Transcript Osteoporosis Part 1 of 3: Risk Factors

Osteoporosis
Part 1 of 3: Risk Factors
Ellen Davis-Hall, PhD, PA-C
Professor
Clare J. Kennedy, MPAS, PA-C
Assistant Professor, PA Program
SAHP , COM
UNMC
Omaha, NE.
office: 402-559-4738
email: [email protected]
PROCESS
Series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Objectives
• Part 1: Identify risk factors for
osteoporosis with an emphasis on
modifiable risk factors
• Part 2: Describe the most current
methods of, and standards for, diagnosis
and monitoring of treatment
• Part 3: Describe the available treatment
modalities for osteoporosis and their
effectiveness
Scope of the Problem
• An estimated 1.5 million people suffer osteoporotic
fractures each year. This number is expected to
double by the year 2040.
(Riggs, et al, 1995)
• 50% of all post-menopausal women and 15% of
while males greater than 50 years old will have an
osteoporotic-related fracture in their lifetime.
(Green et al, 2004)
• Presently, the treatment of osteoporotic hip fractures
n the USA costs $20 billion/year
(Field-Munves, 2001)
Primary Osteoporosis-Two Types
Type I:
• A primary bone loss from estrogen
deficiency (post menopausal
osteoporosis) affecting primarily
trabecular bone.
Type II:
• An age related bone loss, affecting
trabecular and cortical bone.
Secondary Osteoporosis-Causes
• Medications:
–
–
–
–
glucocorticoids
Heparin
loop diuretics
gonadotropin
releasing hormone
agonists
– phenytoin
• Disease states
–
–
–
–
–
–
Hyperparathyroidism
Hyperthyroidism
Hypogonadism
Cushing’s Disease
Malabsorption
Metastatic bone
disease
– Multiple myeloma
– Rheumatoid arthritis
– Chronic renal failure
Osteoporosis Types and Associated
Fractures
• Vertebrae is mostly trabecular bone
– Affected most by Type I primary
osteoporosis.
– Fractures seen most commonly in postmenopausal women
• Femoral bone is more cortical bone
– Affected most by Type II primary
osteoporosis.
– Hip fractures occur with increasing
frequency in older adults (both men and
women).
Risk Factors
Non-modifiable:
•
Advanced age
•
Female gender
•
Family history of
osteoporosis/fracture
•
Caucasian and Asian race
•
Thin body frame
Risk Factors
Modifiable:
• Excessive ingestion of coffee, alcohol or
protein
• Inadequate exposure to sunlight
• Insufficient exercise
• Malnutrition (poor calcium and vitamin D
intake)
• Premature menopause
• Smoking
• Secondary causes
Addressing Potentially Modifiable
Risk Factors
Excessive ingestion of coffee, protein or
alcohol
– Even 2 cups of coffee/day is a risk
– High protein and sodium intake increases
urinary calcium loss
– Alcohol inhibits osteoblastic activity and
decreases levels of Vitamin D
Management: Lifestyle changes and calcium
Addressing Potentially Modifiable
Risk Factors
Inadequate exposure to sunlight
– Adequate sunlight is necessary for the skin to make Vitamin D
– This problem often exists in homebound or institutionalized
elderly
– Vitamin should be increased in the diet (ie Viitamin D fortified
milk or orange juice)
Basic nutritional support goals ( should be for all patients) [i]
– Calcium > 1500 mg/day
– Vit D 800 IU per day* [ii]
– Weight bearing exercises [iii]
[i] NIH Consensus Conference JAMA 1994, 272 1942-8
[ii] Trivedi DP et. al. BMJ March 2003;326:469-72
[iii] Feskanich D, Willet W, et. al.. JAMA 2002;288:2300-
Addressing Potentially Modifiable
Risk Factors
Insufficient exercise
– Mechanical loading increases bone
formation
– An additional focus should be placed on
strength, coordination and balance
– Exercise in middle age can slow bone
density decline in later years
Addressing Potentially Modifiable
Risk Factors
Malnutrition (poor calcium and vitamin D
intake)
– Adequate calcium is especially important for
children and adolescents (9-18 years)
– Calcium requirement for those with osteoporosis is
poorly defined
– 2500 mg of Calcium considered a safe upper limit
(IOM, 1997)
Addressing Potentially Modifiable
Risk Factors
Premature menopause
– Premature menopause, physiologic or
surgical may not be preventable
– Estrogen replacement should be considered
Addressing Potentially Modifiable
Risk Factors
Smoking
– Nicotine decreases intestinal calcium
absorption
– Associated with earlier menopause
– Associated with lower spine density
Management: Smoking cessation
Addressing Potentially Modifiable
Risk Factors
• Secondary causes. Pay careful attention to the
use of these drugs relative to osteoporosis risk.
– Glucocorticoid use is a causative agent in both men
and women
– Furosemide is known to promote calcium loss
– Phenytoin and barbiturates enhance hepatic
metabolism of Vitamin D
– Heparin, with long standing use, promotes bone
loss
– Thyroxine, in excessive doses, promotes bone
resorption
Summary of Part 1: Risk Factors
• Risk factor assessment is critically important in
helping us to identify individuals prone to
develop osteoporosis
• Modifiable risk factors must be addressed
• Early patient identification and monitoring,
plus early lifestyle interventions, can help
prevent or slow the development of this disease
The End of Module One
on Osteoporosis
References
•
•
•
•
Riggs et al. Osteoporosis: Etiology, Diagnosis and Management.
Philadelphia, PA: Lippincott-Raven; 1995
Green et al. Does this woman have osteoporosis? JAMA, 2004;292:28902900
Field-Munves, E. Evidence-based decisions for the treatment of
osteoporosis. Ann Longterm Care, 2001;9:70-9
Institute of Medicine. Dietary reference intakes for calcium, phosphorus,
magnesium, vitamin D and fluoride. Washington, DC: National Academy
Press; 1997, 432
Post-test
Which of the following medications are
known to promote bone loss when used
long term?
A. Glucocorticoids
B. Calcium channel blockers
C. SSRIs
D. Thiazide diuretics
Correct Answer: Glucocorticoids
Feedback: Glucocorticoids.
This class of drugs, often used to help
manage COPD adn Rheumatoid Arthritis,
is well known to cause bone loss in both
men and women. Calcium channel
blockers and SSRIs do not have an effect
on bone and thiazides actually act to
improve balance by reabsorption.
end