Transcript OP Intro June 2014 LT

Introduction to
Osteoporosis Clinic
Staff of the UHN OP Program
Divisions of Internal Medicine, Endocrinology,
Rheumatology and Geriatrics
University Health Network
Objectives
What is osteoporosis?
 Why does it matter?
 How is osteoporosis/fracture risk assessed?
 How is it treated?

 Based

on current guidelines
Things to think about in the clinical setting…
2010 Clinical Practice
Guidelines for the Diagnosis
and Management of
Osteoporosis in Canada
2010 Canadian Clinical Practice Guidelines:
Target Population

Focus is on Fracture Risk Identification and
Prevention


Women and men
> 50 years of age

Prior fracture
Papaioannou A, et al. CMAJ 2010; in press.
Osteoporosis - Definition
Osteoporosis is a skeletal disorder characterized by compromised
bone strength predisposing a person to an increased risk of fracture.
Bone strength = bone density + bone quality.
NIH consensus statement [online]. 2000;17:1-36.
Bone Density


Quantitative
Best surrogate
 Measurable
 Precise
 Reproducible
 Predictive
of # risk
Fragility Fracture: Definition

A fracture occurring
spontaneously or
following minor trauma
such as a fall from
standing height or
less1,2
 Excluding
craniofacial,
hand, ankle and foot
fractures
1.
Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.
2. Bessette L, et al. Osteoporos Int 2008; 19:79-86.
Incidence Rates for Fractures
Annual incidence
(per 1000 women)
40
30
Vertebrae
Wrist
Hip
20
10
50
60
70
80
Age (years)
Adapted from Riggs BL, et al. N Engl J Med 1986
Pathogenesis of osteoporotic fractures
Neuromuscular function
Environmental hazards
Time spent at risk
Type of fall
Protective responses
Energy absorption
Risk of
fall
Force of
impact
Risk of fracture
Bone mineral density
Geometry of bone
Quality of bone
Strength
of bone
Falls resulting in Colle’s fracture
Falls resulting in hip fracture
Consequences of Fracture

Increased risk of
 Hospitalization1
 Institutionalization2
 Death3-5
fracture6-8
 Decreased quality of
life9-12
 Economic burden on
healthcare system2
 Subsequent
1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874.
2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.
3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.
4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.
5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472.
6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.
7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.
8. Lindsay R, et al. JAMA 2001; 285:320-323.
9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840.
10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.
11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.
12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.
Relevant Hx
Genetics
 Lifestyle

 Diet,
exercise, habits
Disease
 Drugs

Recommendations for Clinical Assessment
History Identify risk factors for low BMD, future
fractures and falls:
Prior fragility fractures
Parental hip fracture
Glucocorticoid use
Current smoking
High alcohol intake (≥3 units per day)
Rheumatoid arthritis
Inquire about falls in the previous 12 months
Inquire about gait and balance
Relevant Physical Exam




Vision
Gait
Quad Strength
Balance
 Tandem
gait
 Rhomberg
 Timed get up and go





Height
Kyphosis
Rib to Iliac Crest
Distance
Occiput to Wall
Percussion
Tenderness
General Physical Exam to rule out other disease
Recommendations for Clinical Assessment
Measure weight
(weight loss of >10% since age 25 is significant)
Measure height annually
(prospective loss > 2cm)
(historical height loss > 6 cm)
Physical Measure rib to pelvis distance
Examination (≤ 2 fingers' breadth)
Measure occiput-to-wall distance
(> 5cm)
Screening for
Vertebral
Fractures
Assess fall risk by using Get-Up-and-Go Test
(ability to get out of chair without using arms,
walk several steps and return)
Recommended biochemical tests for
patients being investigated for osteoporosis

Baseline:
 Serum calcium,
 CBC
 Creatinine
 ALP
corrected for albumin
 TSH
 SPEP (for patients with vertebral fractures)
 25-OH vitamin D (should be measured after
months of adequate supplementation)
3-4
Other testing may include
 24 hour urine collection for
 PTH
 UPEP
 Celiac antibody screening
 Gonadal function
 Spine XR
calcium
DEXA
≥ age 65
 ≥ age 50 if significant OP risk factors

 Prior
Fragility fractures
 Disease
 Drugs
Indications for measuring bone mineral density
Older Adults (age ≥ 50 years)
 Clinical risk factors for fracture
(menopausal women, men
age 50-64yr):
• Current smoking
• High alcohol intake
• Low body weight (< 60 kg)
or major weight loss
(>10% of weight at age 25)
Younger Adults (age < 50 years)
Indications for measuring bone mineral density
Older Adults (age ≥ 50 years)
Younger Adults (age < 50 years)
 Age ≥ 65 yr (both men and women)




Fragility fracture
+
Prolonged
use
of
glucocorticoids
 Menopausal women, men age 50Use of high-risk medication*
64yr – clinical risk factors for
Hypogonadism or premature
fracture
menopause (age < 45yr)
• Fragility fracture after age 40 yr
 Malabsorption syndrome
• Prolonged use of glucocorticoids+
 Primary hyperparathyroidism
• Use of high-risk medication *
 Other disorders strongly associated
• Parental hip fracture
with rapid bone loss and /or
• Vertebral fracture or osteopenia
fracture
on X-ray
•
•
+At
Rheumatoid arthritis
Other disorders strongly
associated with osteoporosis
least three months cumulative therapy in the previous year at a prednisone equivalent
dose ≥7.5 mg daily; *E.g. aromatase inhibitors or androgen deprivation therapy.
DEXA

World Health Organization (WHO)
definitions for postmenopausal women
(or older men)
= T score ≥ -1.0
 Osteopenia = -1.0 > T score > -2.5
 Osteoporosis = T score ≤ -2.5
 Normal

But…
 Osteopenia
is more common
 Most women who suffer fragility fractures
have osteopenia – in one large cohort 82% of
participants with fragility fractures had BMD >
2.5
More accurate to look at 10 year fracture risk
Siris ES et al. Arch int Med 2004;164:1108-12.
2010 CAROC tool:
Assessment of Basal 10-year Fracture Risk
2010 CAROC tool:
Assessment of Basal 10-year Fracture Risk
Ten Year Fracture Risk
Gender
 Age
 Bone Density Value



Previous Fragility Fracture
Prednisone
Move up 1 category
FRAX Tool:
www.shef.ac.uk/FRAX.
Treatment Thresholds
Risk of any fracture > 20 %
 Risk of hip fracture > 3 %

 Significant
risk
 Pharmaco-economically advantageous to
treat
Initial BMD testing
Assessment of fracture risk
Low risk
Moderate risk
(10-year fracture risk 10%-20%)
(10-year fracture risk < 10%)
Unlikely to
benefit from
pharmacotherapy
Reassess in
5 yr
Lateral thoracolumbar
radiography (T4-L4) or vertebral
fracture assessment may aid in
decision-making by identifying
vertebral fractures
Factors warranting
consideration of pharmacologic
therapy…
High risk
(10-year fracture risk > 20% or
prior fragility fracture of hip or
spine or > 1 fragility fracture)
Always
consider
patient
preference
Good evidence of
benefit from
pharmacotherapy
Initial BMD testing
Assessment of fracture risk
Low risk
(10-year fracture risk < 10%)
Unlikely to benefit from
pharmacotherapy
Reassess in 5 yr
Moderate risk
(10-year fracture risk 10%-20%)
Lateral thoracolumbar
radiography (T4-L4) or vertebral
fracture assessment may aid in
decision-making by identifying
vertebral fractures
Factors warranting
consideration of pharmacologic
therapy…
High risk
(10-year fracture risk > 20% or
prior fragility fracture of hip or
spine or > 1 fragility fracture)
Always
consider
patient
preference
Good
evidence of
benefit from
pharmacotherapy
Moderate risk
(10-year fracture risk 10%-20%)
Lateral thoracolumbar radiography (T4-L4) or vertebral
fracture assessment may aid in decision-making by identifying
vertebral fractures
Repeat BMD in
1-3 yr and
reassess risk
Factors warranting consideration of pharmacologic therapy:
• Additional vertebral fracture(s) (by vertebral fracture assessment or
lateral spine radiograph)
• Previous wrist fracture in individuals aged > 65 and those with Tscore ≤ -2.5
• Lumbar spine T-score << femoral neck T-score
• Rapid bone loss
• Men undergoing androgen-deprivation therapy for prostate cancer
• Women undergoing aromatase inhibitor therapy for breast cancer
• Long-term or repeated use of systemic glucocorticoids (oral or
parenteral) not meeting conventional criteria for recent prolonged
use
• Recurrent falls (≥ 2 in the past 12 mo)
• Other disorders strongly associated with osteoporosis, rapid bone
loss or fractures
Good
evidence
of benefit
from
pharmacotherapy
VFA
JB6/23/04;WW5/11/04 IVA/VFA

On the left we see a
normal lateral VFA
(vertebral fracture
assessment) showing
no VCD as high as
we can see (T6).

On the right, we see
a lateral VFA with a
wedge deformity of
T12
Moderate risk
(10-year fracture risk 10%-20%)
Lateral thoracolumbar radiography (T4-L4) or vertebral fracture assessment may aid in decision-making by identifying
vertebral fractures
Factors warranting consideration of pharmacotherapy:
Repeat BMD in
1-3 yr and
reassess risk
• Additional vertebral fracture(s) (by vertebral
fracture assessment or lateral spine radiograph)
• Previous wrist fracture in individuals aged > 65 and
those with T- score ≤ -2.5
• Lumbar spine T-score << femoral neck T-score
• Rapid bone loss
• Men on ADT for prostate cancer
• Women on AI for breast cancer
• Long-term or repeated use of systemic
glucocorticoids (oral or parenteral) not meeting
conventional criteria for recent prolonged use
• Recurrent falls (≥ 2 in the past 12 mo)
• Other disorders strongly associated with
osteoporosis, rapid bone loss or fractures
Good
evidence
of benefit
from
pharmacotherapy
What are the therapeutic options?
Exercise and prevention of falls
 Calcium and vitamin D
 Pharmacological therapy

Calcium and D

Vitamin D
 Higher



daily vitamin D supplementation (D3)3
400 – 1000 IU for individuals < 50 years
800 – 2000 IU for individuals ≥ 50 years
Calcium
 Lower


daily calcium intake (from all sources)
1200 mg per day
Diet preferred
1. Brown JP, Josse RG. CMAJ 2002; 167(10 Suppl):S1-34.
2. Papaioannou A, et al. CMAJ 2010; in press.
3. Hanley DA, et al. CMAJ 2010; 182: E610-E618.
Pharmacological therapy
First Line Therapies with Evidence for Fracture Prevention in Postmenopausal Women*
Type of
Fracture
Bone
Formation
Therapy
Antiresorptive Therapy
Bisphosphonates
Denosumab
Raloxifene
Estrogen**
(Hormone
therapy)
Teriparatide
Alendronate
Risedronate
Zoledronic
Acid
Vertebral







Hip




----

---
NonVertebral+




----


+ In clinical trials, non-vertebral fractures are a composite endpoint including hip, femur, pelvis, tibia,
humerus, radius, and clavicle.
* For postmenopausal women,  indicates first line therapies and Grade A recommendation. For men
requiring treatment, alendronate, risedronate, and zoledronic acid can be used as first line therapies for
prevention of fractures [Grade D].
** Estrogen or hormone therapy can be used as first line therapy in women with menopausal symptoms.
Considerations with osteoporosis
medications:
MSK pain
 Atypical femur fractures (~1/1000 pt yrs
after 5-10 yrs of use)
 Osteonecrosis of the Jaw (~1/100,000)
 Esophageal Cancer
 Atrial fibrillation
 Duration of therapy

X-ray, CT, Bone Scan
AFFs
Key points

Importance of fragility
fractures

Management guided by
absolute fracture risk

Individualized treatment and
therapy
Questions?