Title: Osteoporosis
1Osteoporosis
- UBC Internal Medicine Program
- Dr. Mark Fok
- Dr. Maria Ashley
2Definition
- Osteoporosis and osteopenia are skeletal
disorders characterized by low bone mass and
microarchitectural fragility.
3Bone remodelling
4Incidence
- 1.4 million Canadians affected
- 1 in 4 women over age 50 and 1 in 8 men over age
50 - Estimated cost of 1.9 billion to treat
osteoporosis and fractures in Canada - 70 of hip fractures are osteoporosis related
- www.osteoporosis.ca
5What else do you want to know?
- Major Risk Factors for Osteoporosis
- Age gt65
- Vertebral compression
- Family hx of osteoporotic
- gt5 months glucocorticoid tx
- Malabsorbtion syndrome
- 1 hyperparathyroidism
- Osteopenia on XR
- Hypogonadism
- Early menopause (before 45)
6- Minor Risk Factors
- Rheumatoid arthritis
- Hyperthyroidism
- Prolonged anticonvulsants
- Prolonged heparin use
- Body weight lt57kg
- Low calcium intake
- Excess caffeine (gt4 cups/day)
- Excess alcohol (gt2 drinks/day)
- Smoker
7Risk for Fracture
- Low Bone Mineral Density
- Prior fragility fracture
- Long term (gt3 months) glucocorticoids
- Increasing age
- Family history of osteoporotic fracture
8Signs and Symptoms of Osteoporosis
- Self reported height loss gt3cm
- Weight lt51kg
- Kyphosis - Self reported hump back
- Grip strength lt40lb
- Tooth count lt20
9Diagnosis of Osteoporosis
- Assessment bone microarchitecture bone biopsy
- Clinical fracture in the right context
- Gold standard
10Bone Mineral Density Assessment
- Dual-Energy Xray Absorptiometry (DXA)
- Strong correlation between mechanical bone
strength DXA measurement of BMD - Strong relationship between fracture risk and BMD
measurement -
Lotz JC et al. J Biomech Eng 1991 Marshall D et
al. BMJ 1996
11DXA
- Xray tube generates photon beams at two energy
levels - Difference in attenuation ? BMD determination
- For comparison, must use same machine
12Interpreting a DXA Scan ?
13Interpreting the DXA
- T-score
- Standard deviation between a pts BMD and that of
a young adult reference population - Z-score
- Standard deviation between a pts BMD and that of
an age matched population
14Interpreting the DXA WHO criteria
Normal - 1 lt T score
Low Bone Mass (osteopenia) - 2. 5 lt T score lt - 1
Osteoporosis T score lt - 2.5
Severe osteoporosis T score lt - 2.5 fragility fracture
15DXA scan hip / L-spine
16Treatment of Osteoporosis
- Non-drug options
- Drug options
17Weight bearing exercises
18- Exercises that utilize your own body weight
include activities like these, but also include
simple activities like walking.
19Calcium rich foods
20Over the counter vitamins
- 1200-1500 mg elemental calcium per day
- 800 IU vitamin D per day
21Drugs Bisphosphonates
- Alendronate
- Risedronate
- Etidronate
22Dosing
- Once weekly dosing (70 mg q week) as effective as
daily dosing of alendronate with similar side
effect profile
Rizzoli et al. J Bone Miner Res 2002
23Risedronate
- Similar efficacy
- Comparable to Alendronate
-
Rosen et al. J Bone Miner. Res. 2005
24Selective Estrogen Receptor Modulators
- Raloxifene
- Tamoxifen
- Bind with high affinity to Estrogen Receptor and
possess tissue selective agonist / antagonist
properties ? bone specific estrogen like action
25Bone Forming (Anabolic) Medications
- Parathyroid Hormone Teriparatide (brand name -
Forteo). - Teriparatide, a type of parathyroid hormone, is
approved for the treatment of osteoporosis in
postmenopausal women and in men who have very low
BMD or are at high risk for a fracture.
26Estrogen therapy
- Fallen out of favor for treatment of osteoporosis
since WHI study - Increased risk of CHD, VT, breast CA
- Should not be used first line, except for in
women using it for other indications
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28- Quick quiz 1.Are you over 65? 2.Has either of
your parents broken a bone after a minor bump or
fall? 3.Have you broken a bone after a minor
bump or fall? 4.Have you taken glucocorticoid
pills (cortisone, prednisone, etc.) for more than
three months? 5.Have you lost more than 4 cm
(about 1 1/2 inches) in height since age 25 (or 6
cm if you are over 60)? 6.Do you have a tendency
to fall? 7.Do you have primary
hyperparathyroidism? 8.Do you have a medical
condition (such as celiac disease or Crohn's
disease) that inhibits absorption of nutrients?
9.Has a recent x-ray suggested you have low bone
density (osteopenia)? - For Women10.Did you undergo menopause before age
45? 11.Have your periods stopped for several
months or more (other than for pregnancy or
menopause)? - For Men12.Have you ever suffered from impotence,
lack of libido or other symptoms related to low
levels of testosterone? - If you're over 50 and have answered yes to any of
these questions, Osteoporosis Canada recommends
that you talk to your doctor about having a bone
mineral density (BMD) test.
29Thank you