AACERecommended Laboratory Tests

1
AACE-Recommended Laboratory Tests

• Complete blood cell count
• Serum chemistry studies (especially calcium,
  phosphorus, total protein, albumin, liver
  enzymes, alkaline phosphatase, creatinine, and
  electrolytes)
• Urinary calcium excretion

2
Additional Laboratory Evaluations for Secondary
Causes

• Serum thyrotropin
• Erythrocyte sedimentation rate
• Serum parathyroid hormone concentration
• Serum 25-hydroxyvitamin D concentration
• Urinary-free cortisol and other tests for
  suspected adrenal hypersecretion
• Acid-base studies

3
Additional Laboratory Evaluations for Secondary
Causes
Continued

• Biochemical markers of bone turnover
• Serum tryptase, urine N-methylhistamine, or other
  tests for mastocytosis
• Serum and/or urine protein electrophoresis3
• Bone marrow aspiration and biopsy to look for
  marrow-based diseases
• Undecalcified iliac bone biopsy with double
  tetracycline labeling
• In men, total serum testosterone

4
Risk Factors for Osteoporosis

• Key modifiable risk factors identified by NOF
• Cigarette smoking
• Low body weight (127 lbs)
• Other modifiable risk factors
• Inadequate calcium and vitamin D intake
• Physical inactivity
• Excessive alcohol

Images National Cancer Institute
5
Recommended Calcium Intake
Pregnancy and lactation needs are the same as
for non-pregnant women. Adapted from Standing
Committee on the Scientific Evaluation of Dietary
Reference Intakes. Food and Nutrition Board.
Institute of Medicine. 1997. National Academy
Press, Washington, DC.
6
Vitamin D Nutritional Recommendations

• National Academy of Sciences
• 400 to 600 IU/day
• National Osteoporosis Foundation
• 800 IU/day for older adults, or individuals who
  are chronically ill, housebound, or
  institutionalized
• 50,000 IU once a week for up to 3 months in
  severe cases of vitamin D deficiency

7
Dietary Sources of Vitamin D1

• DV Daily Value. DVs are reference numbers
  developed by the Food and Drug Administration
  (FDA) to help consumers determine if a food
  contains a lot or a little of a specific
  nutrient. The DV for vitamin D is 400 IU (10 µg)
  for adults.

8
Calcium Supplements
Source Understanding Osteoporosis. Chicago , IL
American Medical Association 2000.
9
Exercise and Physical Activity

• Weight-bearing exercises are most effective
• Walking
• Jogging
• Tai-chi
• Stair climbing
• Dancing
• Tennis

Images National Cancer Institute
10
Assessing Risk Factors for Falls in Elderly
Patients

• Factors the contribute to the risk of falling
  include
• Frailty and associated deconditioning
• Poor visual acuity
• Impaired hearing
• Using medications with neurologic effects that
  compromise protective neuromuscular reflexes

11
AACE Recommendations for Fall Prevention

• Minimize risk of falls with gait and balance
  training
• Adjust dosage of drugs with sedative effects
• Anchor rugs
• Minimize clutter
• Remove loose wires

Hodgson SF, Watts NB, Bilezikian JP, et al.
Endocr Pract. 20039544-564.
12
AACE Recommendations for Fall Prevention
Continued

• Use nonskid mats
• Install handrails in bathrooms, halls, and along
  stairways
• Light hallways, stairwells, and entrances
• Encourage patient to wear sturdy, low-heeled
  shoes
• Hip protectors

Hodgson SF, Watts NB, Bilezikian JP, et al.
Endocr Pract. 20039544-564.
13
AACE Treatment Goals Postmenopausal Osteoporosis

• Prevent fractures
• Stabilize or increase bone mass
• Relieve symptoms of fractures and skeletal
  deformity
• Maximize physical function

Hodgson SF, Watts NB, Bilezikian JP, et al.
Endocr Pract. 20039544-564.
14
Postmenopausal Women Treatment Guidelines

• NOF
• Women with T-scores below -2.0 with no risk
  factors
• Women with T-scores below -1.5 with one or more
  risk factors for fractures
• Women with a prior vertebral or hip fracture

Physicians Guide to Prevention and Treatment of
Osteoporosis. 2nd ed. Washington, DC National
Osteoporosis Foundation 2003. and Hodgson SF,
Watts NB, Bilezikian JP, et al. Endocr Pract.
20039544-564.
15
Postmenopausal Women Treatment Guidelines
Continued

• AACE
• Women with T-scores below -2.5 with no risk
  factors
• Women with T-scores below -1.0 and low-trauma
  fractures
• Postmenopausal women in whom nonpharmacologic
  preventive measures are ineffective

Physicians Guide to Prevention and Treatment of
Osteoporosis. 2nd ed. Washington, DC National
Osteoporosis Foundation 2003. and Hodgson SF,
Watts NB, Bilezikian JP, et al. Endocr Pract.
20039544-564.
16
Antiresorptive Therapies

• Bisphosphonates
• Alendronate
• Risedronate
• Ibandronate
• Hormone replacement therapy
• Estrogen

• Selective estrogen receptor modulators
• Raloxifene
• Calcitonin

17
Pharmacotherapy Bisphosphonates







18
Alendronate Clinical Studies

• Postmenopausal women
• (4 years)
• Hip fractures decreased 36
• Vertebral fractures decreased 44
• Men (2 years)
• Spine BMD increased 5

19
Risedronate Clinical Studies

• Postmenopausal women (3 years)
• Vertebral fractures reduced 41-49
• Nonvertebral fractures reduced 39
• Hip fractures reduced 40-60

20
Risedronate Clinical Studies

• Postmenopausal women (5 years)
• Vertebral fractures reduced 50
• Nonvertebral fractures reduced 37
• Glucocorticoid-Induced Osteoporosis (1 year)
• Vertebral fractures reduced 70

21
Ibandronate Clinical Studies

• Postmenopausal women (3 years)
• New vertebral fractures decreased by 52
• Spine BMD increased by 5
• Once monthly dosing

22
Bisphosphonate Dosing Instructions

• Take first thing in the morning
• Take on an empty stomach with a full glass of
  water
• Avoid food and remain upright for 30 minutes
  after taking the drug
• Use cautiously in patients with stricture,
  esophageal ulcers, stomach ulcers, or heartburn
• Do not give to pregnant women or patients with
  poor renal function

23
Hormone Therapy Clinical Studies

• WHI confirmed the effects of hormone therapy on
  fracture reduction
• WHI found HT provides no cardioprotective
  benefits and increases breast cancer risk
• Hip and vertebral fractures decreased by
  one-third
• Total fractures decreased by 24 to 30
• Adverse effects (increased risk of stroke,
  cognitive impairment, deep vein thrombosis)
  offset benefits

24
HRT Government Recommendations

• US Surgeon General
• Decisions to use HRT must consider its impact on
  overall health outcomes
• These outcomes include the potential to reduce
  fracture risk
• FDA
• Postmenopausal women who use or are considering
  estrogen or estrogen/progestin should discuss
  benefits and risks with their physicians
• Estrogens and progestins be used at the lowest
  possible dose for the shortest time needed to
  achieve goals

25
Hormone Therapy ACOG Recommendations

• Combined hormone therapy should not be used to
  prevent diseases, such as cardiovascular disease
• Estrogen-alone therapy should also not be used to
  prevent diseases
• Hormone therapies are appropriate to relieve
  vasomotor symptoms, if a woman has weighed risks
  and benefits with her doctor
• Women should take the smallest effective dose for
  the shortest time possible and annually review
  the decision to take hormones

Hormone Therapy. Obstet Gynecol. 2004104(supp
4)1S-129S.
26
Hormone Therapy Other Recommendations

• AACE Recommends
• Against prescribing HRT to asymptomatic women to
  prevent or treat osteoporosis
• Against prescribing HRT to prevent heart disease
  or other chronic medical conditions

27
SERMS Raloxifene Clinical Studies

• Vertebral fractures reduced 50
• Reduction of hip and other nonvertebral fractures
  not demonstrated
• Discontinuing raloxifene returns bone turnover to
  previous state, resulting in bone loss
• Other benefits include decreased cholesterol and
  LDL, reduced breast cancer risk
• Adverse effects included hot flashes and venous
  thromboembolism

28
Antiresorptive Therapy Calcitonin Clinical
Studies

• Continuous use associated with decreased bone
  resorption
• PROOF trial demonstrated a reduction in vertebral
  fractures for individuals receiving 200 IU/d
• No significant decline for those receiving 100
  IU/d or 400 IU/d

29
Anabolic Therapy Teriparatide Clinical Studies

• Effects when used with calcium and vitamin D
  supplements
• Increased BMD
• 9 at the spine and 2.6 at the hip in
  postmenopausal women
• 5.9 at the spine and 1.2 at the hip in men
• Decreased fracture risk
• 65 for vertebral fractures in postmenopausal
  women
• 53 for nonvertebral fractures in postmenopausal
  women

30
Combining Antiresorptive Therapies

• Clinical studies have not shown combinations of
  HT or raloxifene with bisphosphonates to increase
  BMD more than each agent alone
• Studies have not determined whether combinations
  produce greater fracture risk reduction
• Reserved for patients who experience fracture
  while taking one drug, who have very low BMD and
  a history of multiple fractures, who have very
  low BMD lose more bone mass on single-drug therapy

31
Combining Antiresorptive and Anabolic Therapies

• Alendronate and PTH used together
• Increases in cortical bone BMD with short-term
  combination therapy less than for PTH alone
• Antifracture benefit not evaluated
• PTH followed by alendronate vertebral BMD
  increased substantially
• Raloxifene followed by PTH rapid and complete
  response to PTH
• Alendronate followed by PTH reduced response as
  judged by bone turnover markers and BMD

32
Postmenopausal Women Monitoring Therapy

• Serial BMD
• BMD changes slowly
• Assessment is required every 2 years to measure
  change
• Measurements from peripheral sites are not useful
• Should be performed on the same machine if
  possible
• Bone turnover markers
• Evolving method of clinical assessment
• Large changes in biochemical markers associated
  with fracture reduction

33
Treatment of Osteoporosis in Men Testosterone

• In men with hypogonadism, testosterone
  replacement therapy increases BMD
• No prospective studies on fracture prevention
  with testosterone
• BMD did not increase in men with normal
  pretreatment levels
• Not appropriate in elderly men, because of
  potential for undiagnosed prostate cancer

34
Treatment of Osteoporosis in Men Bisphosphonates

• Alendronate
• Increased BMD
• Decreased vertebral fractures
• Magnitude of effect similar to that in women
• Risedronate, in men receiving glucocorticoid
  therapy
• Increased BMD
• Reduced fractures

35
Treatment of Osteoporosis in Men Teriparatide

• After 11 months of treatment
• Spine BMD increased 5.9
• Femoral BMD increased 1.5
• Peripheral BMD did not change

36
Glucocorticoid-Induced Osteoporosis ACR
Guidelines

• For patients beginning glucocorticoid therapy (5
  mg/d or prednisone equivalent)
• Modify lifestyle risk factors for osteoporosis
• Cease or avoid smoking
• Reduce alcohol consumption if excessive
• Instruct in weight-bearing exercise
• Initiate calcium supplementation
• Initiate supplementation with vitamin D
• Prescribe bisphosphonate (use with caution in
  premenopausal women)

Arthritis Rheum. 2001441496-1503.
37
ACR Guidelines for Long-Term Glucocorticoid
Therapy

• For patients receiving long-term therapy
• Modify lifestyle risk factors
• Cease or avoid smoking
• Reduce alcohol consumption if excessive
• Instruct in weight-bearing exercise
• Initiate calcium supplementation
• Initiate supplementation with vitamin D
• Treatment to replace gonadal sex hormones if
  deficient or otherwise clinically indicated

Arthritis Rheum. 2001441496-1503.
38
ACR Guidelines for Long-Term Glucocorticoid
Therapy

• Measure BMD at lumbar spine and/or hip
• If BMD is not normal (i.e., T-score lt -1)
• Prescribe bisphosphonate (use with caution in
  premenopausal women)
• Consider calcitonin as second-line agent if
  patient has contraindications to or does not
  tolerate bisphosphonate therapy
• If BMD is normal, follow up and repeat BMD
  measurement annually or biannually

Arthritis Rheum. 2001441496-1503.
39
ACR Guidelines for Bisphosphonate Use in
Glucocorticoid-Treated Patients

• Patients in whom glucocorticoid therapy is being
  newly initiated to prevent bone loss.
• Patients receiving long-term glucocorticoid
  therapy, with documented osteoporosis based on
  BMD measurements or the presence of an
  osteoporotic fracture.
• Patients receiving long-term glucocorticoid
  therapy who have had fractures while receiving HT
  or in whom HT has not been well tolerated.

Arthritis Rheum. 2001441496-1503.
40
NOF Components of Rehabilitation of Patients
with Osteoporosis

• Psychosocial assessment and support
• Exercise programs and conditioning to increase
  weight bearing and physical fitness
• Nutritional counseling
• Patient and family education, especially on steps
  to prevent falls
• Pain management techniques

41
NOF Guide to Rehabilitation Recommendations

• Avoid long-term immobilization and recommend
  partial bed rest, when necessary, for the
  shortest periods possible
• Assess the patient 's current medical status,
  nutritional status, and medication use, including
  her/his physical, functional, psychological, and
  social status, prior to prescribing a
  rehabilitation program

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
42
NOF Guide to Rehabilitation Recommendations
Continued

• Provide training for the performance
  of safe activities of daily living (ADL) and safe
  movement
• Include principles of safe movement in all
  activities, including walking, housework, and
  gardening

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
43
NOF Guide to Rehabilitation Recommendations
Continued

• Prescribe assistive devices for ambulation
  and for reaching/lifting to compensate for
  physiological deficits
• Implement steps to correct underlying deficits
  whenever possible
• Based on the initial condition of the patient,
  provide a complete exercise program

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
44
NOF Guide to Rehabilitation Recommendations
Continued

• Evaluate the patient, her/his current
  medications, and the home environment for major
  risk factors for falls. Intervene as appropriate
• Recommend hip protectors
• In patients with acute vertebral fractures or
  chronic pain after multiple vertebral fractures,
  consider prescribing trunk orthoses

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
45
NOF Guide to Rehabilitation Recommendations
Continued

• Implement effective pain management
  following vertebral fractures through a variety
  of physical, pharmacological, and behavioral
  techniques
• Consider kyphoplasty or vertebroplasty for
  individuals with painful vertebral fractures that
  fail conservative management

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
46
Evaluation of Patients with Osteoporosis

• Clinical symptoms of vertebral fractures
• Back pain
• Loss of spine mobility
• Loss of height
• Diminished function

47
Evaluation of Patients with Osteoporosis

• Psychosocial assessment
• Decreased functional status and independence
• Social relationships
• Emotional well-being
• Depression
• Sleep problems
• Reduced appetite
• Feeling blue/hopeless
• Isolation

48
Rehabilitation Management of Acute Back Pain

• In patients with vertebral fracture
• Advise partial bed rest.
• Recommend analgesics.
• Treat to avoid constipation, especially in
  patients using opiates.
• Recommend proper posture, positioning, and
  activity principles to avoid undue back strain
  during normal activities and exercises.
• Provide and train in the use of braces or other
  assistive devices.

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
49
Rehabilitation Management of Acute Back Pain
Continued

• Advise on proper type of walker
• Train family members or caregivers to assist
  patients safely with minimal spine loading
• Recommend physical and occupational therapy
• Recommend the avoidance of resistance/strengthenin
  g exercises for the first 2 months

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
50
Rehabilitation Management of Chronic Back Pain

• In Patients with Vertebral Fracture 
• Improve any faults in posture.
• If beyond correction, consider a back support to
  decrease ligament stretch.
• Avoid activities that increase vertebral
  compression forces.

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
51
Rehabilitation Management of Chronic Back Pain
Continued

• Prescribe a sound, ongoing,
  therapeutic exercise program.
• Start appropriate medications, as indicated.
• Use acupuncture, biofeedback, relaxation therapy,
  and guided visualization as appropriate.
• Evaluate and treat psychological and social
  consequences.
• Consider support groups and self-management skill
  training.

Bonner FJ, Sinaki M, Grabois M, et al. Health
professional's guide to rehabilitation of the
patient with osteoporosis. Osteoporosis Int.
200314S1-S22.
52
Nonpharmacologic Pain Management

• Initial management
• Bed rest
• Bracing
• Persistent pain
• Individualized physical therapy program
• Strengthening back muscles
• Supportive pillows
• Specialist referral (physiatrist, physical
  therapist)

53
Pharmacological Pain Management

• Acetaminophen
• NSAIDs
• Acetaminophen-opioid combinations
• Short-acting or controlled-release opioids
• Calcitonin

54
Summary

• Osteoporosis remains underdiagnosed and
  undertreated
• Assessment involves identifying those at risk,
  followed by BMD measurement
• Prevention and treatment require both
  pharmacologic and nonpharmacologic strategies

55
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