Transcript holiday cottage

Osteoporosis Update
DR. SYLVIE OUELLETTE
RHEUMATOLOGIST
Disclosures
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Speaker programs
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Research
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Amgen, Novartis
Education/ conference support
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AbbVie, Amgen
Amgen, Roche
Advisory Boards
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AbbVie, Amgen, UCB, Roche
Objectives
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By the end of this presentation, you will be able to:
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Effectively counsel patients regarding Calcium and Vitamin D
supplementation
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Counsel patients regarding risk of atypical femoral fractures with
osteoporosis therapy
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Have a plan for when and how to consider treatment interruption for
patients who have received anti-resorptives for osteoporosis
Key Changes from 20021 to 20102 –
Osteoporosis Canada
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Higher daily vitamin D supplementation (D3)3
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400 – 1000 IU for individuals < 50 years
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800 – 2000 IU for individuals > 50 years
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Lower daily calcium intake (from all sources):
1200 mg
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Updated evidence-based approach to
therapies
1. Brown JP, Josse RG. CMAJ 2002; 167(10 Suppl):S1-34.
2. Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].
3. Hanley DA, et al. CMAJ 2010; 182: E610-E618.
Calcium - What I used to do
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Concerns of calcium supplement
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Kidney stones
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Cardiovascular events
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GI intolerance
Favour dietary Calcium (3-4/d)
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Milk
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Yogurt/ cottage cheese
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Block cheese
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Calcium fortified orange juice, soy milk, almond milk
Calcium - What I do now
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Community dwelling individuals
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No demonstrated benefit to promoting dietary Calcium or supplements
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Benefits likely = harm
Frail, institutionalized patients
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Encourage Calcium to 1000 mg/d
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Diet first
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Then supplement
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Supported by
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Weaver CM et al, OI 2016, 27:367
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Chapuy MC et al, NEJM 327(23):1637
Vitamin D
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Essential for Calcium homeostasis
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Vitamin D receptors in muscle
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Vitamin D deficiency associated with muscle weakness
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Studies suggested
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Decreased incidence of falls, fractures
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Improved lower extremity function in high risk seniors
Vitamin D –
Hansen KE JAMA Int Med 2015;175(10): 1612-21
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3 year DBRCT of 230 post-menopausal women less than 75 yo
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Vitamin D 800 IU daily + twice monthly placebo
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Daily placebo and twice monthly Vitamin D 50 000 IU
No difference in:
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BMD
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Muscle mass
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Timed Up and Go
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Number of falls
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Functional status
Vitamin D –
Bischoff-Ferrari HA, JAMA Int Med 2016;176(2):175-183
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1 year, DBRCT
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200 men and women over 70 yo with prior fall (community-dwelling)
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Low-dose control group – Vitamin D3 24 000 IU monthly
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Vitamin D3 60 000 IU monthly
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Vitamin D3 24 000 IU + 300 mcg of calcifediol monthly
Despite improved Vitamin D levels,
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No benefit on lower extremity function
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INCREASED falls with higher doses
Vitamin D – what I do now
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Community-dwelling adults (with no other health issues)
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Institutionalized patients
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No benefit to greater than 800-1000 IU/d Vitamin D3
Consider supplement 1000-2000 IU/d
Can consider pooled weekly dose, but not monthly or greater interval
Drug holiday
Risk of Fractures
Adler et al JBMR, 31(1), 16-35
Fracture risk of bisphosphonates
N Engl J Med
2016;374:254-62.
DOI:
10.1056/NEJMcp151
3724
NNT 90
Weighing the risks and
benefits of bisphosphonate
treatment
Based on treatment for 3 years - Black DM, Rosen CJ. N Engl J Med 2016;374:254-262.
NNH 800
Drug Holiday
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Task Force of the American Society for Bone and Mineral Research
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JBMR 2016, 31(1): 16-35
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Treatment decisions MUST be individualized
Drug holiday - Exclusions
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2014, Epidemiology/Quality of Life Working Group of the
International Osteoporosis Foundation
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HIGH risk patients
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Lowest T-score < -3.5
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Glucocorticoids >5 mg/d
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History of multiple fractures
Adler et al JBMR, 31(1), 16-35
Summary
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In high risk patients, treatment with bisphosophonates out-weighs risks of
atypical femoral fractures
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May consider halting therapy with bisphosphonates after 5 years (3 yrs if IV)
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Community-dwelling individuals probably don’t need Calcium
supplements or advice about dairy
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High dose Vitamin D is unlikely to confer much benefit
How much Calcium supplement would you
recommend to a 65 yo woman?
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A- 1500 mg/d as supplement
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B- 1200 mg/d (including her diet AND supplement)
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C- none, if she is community dwelling
How much Calcium supplement would you
recommend to a 65 yo woman?
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A- 1500 mg/d as supplement
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B- 1200 mg/d (including her diet AND supplement)
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C- none, if she is community dwelling
How long should patients continue on antiresorptive therapy?
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A – it depends on fracture risk
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B – 5 to 10 years
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C – indefinitely
How long should patients continue on antiresorptive therapy?
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A – it depends on fracture risk
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B – 5 to 10 years
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C – indefinitely
Questions?