Transcript osteoporosis - Idaho Academy Of Family Physician

Osteoporosis
Todd Palmer, MD
Excellence in Primary Care
March 18th, 2017
CASE 1 (1 of 4)
 A 65-year-old woman comes to the office to establish care.
 History: menopause at age 50; mother died at age 90 after hip fracture
 Medications:
Omega-3 fish oil 2,000 IU/d
Daily multivitamin
Vitamin C 500 mg/d
Vitamin E 400 IU/d
Calcium 1,000 mg twice daily
 Diet:
2 glasses skim milk, 1 glass calcium-fortified juice daily
Red meat twice/wk; organically raised chicken or fish on other days
Diet high in fruits and vegetables
 Never smoked; drinks wine occasionally
 Activity: aerobic weight-bearing exercise 30 min/d; weight training 30
minutes, 3 times/wk
CASE 1 (2 of 4)
• Examination
 Blood pressure 120/70 mmHg
 No documented height loss
• Lab results
 CBC, basic comprehensive metabolic panel, and fasting serum
lipid panel all normal
 Serum calcium: 9.5 mg/dL
 25(OH)D: 25 ng/mL
• DEXA results
 T-score: –2.2 for lumbar spine, –1.5 for total hip, –1.9 for left
femoral neck
 FRAX 10-year probability for major osteoporotic fracture: 14%
 FRAX 10-year probability for hip fracture: 2%
CASE 1 (3 of 4)
Which one of the following is the most appropriate
intervention?
A.Prescribe oral ibandronate 150 mg, once each
month with glass of water 1 hour before breakfast.
B.Prescribe oral raloxifene 60 mg/d.
C.Discontinue calcium supplement.
D.Add supplemental vitamin D3 to 1,000 IU/d.
CASE 1 (4 of 4)
Which one of the following is the most appropriate
intervention?
A.Prescribe oral ibandronate 150 mg, once each
month with glass of water 1 hour before breakfast.
B.Prescribe oral raloxifene 60 mg/d.
C.Discontinue calcium supplement.
D.Add supplemental vitamin D3 to 1,000 IU/d.
CASE 2 (1 of 4)
• A 65-year-old woman comes to the office to establish
care.
 Unknown family history (adoption)
• Medical history unremarkable, no medications or
supplements
• Active lifestyle with regular weight-bearing exercise and
varied diet, including dairy products
• Examination
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Blood pressure 120/80 mmHg, heart rate 65 bpm
Height: 3.8 cm (1.5 in) lower than previous measurements
Slight accentuation of dorsal kyphosis
No point tenderness on palpation of thoracic or lumbar spine
CASE 2 (2 of 4)
Laboratory findings:
Calcium 9.5 mg/dL
25(OH)D 30.1 ng/mL
Serum creatinine
1.0 mg/dL
Estimated glomerular filtration rate
>60 mL/min
CASE 2 (3 of 4)
Which one of the following is the most appropriate
test to confirm a diagnosis of osteoporosis?
A.Peripheral dual-energy x-ray absorptiometry
(DEXA)
B.Central DEXA
C.Central DEXA with vertebral fracture assessment
D.Quantitative computed tomography
CASE 2 (4 of 4)
Which one of the following is the most appropriate
test to confirm a diagnosis of osteoporosis?
A.Peripheral dual-energy x-ray absorptiometry
(DEXA)
B.Central DEXA
C.Central DEXA with vertebral fracture
assessment
D.Quantitative computed tomography
CASE 3 (1 of 4)
•
A 75-year-old man undergoes preadmission physical examination
for an assisted-living facility.
•
History: mild early dementia, hypercholesterolemia
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Medications: donepezil, simvastatin, multivitamin, aspirin
•
Examination
 Blood pressure 120/75 mmHg, heart rate 75 bpm
 Accentuated kyphosis of thoracic spine but no pain on palpation
 Normal heart, lung, and abdominal findings
 Uses his arms to stand from a seated position
 Appears unsteady when asked to turn around while walking
 Uses a cane to steady his gait
CASE 3 (2 of 4)
•
Laboratory findings
 25(OH)D level: 30.2 ng/mL
 All other findings normal, including serum calcium level and
estimated GFR
 DEXA results: T-score –1.0 in lumbar spine, –2.0 in left total
hip, –2.7 in left femoral neck
•
Recommendation: high-calcium diet, participation in an exercise
program, and pharmacologic treatment
CASE 3 (3 of 4)
Which one of the following is the most appropriate
pharmacologic treatment for this patient?
A.Oral alendronate 70 mg weekly, 30 minutes
before breakfast with a glass of water
B.Intravenous zoledronic acid 5 mg yearly
C.Topical testosterone cream 5 g applied daily
D.Subcutaneous denosumab 60 mg every 6
months
CASE 3 (4 of 4)
Which one of the following is the most appropriate
pharmacologic treatment for this patient?
A.Oral alendronate 70 mg weekly, 30 minutes
before breakfast with a glass of water
B.Intravenous zoledronic acid 5 mg yearly
C.Topical testosterone cream 5 g applied daily
D.Subcutaneous denosumab 60 mg every 6 months
Objectives
1) Screening using DXA (Dual-emission X-ray absorptiometry) and risk factors
2) Frequency of screening? Use of the FRAX tool.
3) Management of postmenopausal osteoporosis: meds-oral and IV, vit. D and calcium.
4) Following treatment progress or failure.
5) Duration of treatment (drug holidays)
6) Problems with bisphosphonates
7) Other agents
8) Men: screening and treatment.
9) Managing patients placed on long term steroids
9) Prevention of OP
Not covering premenstrual OP
Osteoporosis
 Low bone mass with micro architectural
disruption and skeletal fragility leading to
increased risk to fracture particularly at
the spine, hip, wrist, humerus, rib, and
pelvis.
 Osteoporotic or fragility fractures are
those occurring from a standing height or
less with out major trauma.
Why is this so important
 Pain
 Disability (approximately one-half of patients are unable to walk
without assistance and 25% will require long term care). Can have
difficulty bending, lifting, reaching, walking down stairs, or cooking
after a vertebral compression fracture.
 1 in 2 postmenapausal women and 1 in 5 men >50 will have
fracture in their lifetime.
 Hip fractures in 15% of women and 5 % of men by age 80.
 Death (one year mortality rates after hip fractures range from 12%37%).
 5 year mortality after hip or clinical vertebral fracture is 20%
greater than expected.
 17 Billion a year cost in US.
Screening
 No symptoms until fracture (unlike
osteomalacia)
 Vertebral fractures are most common
manifestation and about 2/3’rds are
asymptomatic.
 The majority of women who have typical OP
fractures like vertebral, hip, and distal radius
have no evaluation or treatment for underlying
OP.
What can happen
physiologically?
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Bone formation/resorption imbalance
Low BMD (bone mineral density)
Abnormal micro architecture
Most women with OP have age or
estrogen related bone loss related to
excessive bone resorption.
BMD (bone mineral
density)
 Low BMD associated with increased fracture risk ( about a twofold
increase in risk for every standard deviation decrease).
 DXA is the gold standard.
 DXA scores from different sites and different technologies are not
interchangeable.
 WHO criteria for OP based on this.
 DXA-Hip measurements best at predicting hip fracture as well as
overall risk for osteoporotic fractures.
 Lumbar spine measurements less useful in older people where
structural abnormalities can falsely raise BMD. However, early
menopause has greater loss at the spine than the hip and the
spine in general may be better for following response to treatment.
There is also less variability at the spine
 FRAX uses femoral neck BMD
How to interpret the BMD
 T score-matched against younger woman. Most will compare men
to male data base.
 Z score-matched against women their own age. Mainly used for
children and young adults (less than 50).
 One way to remember-T comes before Z in the alphabet.
 Z score below -2 considered outside the of the expected range.
 T score -1 to -2.5 =osteopenia, and less than -2.5=OP.
 World Health Organization applies this to people over 50, post,
and perimenapausal women..
 We use the lowest score from the hip or spine.
 Using T of -2.5 30% of postmenopausal Caucasian women have
OP and this is about the same for lifetime risk of fracture.
Other tests
 DXA machine is large, test is expensive and uses a
small amount of radiation (similar to daily background
radiation). Don’t have to shield tech. Just keep 3 feet
from table. But still avoid in pregnancy.
 Peripheral DXA: not optimal-lack of standardized data
references for calculating T scores.
 Really have to use the distal 1/3 of the radius for diagnostic
purposes.
 Can help predict fracture risk.
 P-DXA not useful for monitoring therapy.
Other tests continuedUltrasound (US)
 US: Can identify patients at risk for fractures
and at least as good as assessing risk factors
for identifying patients at risk for OP.
 Cannot be used for diagnosis.
 No studies showing reduction in fracture risk
when used to determine who gets treated
 Not good for monitoring therapy.
 Less expensive, no radiation.
Which patient does not need
to be screened for OP
 1) 65 year old woman with a BMI of 25 and average
risk.
 2) 69 year old man who has lost 1 inch of his height.
 3) A 55 year old woman with a parental fracture
history.
 4) A 50 year old woman with a BMI less than 21,
smoker, daily etoh use, and parental fracture history.
 5) A 60 year old female with daily drinking and
smoking.
 6) 60 year old with BMI of less than 21 and daily etoh
use.
Who gets screened
 All woman at 65.
 Post and perimenapausal women ages <65
with risk factors that put them at the same risk
as a 65 year old woman without risk factors
which is a ten year risk of osteoporotic
fractures of 9.3 %.
 Men: depends on which group. No screening if
no risk factors probably makes the most sense.
More on this later
 In Europe they only screen woman and men
with risk factors.
How do we determine their
fracture risk? Do they reach
the 9.3 % cutoff?
Clinical risk assessment or
considering risk factors.
 Advanced age
 History of low trauma or fragility fracture (from standing level or
less without major trauma).
 Steroid use: dose dependant but even doses of less than 2.5 mg
of prednisone had an association.
 Fragility fracture in first degree relative.
 Low body weight: less than 127 lbs. or BMI<20). Weight loss 10%
decline in body weight) by exercise alone not associated with
increased risk. Weight loss after 50 worse, also increased height.
 Tobacco
 Alcohol ( more than two drinks a day), dose dependant.
 Rheumatoid Arthritis and other medical problems as well as meds.
 White or Asian race.
 Physical inactivity.
FRAX (Fracture Risk
Assessment tool)
 Estimates the 10 year probability of a hip fracture or all
osteoporotic fractures combined for an untreated adult, with or
without DXA results, ages 40-90..
 Using country specific economic analysis, provides guidance for
testing (?) and treatment.
 http://www.sheffield.ac.uk/FRAX/
 Tells us which osteopenic women to treat and ALSO which
women ages 50-64 to screen and may help in deciding which men
to screen.
 Also can tell us which women we would treat without a Dexa as it
would not change our decision.
 May be useful in in women currently or previously treated.
Previous fracture A previous fracture denotes more accurately a previous
fracture in adult life occurring spontaneously, or a fracture arising from trauma
which, in a healthy individual, would not have resulted in a fracture.
Parent fractured hip.
Current smoking.
GlucocorticoidsEnter yes if the patient is currently exposed to oral
glucocorticoids or has been exposed to oral glucocorticoids for more than 3
months at a dose of prednisolone of 5mg daily or more (or equivalent doses of
other glucocorticoids).
Rheumatoid arthritis.
Secondary osteoporosisEnter yes if the patient has a disorder strongly
associated with osteoporosis. These include type I (insulin dependent) diabetes,
osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism,
hypogonadism or premature menopause (<45 years), chronic malnutrition, or
malabsorption and chronic liver disease
Alcohol 3 or more units/day.
Bone mineral density (BMD)(BMD) Please select the make of DXA scanning
equipment used and then enter the actual femoral neck BMD (in g/cm2).
Alternatively, enter the T-score based on the NHANES III female reference data.
In patients without a BMD test, the field should be left blank (see also notes on
risk factors) (provided by Oregon Osteoporosis Center).
FRAX fine points and
limitations
 Patients older than 40
 Only incorporates the Hip T score
 Some important risk factors not included like vitamin D
levels, risk of falls, physical activity, dose or length of
steroid use, multiple fractures. Answers are yes, no.
Individual consideration is important.
 May underestimate with low lumbar but normal hip, DM
, severe vertebral fractures and other reasons.
 US data validated in only 4 ethnicities (Asian, African
American, Hispanic, whites).
More on risk factors and
other risk factors.
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Poor visual acuity, Neuromuscular disorders.
Vit D deficiency
Recurrent falls or use of walkers.
Dementia
Poor health/fragility.
Meds: PPI’s, Androgen deprivation agents, aromatase inhibitors, used for
breast cancer, anticonvulsants, anxiolytics, SSRi’s, thiazolidinediones,
Methotrexate, too much thyroid meds, long term heparin, antiretrovirals,
cancer chemotherapy agents, Calcineurin inhibitors. GnRH agonists for
prostate cancer.
History of breast cancer
History of falls when younger (before 50)
Late menarche (15 or later)
Hypercalcuria.
Previous fracture between ages 20-50
Possible risk factors
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Depression
Mild low sodium
Elevated markers of inflammation.
Aortic calcification on CT.
Sedentary lifestyle.
B 12 deficiency
High Homocysteine.
Large amounts of caffeine (only if the patient does not drink milk?),
studies conflicting.
Carbonated beverages may be associated with adverse skeletal effects in
adolescents, possibly because of displacement of nutricious foods and
beverages. In older woman less clear. One study showed cola but not
other beverages decreased BMD.
High dietary retinol intake. Don’t consume excessive amounts of vitamin
A.
Medical diseases
 Rheumatoid arthritis
 Cystic Fibrosis
 Celiac Disease (suspect especially if see anemia, and/or low vit D
and urinary calcium excretion.
 Diabetes
 Kidney disease
 Inflammatory bowel disease.
 History of or present hyperthyroidism
 Hyperparathyroidism
 Multiple Myeloma
 Solid organ transplant
 And many more (see later section on OP in men).
How often do you repeat
screening DXA
 Data is limited. Some of it based on NEJM
article 2012 which showed risk of OP based on
initial BMD.
 Depends on risk factors and T score.
 If initial T score 2-2.49 or risk factors that might
cause ongoing bone loss like steroids or high
pth, do q 2 yrs.
 T score 1.5-1.99 at any site with no risk factors,
do in 3-5 years.
 T score 1-1.49 and no risk factors 10-15 years.
What other workup should
be done?
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If T score is below -1 but higher than -2.5 get cbc, CMP labs to include
serum Calcium, and creatinine, vitamin D level (25OHD), . Also make
sure they are on 1200 calcium and 800-1000 units of vit. D.
If T score is below -2.5 add: Complete metabolic panel (to include
phosphorus, albumin, total protein, Liver tests including Alkaline
Phosphatase, electrolytes), blood count. Urine calcium/creatinine, spot of
24` hours, TSH.
If Z score is below -2 consider secondary cause and more involved
workup. More on this in the OP in men section.
There are many other tests which can be done especially if woman is premenopausal.
Idiopathic Hypercalcuria is found in approximately 10 % of the population
and is an important cause of secondary OP. Diagnosed by 24 hour urine
excretion of >4 mg/kg and treated with thiazide type diuretic.
Other tests to do triggered by
different clinical scenarios and
abnormalities in the initial eval.
 Urinary calcium and creatinine in woman with GI
disorders (IBD, Celiac) or GI surgery (weight loss
surgery). Also if kidney stones and maybe in others
without other risk factors.
 Test for celiac disease.
 High calcium, anemia, weight loss, proteinuria consider cancer or multiple myeloma (SPEP, UPEP).
 PTH if high CA+, hypercalcuria, stones.
 Urinary cortisol for Cushings.
 There are many others depending on clinical scenario.
 Z score of <-2 should make you think of secondary
cause.
Continuation of additional
labs if indicated
Management in the
postmenopausal woman
 Exercise to treat or prevent: 30 minutes at least
three times a week-but nearly every day is best
(weight bearing-jogging, jumping, walking, but
progressive resistance non weight bearing
strength training most effect for femur). Combo
most effective for spine. Does help BMD some
but probably more significant is that it
strengthens muscles.
 Smoking cessation
 Counseling on fall prevention.
 Avoidance of heavy alcohol use.
Calcium
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1200 mg a day from supplements as well as diet for postmenapausal women with bone
disease and 1000 a day for premenopausal woman and men with bone thinning.. 1200 in men
>70.
Average diet may have 600-1000 mg. a day. Most adults getting adequate amount of calcium
from diet. An average dairy serving (8 oz. of milk, yogurt or 1 oz. hard cheese=300 mg. Other
foods less (see table on next page). Other sources like green vegetables, nuts have variable
absorption.
Calcium intake should not exceed 2000 mg a day. Get at least half in diet.
Calcium supplements: need to look at elemental calcium not total. Calcium Carbonate 40%
elemental CA+. 1250mg=500mg. Not always stated on packaging. Also pay attention to
amount per serving (not tablet) if it is listed that way on package.
Calcium carbonate: better absorbed with food and needs acid around to absorb it.
Calcium citrate: more expensive and better absorbed in fasting state and is absorbed in the a
absence of acid (pt. on PPI or H2 blocker like Prilosec or Zantac).
It is recommended that patients on PPI or H2 blocker take calcium citrate.
However, dietary calcium (milk and cheese) absorption was not reduced in healthy individuals
treated with Omeprazole , suggesting that a meal induces a sufficient amount of acid secretion
for calcium absorption despite PPI therapy.
More on Calcium
 You can only absorb 500 mg of elemental calcium at a
time.
 High calcium intake can >dyspepsia and constipation
and calcium supplements have been associated with
an increased risk of kidney stones.
 Calcium supplements can interfere with the absorption
of thyroid hormones and iron and should be taken at
different times.
 Thiazides (hydrochlorothiazide) decrease urinary
excretion, loop diuretics (eg. Lasix) increase it.
 Calcium supplements (not dietary calcium) can >kidney
stones.
Foods and drinks with calcium
Food
Calcium, milligrams
Milk (skim, 2 percent, or whole, 8 oz)
300
Yogurt (6 oz)
250
Orange juice (with calcium, 8 oz)
300
Tofu with calcium (1/2 cup)
435
Cheese (1 oz)
195-335 (hard cheese = higher calcium)
Cottage cheese (1/2 cup)
130
Ice cream or frozen yogurt (1/2 cup)
100
Soy milk (1 cup)
100
Beans (1/2 cup cooked)
60-80
Dark, leafy green vegetables (1/2 cup cooked) 50-135
Almonds (24 whole)
70
Orange (1 medium)
60
Elemental Ca/tablet
Ca compound
Vitamin D
Caltrate 600
600 mg
Carbonate
Caltrate 600 + D
600 mg
Carbonate
200 I.U.
Caltrate 600 plus chewables
600 mg
Carbonate
400 I.U.
OsCal 500
500 mg
Carbonate
OsCal 500 + D
500 mg
Carbonate
200 I.U.
Oscal 500 + Extra D
500 mg
Carbonate
400 I.U.
Oscal Ultra
600 mg
Carbonate
200 I.U.
Tums
200 mg
Carbonate
Tums EX
300 mg
Carbonate
Tums Ultra
400 mg
Carbonate
Citracal Ultradense Petites
200 mg
Citrate
200 I.U.
Citracal caplets + D
315 mg
Citrate
200 I.U.
Citracal 250 + D
250 mg
Citrate
200 I.U.
Caltrate 600 + soy
600 mg
Carbonate
200 I.U.
Posture-D
600 mg
Phosphate
125 I.U.
Cal-100 with vitamin D
1000 mg
Carbonate
400 I.U.
Calcium gummy bears
200 mg
Phosphate
Viactiv plus D + K
500 mg
Carbonate
200 I.U.
Calcium and MI’s
 Neither CA+ supplements up to 1000 mg increased dietary
calcium, or vit. D supplements have been shown to increase CV or
all cause mortality, and in one study CA+ and Vit. D reduced all
cause mortality.
 But, two meta-analysis showed CA+ with or without Vit. D raised
concerns about increased risk of MI’s. Many were getting total of
1500-2000/d.
 There were limitations to the study and other meta-analysis
showed conflicting evidence.
 Some but not all prospective studies showed increased CV
problems with CA+ supplements. Not shown with dietary sources.
 What to do: encourage calcium from food sources, consider low
dose calcium supplementation if need to. Don’t have total CA+
intake be too high. No more than 500 mg at a time.
Vitamin D
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Low 25OHD>^PTH>bone loss. 30 mg/ml is a good level to be above. Postmenopausal women
should take at least 800 units if not1000 (AGS recommendation) a day. Premenopausal and
men 600. Men >70, 800. Many people require higher to get >30ng/ml
Fortified milk has 100 units per 8 oz. (although at a recent talk that I heard tests have shown
that the actual vitamin D is much lower than reported on carton).
Sunscreen blocks Vit. D synthesis.
Older skin does not convert Vit. D as well.
D3 (Choleclcferol) is the preferred form.
Avoid calcitrol except in secondary hyperPTH from chronic renal ds. Can cause hypercalcemia.
Safe upper limit of Vit. D not known-but can >high Ca+ and kidney stones. 4000 untis/d if not
deficient?
Chronically high levels of 25(OH)D (over 40-50) have been found in some studies to be linked
to increased risk of some cancers, falls, and mortality.
Rise in vit D faster for unit taken at lower blood levels.
Bisphosphonates may be less effective with low Vit. D levels.
Advanced Cystic Fibrosis patients usually deficient in Vit. D.
African Americans have lower vit. D levels and the WHI actually showed increased fractures
with levels>20, the opposite of caucasians.
Medications (we are mainly
talking about
Bisphosphonates here): who
gets them?
 Postmenopausal woman and men 50 and over
who have had a fragility fracture.
 BMD -2.5 or less.
 What about patients who are osteopenic (T
score between -1 and -2.5)
 Bisphosphonates decrease all cause mortality
when taken after hip fractures.
Osteoporosis and
Fractures
 There are greater absolute numbers of people
who suffer fractures (spine, hip, wrist,
humerus, and pelvis are fractures most
commonly related to OP) who are osteopenic
(T score of -1 to -2.5) than for those who are
osteoporotic (equal to or less than -2.5).
 82% of women of the women who fractured
had a T score of greater than -2.5 and 67 %
had a T score greater than -2
 So, fracture risk factors become important
when considering starting medication.
What to do with Frax score
to determine who gets
bisphosphonates?
 People with BMD of -1 to -2.5 who based on the FRAX have a 10
year probability of a hip fracture of 3% or more or a 10 year
probability of 20% or more of any osteoporotic fracture should be
considered for medical therapy.
 This is based on generic drug prices and for US patients.
 These are only guidelines and clinician still needs to individualize.
 For patients at moderate risk (10%-20%) decision to treat should
be based on the presence of additional risk factors not fully
considered and individual preferences.
 Can also apply to women previously on bisphosphonates.
 A lot more women will be put on bisphonphonates with this
system. Will it reduce fractures?
Bisphosphonates
 Alendronate (Fosamax) 10/d, or 70/wk (or 5/d or 70/wk
for prevention). Also available in liquid form. Comes in
Generic. People often use first.
 Risendronate (Actonel) 5/d or 35/wk. Comes in
generic.
 Ibandronate (Boniva) 2.5 by mouth qd, 20 mg po qod x
12 once every three months 150 mg Po q month (more
effective than qd), or 3 mg IV q 3 months. Hasn’t been
shown to prevent hip fracture but has for spine..
 Zoledronic acid (Reclast) 5 mg IV once a year (or Q2yr
for prevention). Available in generic form.
Bisphosphonate IssuesHow to take PO
 Get Vit. D level and CA + level up to normal before
starting and then continue maintenance dose.
 Even if taken correctly, less than 1% gets absorbed.
 Take on empty stomach, first thing in the morning with
8 Oz. of water (to try to prevent lodging of pill). I
recommend distilled water.
 Nothing by mouth after that (even mineral water) for at
least 30-60 minutes (60 for sure with Ibandronate).
 Patient should remain upright for at least 30 minutes to
prevent reflux. Can they do this??
Who shouldn’t take oral
bisphosphonates?
 They are generally not recommended for patients with creatinine
clearance below 30 (risedronate, ibandronate) to 35 (alendronate,
Zolendronic acid), and dose needs to needs to be modified for
more mild kidney failure.
 Patients with Barretts esophagus (possible esophageal cancer
association) and other esophageal disorders , (achalasia,
scleroderma , strictures, varices) .
 Active or not well controlled upper GI disease.
 Women who could get pregnant.
 Patients unable to take correctly, like stay upright for at least 3060 minutes.
 Discontinue if any symptoms of esophagitis or GI intolerance.
 Allergies or severe bone pain.
 If well controlled GERD or PUD, can use.
Alendronate vs.
Risendronate
 Alendronate increased BMD more in first 1-2 years but
no difference on fracture rate.
 70 mg weekly dose of Alendronate also available in
dissolvable form in 4 oz. of water.
 Risendronate has an enteric coated delayed release
form which is given immediately after breakfast with 4
oz. of water. May see more lower GI side affects with
this preparation.
 Risendronate also available as monthly dose (150
mg/month) and as effective as daily.
 In general Risendronate might cause less GI side
effects???
Bisphosphonates which
can be given IV.
 Ibandronate (Boniva) can be given daily by
mouth, monthly (and monthly seems to
improve BMD more than daily and
manufacturer will send reminders to patients),
or IV every three months (also appears to
improve BMD better than daily oral).It has not
yet been shown to reduce hip fractures.
 If using IV, go with Zoledronic acid as good
data for fracture prevention, including hip.
Affect may last longer than a year especially
the 5 mg dose.
Monitoring patients on
therapy
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No consensus on optimal approach.
Lumbar spine usually the best site to monitor-responds quickly and low
LSC.
Use same machine and position. Need to compare BMD in g/cm2 not T
score because of reference data base and software upgrades.
DXA in 2 years after start of therapy, if BMD stable, decrease frequency.
Medicare will pay for 2 year interval.
Other groups say monitor every year until stable or no monitoring at all as
only small % of patients don’t respond to therapy (hardly anyone does
this). Change has to exceed the least significant change. (LSC)
If decrease in BMD may suspect: poor compliance, inadequate GI
absorption, inadequate intake or low levels of calcium and/or vit. D, or
development of a new disorder with negative effects on bones. is there a
secondary cause which is not being treated?
Confirm compliance at every visit.
Strategy using BMP
 One strategy is that if BMD decline is greater
than least significant change and good
compliance and no contributing factors,
continue same regimen and repeat DXA in
one-two years. Or some would switch then. If
greater than 5%, switch to IV form.
 If BMD less than -2.5 and continuing to fracture
on therapy, consider switching to PTH
(parathyroid hormone)
Biochemical bone
turnover markers
 Not useful for making the diagnosis of
OP. DXA is far superior.
 Can help predict the rate of bone loss
(clinical usefulness?)
 Can help determine compliance,
absorption, drug efficiency/effectiveness
of bisphosphonates
 Not used very much.
Strategy using biochemical
bone turnover markers.
 Measure urinary N-telopeptide(NTX) or serum carboxy-terminal
collagen crosslinks(CTX) before and three to six months after
starting bisphosphonate. A decrease greater than 50% of NTX`or
30% of CTX provides evidence of compliance, absorption, and
drug efficiency and the next BMD should be stable or better. If
decrease is less, may be from poor absorption or compliance eg.
often not waiting long enough before eating. I would follow these
patients closely with DXA’s
 No good prospective studies.
 Sharing results of markers with patients can help with
bisphosphonate compliance which is not uncommonly poor. Not
used for PTH.
 Markers may be useful in patients who you suspect may have
absorption problems
How long do you give
bisphosphonates for?
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No current consensus.
But DC when life expectancy is <2 years, and when nonambulatory.
Alendronate: stopping after 5 years may be reasonable as there appears to
be a residual affect of up to 5 years. Stopping after five years did result in
decreased BMD over first five years but no increased fracture risk except
vertebral. So consider stopping in low risk osteopenic women without
previous fracture and follow carefully with DXA and monitoring risk factiors
Risedronate:?? Only one study and stopped after three years. Effects on
markers of bone turnover reverted back in one year..BMD decreased but not
to baseline and the incidence of fractures was lower then never treated
patients.
Reclast: In general benefits seen after using for three years lasted another
three years when stopped.
Atypical fractures.
 Theoretical concern for over suppression of bone turnover and
increased fragility. Studies do show increased in atypical fractures.
 Up to 5 years Bisphosphonate therapy does not seem to increase
risk.
 These seem to be stress fractures. Bisphosphonates impair
normal healing of these.
 They evolve over time with patients typically having prodromal
symptoms like aching or dull pain in groin or thigh, and there may
be cortical thickening on x-ray prior to fracture. Patient on
Bisphosphonates for 3-10 years and groin or mid thigh pain, work
up. Xray both femurs. May need MRI or bone scan.
 Treat by stopping med and give vit. D and Calcium. And limited
weight bearing or may need ortho referral for more complete
fracture and ^ pain. PTH ?
Subtrochanteric fractures
Bottom line on duration of
holiday.
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No one knows.
If on oral for five years, IV for 3, and have stable BMD, no prior fragility fractures,
and who are at low risk for future fractures, can stop meds and check BMD every
two years. Restart if BMD decreases significantly or fragility fracture.
For women at high risk, like prior fragility fracture or T score <-3.5, go up to 10
years with orals, and up to 6 years with zoledronic acid. Individualize.

In the vast majority of women who are at high risk for osteoporotic fracture,
concern about atypical fractures is not a reason to stop bisphosphonate
therapy.
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How long is the holiday ?
One strategy would be to follow with DXA and restart when BMD has fallen 5% on
at least two scan taken at least two years apart with the same scanner.
Or if they showed improvement with their initial treatment and had no history of
fracture, might want to restart after 3-5 years.
Biochemical markers: no good data.
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Adverse affects of
bisphosphonates
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IV Zoledronic acid can cause acute phase reaction in first 24-72 hours
with low grade fever, mylalgias, and arthralgias. flu like symptoms.
Low CA+: more common with IV. 9-11 days post infusion. Also be careful
with low Vit D levels, low PTH, Low dietary CA+
Reports of decreased renal function and acute renal failure after
Zoledrocin acid infusion, particularly in patients with multiple myeloma
but also in some on diuretics. Check renal function before each IV
infusion as` well as after if on diuretics or other nephrotoxic drugs. Make
sure patient is well hydrated. Also be sure to check CA+, 25 OHD before
each dose.
Can also cause significant bone pain particularly if VIt D is low. A local
rheumatologist says to make sure vit. d is 40 or more before giving IV
Reclast. Up to date says 25-30. Good idea to double the dose of calcium
supplementation for 5-7 days starting on day one of the infusion,
More Adverse Effects from
Bisphosphonates
 GI SE’s from bisphosphonates very low if taken correctly.. Main
thing is that patient takes them correctly. Weekly better than daily
??, and some woman may tolerate Risendronate better than
Alendronate ?? Enteric, delayed release Risedronate slightly
worse than nonenteric ? Concurrent NSAIDS may potentiate.
 Rare symptoms of severe musculoskeletal pain which can come
on days, weeks, or years after starting therapy and does not
always resolve when stopping therapy. FDA recommends
discussing with patients.
 Rare ocular side effects: blurred vision, conjunctivitis, scleritis, and
uveitis.
 A Fib: conflicting data, more association with IV than oral.
Consider cardiac history.
Osteonecrosis of the jaw
(avascular necrosis)
 Associated with pain, swelling, local infection, exposed
bone, and pathological fractures of the jaw.
 Most cases seen with bisphosphonates have been
seen in cancer patients (particularly multiple myeloma
and metastatic breast cancer and cancer treatment
plays big role) or immunocompromised patients who
received high dose IV bisphosphonates.
 Other risk factors are duration of exposure, dental
extractions and implants, poorly fitting dentures,
smoking, steroids, and preexisting dental disease, DM,
and IV bisphosphonates.
 Risk for patients on oral bisphosphonates is estimated
at 1 in 10,000 to 1 in 100,000 patient years.
So what to do and say?
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Discuss risks, signs, and symptoms of ONJ with patients and encourage
good dental care and regular visits to the dentist, but dental visit prior to
starting the med is not needed.
Individualize on basis of risk for ONJ and risk for adverse consequences
of bone health. Extensive invasive oral surgery, smoking, roids, DM,
peridontal disease, cancer and cancer treatment.
If had procedure and not on Bisphosphonates, delay giving them for a few
months until complete healing
If patient needs dental/jaw surgery like extractions and implants and has
been on the meds for less than 4 years, go ahead with the surgery.
If on for more than 4 years or has also been on steroids, recommendation
is to stop the meds for two months before the surgery; although no good
data to support this, but it shouldn’t adversely affect patient with regard to
fracture risk.
Timing of bisphosphonates
around fractues.
 Bone healing requires remodeling which requires
activity of both osteoclaths and osteoblasts. There is
theoretical concern that by inhibiting osteoclasts,
bisphosphonates might impair bone healing.
 Little data to guide decision but should wait 4-6 weeks
before starting bisphosphonates after a fracture even
though data does not really support this.
 Little or no difference in healing for continuing or not if
already on a bisphophonate at the time of fracture. So
if already taking bisphosphonate and on for less than 5
years, just leaving them on it is probable fine, unless
they have an atypical fracture (described elsewhere).
Other agents
 Raloxifene: does not increase BMD as much as
bisphosphonates, decreases risk of vertebral fractures
(not other fractures), lowers risk of breast cancer, does
not ^ endometrial hyperplasia or heart disease, ^’s risk
for thromboembolic events, ^’d fatal CVA’s (not overall
CVA occurrence). May want to use in woman who
cannot tolerate bisphosphonates and have no history
of fragility fractures or who have OP and an increased
risk of invasive breast cancer. Not effective for
prevention of OP because blocks estrogen effects on
bones in premenapausal women. Can also ^ leg
cramps, peripheral edema, hot flashes, and flu like
symptoms.
Calcitonin
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Binds to osteoclats and inhibits bone resorption. Salmon Calcitonin 40
times greater affinity for receptor than human and is used.
Nasal, SQ, and IM forms. Nasal has less side effects and may provide
better pain relief.
Not very effective ( works best or probably only on spine) but does help
with pain from more acute vertebral compression fractures at 1,2,3 and 4..
So may be the antiresorptive drug of choice for pain in acute osteoporotic
fracture. Patients can develop antibodies and become resistant to it’s
effects ( studies conflicting). Can also have hypersensitivity reactions
including anaphylaxis, low CA+, and adverse nasal reaction (most
common)
Concerns about long term use and cancer. FDA says benefits do not
outweigh risks and if you do use it, use for less than 6 months.
So use for short term in OP fracture with significant pain and then switch
to more effective agent when pain has subsided.
PTH or parathyroid hormone
(Forteo or Teriparatide)
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Chronically high PTH> bone resoprtion and also increases renal tubular
calcium resorption. But, intermittent use of recombinant PTH stimulates
bone formation more than resorption.
PTH: consider using in patients with t score less than -2.5 who are unable
to tolerate bisphosphonates or have contraindications, or who have T
scrore of <-2.5 plus fragility fractures or are on bisphosphonates but
continue to fracture after one year on them.
Also consider using with severe OP (T score <3.5)
It is expensive and given SQ QD
Contraindications: primary or secondary hyperparathyroidism,
hypercalcemic disorders (can’t use if high calcium in blood or urine),
patients at increased risk for osteosarcoma (Pagets, radiation to bone,
unexplained elevation of alk phos) and don’t use on younger patients with
open epiphysis.
Also try to avoid in preexisting malignancies, kidney stones, renal
insufficiency.
How to give Forteo
 What to do before starting:
 DXA if not done in the prior two years.
 Check Ca+, Phos, Creatinine, Alk Phos, Albumin, 25-OHD, 24
hour urine calcium and creatinine.
 Replace Vit. D if deficient. Others will need 800 units/d.
 Total Calcium intake should be 1000-1200/d. Don’t go
over 1500. Have to be cautious. If high calcium
develops, decrease calcium and stop vit. D and
recheck calcium 24 hours after last PTH dose. If CA+
stays up, go to QOD PTH and if this does not do it,
have to DC Forteo.
 If baseline urinary calcium is >400 need to check PTH
and evaluate for other causes also.
More on how to give
Forteo
 Give first dose when lying down because of risk of orthostatic
hypotension, and be sure to check vitals after first dose in patients
with vascular insufficiency or hx or orhtostatic hypotension.
 Checking calciums: no standards. Can check at baseline, 1,6, and
12 months or check once at 3 months and let this guide further
testing. Wait 24 hours after last pth to check.
 Do not give for more than 2 years because of concerns over
osteosarcoma and lack of proven efficacy. Re-treatment not
recommended.
 If patient at high risk for fracture, typically use bipsphosphonates
after stopping or Denosumab or Raloxifine (women only) if can’t
take bisphosphonates.
More on Forteo
 Occasional ^P, decreased BP, with first
few doses. Maybe nausea and
headache-maybe. Muscle cramps.
 Can increase uric acid and >gout attack,
so check it. You also need to be checking
renal function at least once during course
of treatment and again watch your CA+
Denosumab or Prolia
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RANKL (receptor activator of nuclear factor kappa-B ligand) is essential for bone
resorbing osteoclasts. Denusomab is a monoclonal antibody against RANKL.
SQ injection every six months, stored in refrigerator, bring to room temp before
giving.
Not considered first line therapy for OP.
Consider when high risk for fractures (but not severe enough for Forteo) and
difficulties with bisphosphonates or impaired renal failure, or in men undergoing
androgen deprivation therapy (increases BMD but no data on preventing fractures
in other men). More effective than Alendronate.
Inadequate data for use in more severe renal disease and high PTH and lack of
safety data in this group. Need to be certain that they have OP and not from renal
disease-not always easy to do.
Discontinuation results in bone loss in relatively short time unlike bisphosphonates
and Forteo does not seem to help this.
Duration of use?
Not recommended for OP prevention.
Denosumab Adverese
Effects and precautions
 Generally well tolerated. Most common side effects:
back, extremity, and musculoskeletal pain, high
cholesterol, and cystitis.
 Be careful regarding low CA+ in patients who may be
prone like low PTH, renal disease (Creatinine
clearance <30), GI absorption issues. Make sure
patient repleted before starting. And CA+ needs to be
checked 10 days after starting, and be careful if they
get sick and can’t take CA+
 Affects immune system so increased risk for infections
and skin reactions so patients need to be seen if any S
and S develop.
 ONJ and atypical fractures have been reported.
Estrogen
 Estrogen does help in a dose dependant
manner, but it should not be used solely for
treating osteoporosis because of other risks
that it poses to women, especially older
women.
 WHI: Decreased risk of hip, spine fracture and
colon cancer, but increased risk for breast
cancer, heart disease, CVA, and venous
thromboembolism.
 Might use if having perimenapausal symptoms
and/or patient cannot tolerate other meds.
Combination therapies??
Generally not recommended.
Men
 Stronger bones, and lose bone slower than women. Incidence of
fragility fractures begins about 10 years after women.
 By age 90 1 in 6 will have had hip fracture. Hip and spine fracture
1/3 the incidence in women. But if they get fracture, mortality rate
is higher.
 And if they suffer fracture only 4.5% will receive antiresorptive
therapy verses 49% in women. Wow!
 40-60% have underlying cause.
 Most common causes are Hypogonadism, steroids, GI ds, Vit. D
deficiency, ETOH (> 10 drinks/week), anticonvulsants, and
hypercalcuria. Delayed puberty can also have role.
 Others: hx of CVA, DM, prior fractures and falls (especially in the
past year), weight loss, low physical activity, decreased GH if
untreated.
Men-Do we screen?

1)
2)
3)
4)
5)
6)
1)
Depends on the group but probably not except:
Osteopenia on x-ray.
Loss of height more than 1.5 inches
Other risk factors like long term steroids Rx,
hypogonadism (low testosterone), primary
hyperparathyroidism, intestinal disorders.
History of low trauma fractures.
Or can use frax tool.
50-69 if diseases or meds known to increase risk of
hx of fragility fracture after 50
Some groups screen at 70 for all
DXA results in men
 Same cutoffs as in women.
 They use a male database for T and Z
scores.
 Classification applies to men over 50
 For men <50 with low Z score (<-2) use
other factors, like fragility fractures, and
look at risk factors.
Initial workup if T score
less than -2
 Initial evaluation for secondary cause
should include: blood count, complete
metabolic panel, 25 OHD, testosterone
level, 24 hour urinary calcium and
creatinine excretion.
Further workup for
secondary causes
 PTH (parathyroid hormone) if calcium is high (some
may check PTH as part of primary workup).
 If suspect celiac disease for instance when 25-OHD is
low or urinary calcium excretion is low
 Serum and protein electrophoresis particularly if
anemic or vertebral compression fractures.
 Markers of bone resorption and formation
 Cushings workup- urinary cortisol.
 Serum Tryptase for systemic mastocytosis.
 Estradiol
 And others less commonly obtained.
 And other workup similar to in women.
Other miscellaneous causes
you might consider
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Growth hormone deficiency
Cirrhosis
Other malabsorptive disorders.
RA
Immobilization
MM
Lymphoma
Leukemia
Disseminated carcinoma
Chronic hemolytic anemia
Osteogenesis imperfecta
Ehlers-Danos
Marfans
Homocystinuria
Drugs-ETOH (alcohol), anticonvulsants, roids, Thyroxine suppressive therapy,
chemotherapy, Cylclosporin, Gonadotropin releasing hormone analogues.
Treatment of OP in Men
 Lifestyle-weight bearing exercises,
Calcium (1000 mg, maybe 1200 if over 70)
vit. D 800 units a day.
 Secondary causes-treat. Low testosterone
is the most common. Efficacy on fracture
prevention questionable in older men but
generally recommended.
Bisphosphonates

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
Over 50 with history of fracture or T score <-2.5.
T score -1---2.5 and 10 year probability of hip fracture of 3 % or
probability of all osteoporotic fractures combines 20% or more. (Use
FRAX tool).
Also consider in high risk groups such as on roids, S/P hemiplegic CVA,
GI disorders, Androgen deprivation therapy.
Alendronate and Risedronate best studied in men. IV not well studied in
men but probably also an option. Zoledronic acid reduced vertebral Fx.
PTH can also be used with the same indications as in women.
If low testosterone, treat for two years with testosterone and if T score still
below -2.5 or who fracture then add bisphosphonate to testosterone. If
other risk factors present (eg. on steroids, recent fragility fracture
particularly if T score <-2.5, frequent falls, or very low t scrores (-3.5 or
even -3 if other risk factors) don’t wait to add bisphosphonate.
Managing patients placed
on long term steroids
 Bone loss greatest in the first few months of steroid use and
fractures occur at higher BMD’s. Fracture risk greatest in first 3-6
months.
 Increased risk with as little as 2.5 pred./d. Even inhaled steroids
can cause bone loss.
 Be aware of this and be aggressive.
 Recommend weight bearing exercises for 30 minutes a day. Avoid
smoking and excess etoh, Fall prevention.
 Put all patients on a total of Calcium 1200/d. Steroids reduce GI
absorption and increase urinary excretion of CA.
 Put all patients on 800 units vit. D/d.
 Get baseline DEXA and then at one year maybe 6 months in this
case) trying to use same machine and tech? If bones stable, do q
2-3 years. Q5 after roids stopped.
Who should be on meds?
 A lot of different recs from different groups.
Can use Frax tool and adjust for dose because
Frax tool does not consider dose or duration of
steroids. Remember this applies to men 50 and
over and postmenopausal woman as this was
population FRAX designed for
 T score <-2.5 treat as always.
 T score -1 to -2.5, treat if hip>3% or any OP
fracture >20%, but if falls below these cutoffs
and on 7.5 pred or more a day, treat.
What about premenapausal
women and men less then
50?
 If they have a fragility fracture while on
steroids (generally talking about 7.5/d) or
if they have > 4% bone loss/year, treat.
 If hypogonadal, treat with hormones
instead. Steroids reduce production of
sex steroids
Which Meds?
 Bispohosphonates are first line with Alendronate and
Risedronate being preferred in this setting. Zoldronic
acid is alternative if problems taking.
 Forteo also a consideration here with same indications
as in others. Epiphyses need to be fully fused in
younger patients.
 Some possible concerns for fetus in premenapausal
women and bisphonphonates stick around a long
time.Forteo also a concern here.
 Calcitonin and Denosumab generally not
recommended.
American College of Rheumatolgy
Guidelines in case you are curious or
want to be confused more
 Use FRAX to determine risk with low being 10% or less risk of
osteoporotic fracture, medium 10%-20%, high >20 or t score less
than -2.5.
 For low risk treat if pred 7.5/d or more.
 Medium: treat for any dose, amd use Zoledronic Acid if 7.5 mg
pred./D or more.
 High risk: treat any dose or duration, consider Forteo if 5 or more
a day any duration or any dose > one month.For men <50 or
premenapausal women, bisphosphonate is 5 or more pred for
>one month, Zoledronic acid if 7.5 or more any duration and also
consider Forteo for any steroids greater than 3 months.
 For child bearing age women, Bisphosphonates or Forteo if 7.5/d>
3 months.
Prevention
 Bone microarchitectural changes are largely irreversible.
 Bone loss 30-40 % environmental.
 Exercise but excessive accompanied by poor nutrition and
reduced body fat can lead to OP.
 Stop smoking, don’t drink too much alcohol.
 In 2013 USPTF recommended against supplementation with <400
units of vitamin D and 1000 mg of CA+ for primary prevention in
postmenapausal women and that there was insufficient evidence
to recommend higher doses. However Up to Date recommends:
1200 CA+ and 800 units vit. D for postmenopausal women and for
premenapausal and men 1000 CA+ and 600 units Vit D through
age 70, 800 after.
 Kids need Calcium and Vit. D (1300 and 600) during bone
formation years but they generally get enough in their diets.
 Carbonated beverages in girls (colas in adults?) or is this just
because this displaces more nutritious beverages.
Calcium and vitamin D.
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The USPSTF concludes that the current evidence is insufficient to assess the
balance of the benefits and harms of combined vitamin D and calcium
supplementation for the primary prevention of fractures in premenopausal women
or in men (I statement).
The USPSTF concludes that the current evidence is insufficient to assess the
balance of the benefits and harms of daily supplementation with greater than 400
IU of vitamin D3 and greater than 1,000 mg of calcium for the primary prevention of
fractures in noninstitutionalized postmenopausal women (I statement).
The USPSTF recommends against daily supplementation with 400 IU or less of
vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures
in noninstitutionalized postmenopausal women (D recommendation).
The USPSTF has previously concluded in a separate recommendation that vitamin
D supplementation is effective in preventing falls in community-dwelling adults
aged 65 years or older who are at increased risk for falls (B recommendation).
Go
Vertebral Compression
Fractures
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Most common type of osteoporotic frcature
Usually Mid-thoracic, thoraco-lumbar junction
If occur slowly over time, no symptoms. May just have kyphosis or loss of
height or clothes not fitting right..
If single vertebrae above T4, look for other causes.
In acute fractures, often no history of trauma. There may be sudden
bending, coughing or lifting. Speed bumps.
Neuro. Eval. needs to be done.
Pain usually last 4-6 weeks but can be debilitating.
May have kyphosis and complain of protuberant abdomen, clothes not
fitting right, early satiety, no longer have waste. Headaches or neck pain
may be seen if thoracic
May refer to other areas.
Caution use of NSAIDS.
Patients who you don’t expect adequate response with oral analgesics,
consider Calcitonin for 2-4 weeks.
PT can help.
Exercise: eg. aquatic, extension.
Bracing: limited data for efficacy. ? Not a great idea. Also use for short
amount of time>weakness, disuse OP.
Chronic pain>3-6 months requires further eval.
Vertebroplasty and
kyphoplasty.
 Percutaneous injection of bone cement into a
fractured vertebrae.
 Some might consider doing in patients within 7 days
of admission who have incapacitating pain and
unable to taper parenteral opioids, or unable to take
or or not improving on oral opioids.
 Also consider 4-6 weeks out if no improvement.
 2009 2 studies showed vertebroplasty did not help.
Third one funded by the manufacturer did show a
difference.
DXA with vertebral fracture
assessment indications.
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T score<-1
Age>70 for women and 80 for men.
Historical height loss greater than 1.5 inches or 4 cm.
Undocumented self report of prior vertebral fracture.
History of steroid use equivalent to prednisone > 5
mg/day for >3 months.
 If you do see a vertebral fracture patient has OP
regardless of T score.
 It only diagnosis fractures and may miss bad stuff and
minor fractures.
Summary
 1) Screen all woman at 65 and younger
woman and men if risk factors.
 2) DXA is gold standard.
 3) Use Frax score to decide which
osteopenic patients should be treated.
 4) Do additional workup guided by their T
and Z scores.
Summary continued
 Repeat screening DXA’s at intervals
determined by the initial T score and risk
factors, especially ones that have
changed. Need to duplicate the same
DXA conditions (machine, ect.)
Summary Continued
 7) Treating OP: make sure on 1200 Ca+ and
recommend calcium citrate if on PPI or H2 blocker and
no more than 500 mg at a time. Make sure on Vit. D
800-1000 units a day. Bisphosphonate is first line drug.
Make sure there are no contraindications and that they
are taking them correctly. Monitor Q1-2 years with
DXA. If stable decrease frequency. If not go to Q year,
and question compliance, absorption or change Rx to
IV if greater than 5% drop. Can use biochemical bone
markers for evidence of compliance, absorption, or
efficiency of meds. Remember how important lifestyle
changes are.
Summary Continued
 8) Duration of treatment: ???, but
recomended to give drug holiday after 5
years (3 if IV) if improvement and low risk
factors. Drug holiday can range from 1-5
years and can use DXA to guide when to
restart.
 9) Be aware of and discuss possible
adverse affects of bisphosphonates with
patients including ONJ.
Summary Conitued
 10) Consider other options if unable to
take bisphosphonates or if OP very
severe.
 11) Consider PTH especially if have OP
and have been on bisphosphonates for a
year and continue to fracture.
Summary continued
 12) Glucocorticoids: Be active and aggressive
to prevent OP in patients who are on long term
steroids : Calcium, vit. D, bisphosphonates if
Frax dictates or if on 7.5 or more a day, and
also use in younger people if fragility fractures
or >4% BMD loss per year -but don’t use in
women of child bearing age. Consider
preventative dose in low risk people.
 13) Lifestyle is important for both treatment and
prevention of OP and prevention is optimal.
Contact information
 Todd Palmer
 [email protected]
 Ph. 208-514-2500