Aging Q3 Osteoporosis Lecture - 1.27 MB
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Transcript Aging Q3 Osteoporosis Lecture - 1.27 MB
Aging Q3 ACOVE #9
Osteoporosis
Jay Brzezinski, MD
Medical University of South Carolina
2011
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
Burden
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
BONE
Trabecular bone
Also called Cancellous bone
Vertebral body bone
Bone near joint lines
Has bone marrow
Light weight
Has spiculated pattern
BONE
Cortical bone
Compact bone
Long bones
Dense
Stiff
hard
heavy
BONE
Trabecular bone, 25% replaced per year
Cortical bone, 3% replaced per year
Osteoporosis occurs in both
It makes sense that trabecullar bone
fractures easier?
RISK FACTORS
Age
Gender
Prior fracture
Family history
Exercise
Smoking
RA
ETOH
Drugs….steroids
NON-RISK FACTORS??
Obesity?
Athletic childhood?
Osteoarthritis?
Diet??
Family history?
SCREENING( i.e. asymptomatic)
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!
How to Screen
DEXA is best
Heel quantitative ultrasound??
DEXA
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”
T-SCORE
-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?
FRAX
www.sheffield.ac.uk/FRAX/tool.jsp
Treatment
Calcium
Vitamin D
Should I measure
What does it mean
Will replacement help
Exercise??
Bisphosphonates
alendronate (Fosamax®) 70 mg qweek
Ibandronate (Boniva®) 150 mg qmonth
risedronate (Actonel®) 5 qday,35 qweek, 150
qmonth
Zoledronic acid (Reclast®) qyear IV
Forteo®
Teriparitide sq qday times 2 years
Risk…osteosarcoma
Used to treat osteoporosis with prior fracture
or high risk who cannot take
bisphosphonates
How long to Treat?
5 years?
7 years?
Life?
Until BMD better?
Bisphosphonates accumulate in bone and
after stopping leach out over 1-2 years
Expert Opinion
Mild risk: rx 5 years and follow BMD
High risk: rx 10 years and do 1-2 year drug
holiday
When to rescan
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
Risks
NNH
Osteonecrosis of jaw=>60,000 and most
occurred in cancer patients treated with very
high dose zoledronic acid
Atypical femur fracture=? 25,000?
Benefits
NNT
Prior Fracture
No Prior Fracture
Any Fracture = 21
100
Vertebral Fracture = 8
29
Hip Fracture = 35 - 46
4.5 - 66
Other Fracture = 21 - 43
35 – 66
Osteoporosis Blue Sheet
Osteoporosis
Aging Q3 ACOVE # 9
PCT Ask:
PCT
CIRCLE:
MD ACTION:
YES or
NO
1. Have you ever had a DXA scan (bone
density) for osteoporosis?
YES
YES
1a. If YES,
Is the DXA documented in
Practice Partner?
NO
1b. If NO,
Was the patient referred for a
DXA?
2. Was the patient’s risk of fracture
(FRAX) calculated?
3. Did the patient’s FRAX score
influence any clinical decisions in
today’s visit?
4. Have you ever had a fractured bone?
YES
MD
CHECK:
4. If YES,
4a. Did you do a fracture history?
4b. Did the fracture history indicate
any need for change in
medications or further treatment?
NO
If NO – No further action needed
NO
o
s
Osteoporosis Detailing Sheet
Aging Q3
Osteoporosis and Aging
ACOVE #9
An estimated 25million Americans have osteoporosis. It affects elderly people of all races and
ethnicities. 20-25% of persons with a hip fracture are unable to return to independent living
and 12-20% die within 1 year.
Risk Factors
Screening
DXA for all Women 65+ years
Diagnosis
T-Score
Osteoporosis
≤ -2.5
Osteopenia
-1.0 to - 2.4
Normal
> -1.0
Age
Gender
Previous fracture
Family history
Low BMI
Physical activity
Currently smoking
Rheumatoid arthritis
Alcohol use
Steroid use *
False Positives with Compression
Fractures
*Note: If patient uses >5 mg/day
Prednisone or equivalent
< 3 months: Warning
> 3 months: Rx Bisphosphonate
65+ Female
Fracture
(Major trauma NA)
DXA (Baseline)
No Fracture
DXA and FRAX
Treat
>-1.0 DXA
No Treatment
< -2.5
Treat
-1.0 to - 2.4 DXA
Look for the FRAX at:
http://www.shef.ac.uk/FRAX/tool.jsp?country=9
≥ 3% FRAX (Hip
Fracture)
Treat
≥ 20% FRAX
(Osteoporotic
Related Fracture)
FRAX should not be used with persons on treatment for
osteoporosis.
Treat
Practice Partner Template
Progress Notes
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?
Osteoporosis ACOVE begins in
clinic Thursday, July 21, 2011
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