonates Cause Atypical Femoral Fractures?

JBMR 2010

Features of Atypical Femoral Fractures • Rare • Low energy or spontaneous • Subtrochanteric • Thickened lateral cortex (often bilat.) • Transeverse or spiral fracture • “beak” assoc. with stress fracture • Thigh pain before fracture • After 5-10 years of bisphos. use

Goh JBJS 2007, Nevaiser J Ortho Truama 2008, Somford JBMR 2009, Capeci JBJS 2009, Lenart Osteoporosis International 2009, Koh J Ortho Trauma 2010 Bukata S ISCD Ann Mtg San Antonio 2010

Sub Trochanteric Fractures

• 250,000 hip fractures /year US • 25-80,000 subtrochanteric femoral shaft

fractures (SFSF) • Atypical SFSF , rare: 5 cases /10,000 patient-years

• ASBMR Task Force report to FDA: 50% have premonitory thigh or hip pain

25% bilateral involvement

Black et al NEJM 2010 Girgis et al NEJM 2010, JBMR 2010

Goh SK. JBJS 2007;89:349

Presenter

Presentation Notes

Fig. 1a, Fig. 1b Radiographs of a 65-year-old woman who had tripped and fallen while walking on flat ground and had been on alendronate for the past five years, showing a) a type-A left subtrochanteric fracture with b) a cortical reaction in the lateral (tension) side of the femur.

Goh SK. JBJS 2007;89:349

Presenter

Presentation Notes

Fig. 2a, Fig. 2b Radiographs of a 69-year-old woman with a history of cervical and lumbar spondylosis and who had bilateral thigh pain for two months before the fracture. She had been on alendronate for five years. She heard a snapping sound in a) her right thigh while shopping. b) The left lateral subtrochanteric region shows evidence of a stress injury.

Bisphosphonates & Atypical Femoral Fractures

Mechanism: • Loss of bone turnover & repair? • Similar appearance to hypophosphatasia or

sclerosing bone disorders (osteopetrosis, pycnodysostosis)

• Asian heritage; bowed femur

Is this result of a bone condition that has erroneously been diagnosed and treated as osteoporosis or a side effect of the medication?

• Whyte JBMR 2009 ; 5Dell RM, J Bone Miner Res, 2012;27:2544-50

Atypical Femoral Fractures: What to do?

• X-ray both femurs • ?tetracycline labeled bone biopsy • √ labs: Vit D level, phos, other metabolic

bone parameters • Prophylactic nail? • Consider teriparatide treatment

Bukata S ISCD Ann Mtg 2010 San Antonio

What about a bisphosphonate “holiday”?

• Does the patient need more than 5 years? – DXA – Bone Turnover Markers

• Consider switch to teriparatide for drug holiday from bisphosphonates

• FDA advisory committee,9/9/11 “… no clear evidence of benefit or harm in continuing the drugs beyond 3-5 years.” Ott Clev Clin J Med 2011 Laster, Tanner Rheum Dis Clin of NA 2011 www.fda.gov

7. Questions about Osteoporosis

Are calcium & Vitamin D

supplements needed?

Calcium • Essential for prevention and treatment

regimens

• Institute of Medicine of the National Academy of Sciences Recommendations: – Over age 50 1200 mg daily Institute of Medicine. 1997. Washington, DC, Academy Press

• Fracture reduction in some but not all

studies Recker RR, et al. J Bone Miner Res. 1996;11:1961

But are calcium supplements safe?

Meta analysis: Conclusion: 30% increased MI risk • But: no sig increase in mortality or stroke • Independent of age, sex, type of ca. suppl. • Caveats:

– Not 1° outcome – Dietary Calcium appears to be safe

*Bolland et al, BMJ 2010 **Autier P et al ,Arch Int Med 2007

Dietary Calcium: About 800mg a Day?

•Warensjö E et al. BMJ 2011;342:bmj.d1473

• ©2011 by British Medical Journal Publishing Group

Presenter

Presentation Notes

Fig 2| Multivariable adjusted spline curve for relation between cumulative average intake of dietary calcium and time to first hip fracture. Multivariable adjusted hazard ratio indicated by solid line and 95% confidence interval by dashed lines. Models were adjusted for age, total energy, retinol, alcohol intake, vitamin D intake, BMI, height, nulliparity, educational level, physical activity level, smoking status, calcium supplementation, previous fractures, and Charlson’s comorbidity index. Asterisks on x axis correspond to first (387 mg) and 99th (1591 mg) percentile of the cumulative intake of calcium. Reference value for estimation set at 800 mg, which corresponds to Swedish recommended level of calcium intake for women older than 50 years3

7. What about Vitamin D?

Liu et all Heart Failure Society of America San Diego Sept 2010 Binkley et al ,Endocrinol Metab Clin N Am 2010 Bischoff-Ferrari H. et al. JAMA. 2005;293(18):2257-2264 Janssen HCJP, et al. Am J Clin Nutr. 2002;75:611

Optimal 25-OH Vit D for bone health >32ng/ml IOM: for general pop =20ng/ml

Vit D Deficiency= falls, 3.4 X CHF death Possibly cancer, DM, autoimmune disease,etc., remember Vit E?

Supplements: assoc with decreased mortality 1000 IU daily increase level~ 10ng/ml Too much at once? 500,000 IU and falls Toxicity?

Treatment: vitamin D

• Calcium and Vit D are insufficient to prevent transplant related bone loss

• Calcitriol (1,25 dihydroxy D)may be required by kidney and SPKT patients for a brief period at doses lower than used during dialysis

• All patients required vitd 400-1000 IU at least. Patients with malabsorption, cystic fibrosis or PBC may have higher vit D requirements. Monitor 25 D levels to assess replacement adequacy

#8: Questions About Osteoporosis What about the newest treatment:

denosumab for osteoporosis ?

Prefusion osteoclast

Monoclonal antibody for Osteoporosis:RANKL-Inhibition

Adapted from Boyle et al. Nature. 2003;423:337.

CFU-M

Multinucleated osteoclast

OPG

BONE

OPG RANKL

Stromal cells

Denosumab RANK

Active Osteoclast

Cummings SR et al. N Engl J Med 2009;361:756-765

65% reduction new

spine fractures

40% reduction new

hip fractures

20% reduction new

Non-spine fractures

Denosumab 60 mg q 6 months Decreased Incidence of New Vertebral, Nonvertebral, & Hip Fractures

Presenter

Presentation Notes

Figure 1. Incidence of New Vertebral, Nonvertebral, and Hip Fractures. The primary end point was the incidence of new vertebral fractures at 36 months (Panel A, left), which is shown for each study year (Panel A, right). Risk ratios (RRs) are for subjects in the group receiving denosumab, as compared with those receiving placebo. Kaplan-Meier curves of the time to the first nonvertebral fracture (Panel B) and the first hip fracture (Panel C) were determined on the basis of subjects who did not have a fracture or who did not leave the study before the time point of interest. The subjects at risk at 36 months included all those who completed end-of-study visits at or after the start of the window for the 36-month visit.

Densoumab (Prolia®) • Men & postmenopausal osteoporosis with

high fracture risk or failed, or intolerant of other therapies

• Has been given to renal impairment pts. (including ESRD) single dose, without affecting pharmacodynamics or pharmokinetics of the drug;

• May drop serum calcium, verify nml • Flare ups of Cellulitis? Eczema?

Block et al National Kidney Foundation Mtg, Orlando, FL; April 13-17, 2010

#9. What Lab Tests Should I Order Before Treatment?

• CBC • Creat., LFTS • Calcium, Phos, Mg • 25-OH Vit D • TSH, PTH • Bone Specific Alk Phos • Bone Turnover Marker :P1NP (Procollagen-1 N-terminal Peptide)

• Serum Free Light Chains • 24 hour urine : calcium, creatinine, phos, magnesium, sodium,

protien immunoelectropheresis

#10: Transplantation- Induced Osteoporosis (TIOP)

• 3-11% bone loss 1st yr. post transplant • 14-36% increase incidence of fragility fxs. • Most fracture occur at relatively normal

Bone Mineral Density: Bone Quality? • Pre-transplant: chronic disease & GCS • Post-transplant : GCS & calcineurin inhib. • Controversy: cyclosporine A & tacrolimus

– tacrolimus better?, may allow less GCS

•Carbonare et al Transplantation 2011

Post transplant Immunosuppression

• Simultaneous high dose GC initially and simultaneous administration of CsA, tacrolimus, azathioprine or mycophenolate mofetil

• Sorting out independent effects difficult since given simultaneously

• Immunosuppressant doses higher in liver and cardiac transplants than renal transplants contributeing to greater bone loss

T’plant Medications: CsA

• Causes severe and rapid trabecular bone loss

• Results in accelerated bone turnover wit both increased formation and resorption

• Lowers serum testosterone • Prevented by Bisphoshonates

T’plant medications: Tacrolimus

• Causes high bone turnover loss even greater than CsA

• More potent immunosuppressant than CsA

#10: TIOP :Organ Specific Issues

Kidney Bone loss: greatest in 1st 6-18 months, 4-9% Assoc. with low estradiol & testosterone, not

always gender , age, GCS, rjxn, PTH Fractures: higher early, diabetics, more in hips,

long bones, feet than spine & ribs. Post transplant 34% increase in hip fractures compared to continued dialysis pts.

Treatment: increase BMD, reduce fx, adjust bisph dose, consider Dmab,PTH for low cal,lowPTH


Heart Transplant Bone loss: 3-11% in first year Fractures: 14-36% in first year, 22-35% longterm fractures occur at T-score of -1.5 Treatment: 92% vitamin D deficient


Lung - 37% osteoporosis at txp Bone loss: 2-5% in first year Fractures: 18-37% in first year, fractures occur at T-score of -1.5; pre txp low BMD & GCS = more fx


Liver- Bone loss: 3.5-24% in first year, worse in older pt,

post menopause, & less time since txp Fractures: Highest in 1st 6-12 months, 24-65%,

highest in women with PBC Ribs and spine most common, pre txp vert fx

predict increased risk post txp

Yadav et al Nutr Clin Pract 2013 28: 52


Bone Marrow – Usually younger, shorter time from dz onset to txp,

less bed rest vs. solid organ txp Bone loss: 2-9% 1st year, recovers after 12 mos,

baselinbe at 48 mos., GVHD and GCS contributes to loss

Vitamin D: marked decline pots txp, ? Low sun

exposure to avoid GVHD

Treatment • Counsel all patients with low bone mass or fx prior to

transplant re: increased risk of fracture • Even a nml BMD does not protect against post Transplant fx • Can prevent post transplant bone loss with bisphosphonates

(zoledronic acid) • Should prophylaxis against bone loss should be give to all

transplant recipients without regard to BMD? (Cohen 2004)

• Avoid cigarette smoking and heavy alcohol consumptions • Adequate nutrition • Exercise to provide a mechanical load to bone

Osteoporosis Drugs in Development

• Anabolic drugs – antibody to sclerostin- romosozumab – PTH related peptide -abaloparatide (SQ or

patch) • Cat K inhibitor –odanacatib: withdrawn

Long term monitoring

• Annual BMD assessments • Bone Turnover Markers (PINP, NTx, CTx) • Radiographs/MRI if suggestion of fx • Bone bx occasionally required in renal

transplant patients to evaluate for adynamic bone prior to bisphosphonate therapy

Learn More About Osteoporosis Management

Know How to Read DXA Scans Know How to Treat Your Patients

The International Society for Clinical Densitometry

www.ISCD.org

When Should I Refer A Patient To The Osteoporosis Clinic?

• When you do not feel comfortable treating with osteoporosis medications

• When a patient has already been taking an oral bisphosphonate such as Fosamax or Boniva for 5 years

• When a patient has chronic renal insufficiency

• When a patient continues to have fractures

Presenter

Presentation Notes

This is not your specialty and you don’t have to try to take care of everything for your transplant patient. Don’t leave a patient on an oral bisphosphonate for greater than 5 years due to risk of atypical subtrochanteric femur fractures. No oral bisphosphonates and IV reclast is questionable. You need to be looking for other causes of fractures

Reasons why patients object to taking Osteoporosis Medications

• Cost • Fear of side effects • Fear of needles/injecting themselves

Presenter

Presentation Notes

Cost- $3,000-4,000 . We don’t have samples for prolia injections. Bone pains, infections, cause my reflux to be worse, cancer No one really wants to take a daily injection unless they are already giving themselves insulin

Questions For Us?

the top 10 questions about osteoporosis - … • 69 yo w ♀ • age 26- tah, bso; ... living or...

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