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Bone-Up on Osteoporosis—
Update 2011
3/30/11
Kristine Olson, MS, APN, FNP-BC
Nurse Practitioner Mercer Bucks Hematology
Oncology
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Objectives
Review risk factors and screening for osteoporosis.
Describe the impact of osteoporotic fractures on patients and society.
Explain prevention and non- pharmacologic treatment of osteoporosis.
Describe pharmacologic treatment of osteoporosis.
Osteoporosis—a major public health threat
Estimated 52.4 million Americans at risk (all #s are estimates)
12 million w/osteoporosis
40.4 million w/low bone mass
Equals 55% of those age 50+
80 % w/dx are women (9.1 million)
20% w/dx are men (2.8 million)
All ethnic groups have significant risk
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Osteoporosis Prevalence Race and Ethnicity
20% non-Hispanic Caucasian &
Asian women > age 50 have osteoporosis
52% low bone mass
10% Hispanic women > age 50
49% low bone mass
5% non-Hispanic black women >
age 50
35 % low bone mass
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Osteoporosis Prevalence Race and Ethnicity—Men
7% non-Hispanic Caucasian &
Asian men > age 50
35% low bone mass
3% Hispanic men > age 50
23% low bone mass
4% non-Hispanic black men > age 50
19% low bone mass
–National Osteoporosis Foundation
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Osteoporotic Fracture Incidence
In 2005, osteoporosis responsible for >2 million fractures
~297,000 hip fractures
~547,000 vertebral fractures
~397,000 wrist fractures
~765,000 fractures at other sites
• Burge R, et al. Incidence and Economic Burden of Osteoporosis-Related Fractures in the United States 2005-2025. JBMR. 2007; 22:465-475.
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Significance of
Osteoporosis in Women
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Cost of Osteoporosis
Osteoporotic fractures account for
~$17 billion in direct medical costs
Projected to be over $25 million by 2025
>400,000 hospital admissions
~2.5 million “physician” visits
>180,000 nursing home admissions
Osteoporosis—NIH Definition
A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.
Bone strength = Bone quality including bone density, architecture and bone turnover
• NIH Consensus Conference, 2000
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What is Osteoporosis
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Micrograph: Normal vs. Osteoporotic Bone
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Vertebral Compression
Fractures
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2004 Surgeon General’s Report—Key Points
Many Americans are at significant risk for bone loss and osteoporosis.
Great improvements have been made in the bone health of Americans.
More can be done by applying what is known about early prevention, assessment, diagnosis and treatment.
• US Dept of Health and Human Services, Bone Health and Osteoporosis: A Report of the Surgeon General, Office of the Surgeon General, 2004
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2004 Surgeon General’s Report
Studies showed a failure to diagnose and treat osteoporosis, even in elderly patients who have suffered a fracture.
A gap between what is known and its application in the community remains large and needs to be closed.
Risk Factors
Low bone density (osteopenia)
Age
Hx prior fracture
Parental hx of hip fx
Race
Small frame
Low estrogen or testosterone
Lifestyle factors
Low calcium intake, low activity, low BMI
Vitamin D insufficiency
Excess caffeine,
> 3EtOH/day, tobacco, NaCl
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Risk Factors—
Secondary Osteoporosis
Genetic factors
Parental hx, cystic fibrosis, Marfan
Endocrine disorders
Hypogonadal states
GI disorders .
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Risk Factors—Secondary Osteoporosis
Hematologic disorders
Rheumatic & autoimmune diseases
Miscellaneous conditions
alcoholism, COPD, ESRD, CHF, etc.
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Medications Associated with Decreased Bone Mass in Adults
Anticoagulants (heparin)
Anticonvulsants
Aromatase inhibitors
Barbiturates
Cancer drugs
Cyclosporin A
Glucocorticoids—oral & high-dose inhaled
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Medications Associated with Decreased Bone Mass in Adults
Gonadotropin-releasing hormone agonists
Lithium
Depot medroxyprogesterone acetate
Probable:
PPIs (proton pump inhibitors)
SSRIs (selective serotonin reuptake inhibitors)
TZDs (thiazolidinediones)
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Glucocorticoid-Induced Osteoporosis
Most common form of 2ndary osteoporosis
Long-term use oral > 5 mg prednisone/day for 3 mo.
High dose inhaled steroids
> 800 mcg/24 h
ACR recommends calcium 1000-1500 mg/day, Vit D 800 IU/day,
bisphosphonate if BMD T-score <-1.0
Caution w/premenopausal women
Risk Factors for Falls
Environmental
Medical
Neuro & musculoskeletal
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Bone Mineral Density Testing
DXA (DEXA) of hip & spine preferred method
Peripheral machines check BMD at forearm, heel or finger
Use x-ray or U/S
Hip BMD is single best predictor of hip fx risk
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Defining osteoporosis by BMD
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WHO Osteoporosis
Guidelines
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Pharmacologic Treatment
Antiresorptive Medications
Bisphosphonates
Calcitonin
Estrogen
Estrogen agonists/antagonists
Bone forming (anabolic) Medications
Parathyroid hormone—teriparatide
New: human monoclonal AB to RANK- ligand—denosumab (Prolia)
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Bone Remodeling
Preventive maintenance
Osteoclasts remove old bone
Osteoblasts replace new bone
Imbalance of the 2 processes
Peak bone mass reached at ages 18—25
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Compact (Cortical) Bone &
Cancellous (Trabecular) Bone
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Bisphosphonates
Alendronate—oral
Fosamax, Fosamax Plus D
Ibandronate—oral
Boniva
Risedronate—oral
Actonel
Actonel with Calcium
Atelvia
Zoledronic acid—IV
Reclast
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Alendronate
Fosamax or Fosamax Plus D, generic
FDA approved for prevention & tx of postmenopausal osteoporosis
Men w/osteoporosis
Men & women taking glucocorticoid
Prevention = 5 mg daily or 35 mg weekly
Treatment = 10 mg daily or 70 mg weekly
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Ibandronate: Boniva
FDA approved for tx of postmenopausal osteoporosis
Oral forms also approved for prevention: 2.5 mg tab daily or 150 mg Q mo.
3 mg IV Q 3 mo.
Reduces incidence of vertebral fx by 50% over 3 years
Risedronate: Actonel
Actonel or Actonel with Calcium
FDA-approved for prevention & tx of postmenopausal osteoporosis, also men
& women on glucocorticoids
Approved for men w/ osteoporosis
Multiple dose forms:
5 mg daily tabs, 35 mg Q wk, 35 mg Q wk w/6 tabs of 500 mg CaCO3, 75 mg 2 days/mo., 150 mg Q mo.
Reduces verteb fx 41-49%, non-verteb 36% over 3 yrs., in pt. w/prior v. fx
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Zoledronic acid: Reclast
IV: 5 mg over at least 15 min. Q yr
FDA-approved for tx of postmenopausal osteoporosis
Approved for prevention of new fx in pt w/recent low-trauma hip fx
Reduces incidence of verteb fx 70%, non-verteb fx 25% over 3 yrs
Consider pre-tx w/acetaminophen
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Side Effects of Bisphosphonates
GI problems
Esoph inflam
Difficulty swallowing
Gastric ulcer
Bone/joint/muscle pain
Very rare jaw osteonecrosis
A fib--Zometa
Visual disturbances
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Administration of Bisphosphonates
PO forms poorly absorbed
Empty stomach, 8 oz. H2O only
Except delayed release risedronate
Atelvia 35 mg once weekly after breakfast
Then NPO 30+ min. except 60+ min. w/
Boniva
Sit/stand 30 to 60 min. + after
Check creatinine
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Calcitonin
Miacalcin or Fortical
FDA-approved for tx of
osteoporosis in women at least 5 yrs postmenopausal
Nasal spray 200 IU daily, or SQ
Effect of fx risk not stated in Rx Info
Considered safe.. rhinitis, rare epistaxis
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Estrogen/Hormone Therapy
Multiple brands/formulations
FDA-approved for prevention of osteoporosis, relief of vasomotor symptoms & vulvovag atrophy in menopause
WHI: 5 yrs of HT (Prempro) reduced risk verteb fx 34%, other 23%
WHI: increase risk MI, stroke, breast Ca, PE, DVT in 5 yrs of HT
ET arm, no inc. breast Ca in 7 yrs
Estrogen
Agonist/Antagonist
Raloxifene: Evista (SERM) 60mg PO daily
FDA-approved for prevention &
treatment osteoporosis in post- menopausal women
Reduces risk of verteb fx 30% in pt w/prior v fx, 55% in pt w/o over 3 yrs
Indicated for reducing risk of invasive breast Ca in postmenop w/osteoporosis
Increased risk DVT, no dec. CHD, + hot flashes
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Parathyroid Hormone
PTH (1-34), teriparatide, Forteo
FDA-approved for tx of
osteoporosis in postmenopausal women at high risk for fx.
Men w/primary or hypogonadal osteoporosis w/high fx risk
Anabolic (bone-building)
20 micrograms SQ daily, max 2 yrs
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Parathyroid Hormone:
Forteo
Increased osteosarcoma in rats
Therefore, contraindicated/black box warning:
Paget’s disease of bone, alk phos
Prior XRT of skeleton
Bone mets
Hypercalcemia
Skeletal malignancy
Follow w/ bisphosphonate
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Denosumab (Prolia)
Antiresorptive with different pathway than bisphosphonates
Human monoclonal antibody
Inhibits osteoclast formation & function by binding to RANK ligand
SubQ injection: 60 mg/mL given Q 6 months
Indicated for postmenopausal women w/high risk for fx
Or intolerant of other rx
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Calcium & Vitamin D
All adults require at least 1200 mg calcium/day via food and
supplements
People over age 50 average 600 to 700 mg Ca++ daily!
NOF advises 800 to 1000 IU Vit. D daily to = serum 24(OH)D of 30 ng/mL or higher
Vit D3, cholecalciferol, preferred
FRAX Tool
WHO Fracture Risk Assessment Tool:
www.NOF.org
www.shef.ac.uk/FRAX
Plug in 12 questions: Age, sex, weight, height, previous fx, parent hip fx, current smoking, glucocorticoid use, RA, secondary osteoporosis, EtOH 3 or + units/d, femoral neck BMD, type of DXA
Calculates 10 yr probability of hip fx & 10 yr probability major osteoporotic fx (vertebral, hip, forearm or humerus) Economic model
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FRAX Tool—1 of US versions
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Summary
Osteoporosis affects millions of Americans, #s will increase
Costs, in $ and morbidity & mortality, are very high
$17 billion in 2005
About 400K hosp admissions
24% of hip fx pts die in yr after fx
Prevention and treatment can be effective! …also falls prevention!
Don’t forget lifestyle counseling
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Thank You!
Questions?
