Osteoporosis: DefinitionA condition of skeletal fragility characterized by compromised bone strength predisposing to an

increased risk of fracture

NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000.Source: Dempster DW, et al. J Bone Miner Res. 1986:1:15-21; Reprinted with permission from the American Society of Bone and Mineral Research

Normal Bone Osteoporosis

1,500,000

0

500,000

1,000,000

1,500,000

2,000,000

OsteoporoticFractures

1. Riggs, B.L., and Melton, L.J. III, Bone 17(5)(Suppl.):505S-511S, 19952. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart Association3. Cancer Facts & Figures—1996, American Cancer Society

*annual incidence all ages **annual estimate women 29+†annual estimate women 30+‡1996 new cases, women all ages

*

513,000

Heart Attack

**

228,000

Stroke

†184,300

Breast Cancer

‡750,000 vertebral

250,000 other sites

250,000forearm

250,000hip

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Frequency of CommonMedical Events in Women

•Osteoporosis is a health threat for an estimated 44 million Americans.•Of that 44 million :

•10 million individuals already have the disease •80% of these are women

•34 million more are estimated to have low bone mass and increased risk for osteoporosis.

Prevalence

•Osteoporosis affect people of all ethnic backgrounds.•While osteoporosis is often thought of as an older person's disease, it can strike at any age.

Osteoporosis is highly preventable.  However, if the toll of osteoporosis is to be reduced, the commitment to osteoporosis research must be significantly increased.  It is reasonable to project that with increased research, the future for definitive treatment and prevention of osteoporosis is very bright.

Cost•The estimated national direct expenditures for osteoporotic hip fractures was $18 billion dollars in 2002.•Office visits have increased five-fold (from 1.3 to 6.3 million) in the  past 10 years.•In 2001, about 315,000 Americans age 45 and over were admitted to hospitals with hip fractures.

•An average of 24 percent of hip fracture patients aged 50 and over die in the year following their fracture.•Only 15 percent of hip fracture patients can walk across a room unaided 6 months later.•Hip fractures AND vertebral fractures are linked with an increased risk of death.•One in five hip fracture patients ends up in a nursing home, a situation that participants in one study described as less desirable than death.

Fractures

•Hip fracture risk is increasing most rapidly among Hispanic women.  •Women with a hip fracture are at a four-fold greater risk of a second one.•Osteoporotic fractures lower a patient’s quality of life. 

Fractures

Annually, 1.5 million osteoporotic fractures occur:

300,000 hip fractures700,000 vertebral fractures250,000 wrist fractures 300,000 fractures elsewhere

One in two women and one in four men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime.

Non-Hispanic white and Asian women:•20% have osteoporosis; 52% have low bone mass.

Non-Hispanic black women:•5% have osteoporosis; 35% have low bone mass

Hispanic women:•10% have osteoporosis; 49% have low bone mass.

Osteoporosis is under-recognized and under-treated not only in Caucasian women, but in African-American women as well.

Estimates of Osteoporosis in Women

>50 yr old

Bone density can be temporarily lost during breastfeeding. Several studies have shown that recovering full bone density

occurs within six months after weaning.

Bone loss during breastfeeding?

•White women ≥65 year old have twice the fracture incidence versus African-American women.•Women have a hip fracture rate two to three times higher than men.•A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer.

Shrinking is NOT an Inevitability of Aging and IS NOT normal!!

Osteoporosis and Women

•amyloidosis •use of glucocorticoids•Iatrogenic osteoporosis caused by the therapeutic

Rheumatologic disorders

•rheumatoid arthritis, •ankylosing spondylitis

•Marfan syndrome •hemochromatosis•Hypophosphatasia•epidermolysis bullosa

Etiology

•homocystinuria•porphyria•Menkes' syndrome

INHERITED DISORDERS

OTHER DISORDERS

•immobilization, •pregnancy and lactation•scoliosis•chronic obstructive pulmonary disease

•osteogenesis imperfecta•Ehlers-Danlos syndrome•glycogen storage diseases

Hypogonadal states •Turner syndrome, •Klinefelter syndrome, •Kallmann Syndrome, •anorexia nervosa, •hypothalamic amenorrhea, •hyperprolactinemia.

Nutritional and gastrointestinal disorders

•malnutrition, •parenteral nutrition, •malabsorption syndromes, •gastrectomy,• severe liver disease (especially biliary cirrhosis), •pernicious anemia.

Hematologic disorders/malignancy

•multiple myeloma, •lymphoma and leukemia, •mastocytosis, •hemophilia, •thalassemia.

Etiology

Endocrine disorders •Cushing's syndrome, •hyperparathyroidism• thyrotoxicosis, •insulin-dependent diabetes mellitus, •acromegaly, •adrenal insufficiency

•Osteoporosis, the "silent disease," has bone loss without symptoms.  •Onset only occurs with sudden strains, bumps, or fall causes a fracture or a vertebra to collapse.  •Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis or stooped posture.

Symptoms

WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.

T-Score

World Health Organization (WHO) Osteoporosis Guidelines

1.41.31.21.11.00.90.80.70.60.50.40.3

20 30 40 50 60 70 80

Age

BM

D

Mean–2 SDConsider preventive interventionConsider therapeutic intervention

Mean Lumbar Spine BMD: Decades 3 to 9 of a Woman’s Life

Adapted from AACE Guidelines. Endocr Pract. 2001;7:293-312.

Bone Mineral Density Values

DEXA scan: Hip

T-Score

•Postmenopausal women who present with fractures•Estrogen deficient women at clinical risk for osteoporosis •Individuals with vertebral abnormalities •Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy •Individuals with primary hyperparathyroidism •Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy.

Who Should Be Tested?

*Medicare covers BMD testing for the following individuals age 65 and older. Medicare permits individuals to repeat BMD testing every two years.

•All women aged 65 and older.*•Younger postmenopausal women with multiple risk factors

Risk Factors for Hip Fracture

-Low BMD (T< -2.5)

-Previous Fx

-Family history Fx

-Smoking

FxFx

RiskRisk

Risk of Hip Fx = Risk of Hip Fx = Risk of Hip Fx = Risk of Hip Fx =

Skeletal RiskSkeletal Risk

Factors for FxFactors for Fx

Non-Skeletal RiskNon-Skeletal Risk

Factors for Falls/FxFactors for Falls/Fx

-Age (>80 yr)

-Poor balance/gait

-Impaired eyesight

-Meds that increase risk of falling

-Loss of soft tissue hip padding

-History of falls

-Fall-related injury

-Smoking

Detection: Bone Mineral Density Tests

DXA (Dual Energy X-ray Absorptiometry) spine, hip or total body

pDXA (Peripheral Dual Energy X-ray Absorptiometry)

wrist, heel or finger

SXA (single Energy X-ray Absorptiometry) wrist or heel

QUS (Quantitative Ultrasound) heel, shin bone and kneecap

QCT (Quantitative Computed Tomography)

spine

pQCT (Peripheral Quantitative Computed Tomography)

wrist

RA (Radiographic Absorptiometry) hand

DPA (Dual Photon Absorptiometry) spine, hip or total body

SPA (Single Photon Absorptiometry) wrist

Type of Test Area tested

Therapeutic Agents Used in Osteoporosis

• Inhibitors of bone resorption:– Calcium – Estrogens +/- progest– SERMs– Bisphosphonates– Calcitonin

• Stimulators of bone formation– PTH– Fluoride

A. Normal SpineB. Moderately

Osteoporotic SpineC. Severely

Osteoporotic Spine

Copyright ©1996 American Society for Clinical Investigation

Rodan, G. A. et al. J. Clin. Invest. 1996;97:2692-2696

Mechanism of Action:•inhibition of the production of essential lipid compounds inside osteoclasts

•decreased osteoclast activity •induction of cell death.

• decreases bone turnover •slowing the rate at which new bone remodeling units are formed •reducing the depth of resorption.

• increase in bone mass over time.

Bisphosphonates 1. Alendronate and alendronate plus

vitamin D (brand name Fosamax® and Fosamax® plus D)

2. Ibandronate (brand name Boniva®) 3. Risedronate and risedronate with

calcium (brand name Actonel® and Actonel® with Calcium)

4. Calcitonin (brand name Miacalcin®)

Women's Health Initiative Trial•Hip and vertebral fractures decreased by at least one-third in both of the trials and total fractures decreased by 24%-30%. •The clear fracture benefits of postmenopausal hormone therapy (HT) are offset by the adverse effects:

– increased risk of stroke, –cognitive impairment, and –deep vein thrombosis

•HT provided no cardioprotective benefit, and increased the risk of breast cancer. (AMA)

Estrogen/Hormone Therapy

1. Estrogens (brand names, such as Climara®, Estrace®, Estraderm®, Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle® and others)

2. Estrogens and Progestins (brand names, such as Activella™, FemHrt®, Premphase®, Prempro® and others)

3. Parathyroid Hormone – Teriparatide (PTH (1-34) (brand name Fortéo®)

•The use of an anabolic and antiresorptive agent is less effective than an anabolic agent alone. • Since the effects of antiresorptive therapy with bisphosphonates are long-lasting, until more is known, bisphosphonate use should be discontinued before initiating PTH. •Combination therapy with two antiresorptive agents is generally reserved for those who:

•have experienced a fracture while on therapy with a single drug• start out with a very low BMD and a history of multiple fractures•have a very low BMD and lose more bone mass on therapy with a single drug

Combination therapy

Algorithm for women Older than 80Discuss calcium, vitamin D,

nutrition, exercise.

Rx

Xray

No further work-up

Discuss fall prevention Consider hip pads

Hip DEXA or heel ultrasound

Already Fx?

Height loss >4cm?

Taking estrogen?

•Older women do not convert vitamin D in the skin & should be on an oral supplement

•Check sedative use, vision, muscle weakness, balance, environmental problems (cords, rugs, poor lighting). Hip padding for thin women.

yes

yes

yes

no

no

no

No Fx

Fx

•Raloxifene, calcitonin, or low-dose bisphosphonate. Do not start hormones. BMD not needed to decide treatment.

Counsel All Women on: •Risk factors for osteoporosis •Adequate calcium and vitamin D intake •The need for weight bearing exercise •Fall prevention strategies •Avoidance of tobacco and moderate use of alcohol Consider Bone Mineral Density Screening for:•Women over 65 years of age •Women 50 to 64 with one or more of the following clinical risk factors

•Any fracture after age 40 •Family history of osteoporosis •Current smoking •Weight <127 lbs.

•Post-menopausal women who present with a fracture

Compiled by Judith ChilcotSchool of NursingUniversity of Washington Medical Center

Consider Treatment of Post-menopausal Women with:T-score of < 2.5 or less T-score of - 2.0 or less in the presence of one or more risk factors listed Any vertebral or hip fractures

Web Resources http://www.osteoed.org/

Check out OsteoEd, an educational web site, for quick answers to osteoporosis questions. *Guidelines from pamphlet for providers by the National Osteoporosis Foundation. http://www.nof.org/physguide/impact_and_overview.htm#synopsis

98% of a woman’s skeletal mass is acquired by age 20 Optimal strategies for building strong bones occurs during childhood and adolescence

A study of disease management in a rural healthcare population demonstrated that a preventive program was able to reduce hip fractures and save money.

1. A balanced diet rich in calcium and vitamin D

2. Weight-bearing and resistance-training exercises

3. A healthy lifestyle with no smoking or excessive alcohol intake

4. Talking to one’s healthcare professional about bone health

5. Bone density testing and medication when appropriate

Five Steps Toward Prevention

•The best predictor of fracture is a previous fracture. •Treatment can improve fracture risk considerably.

•Fractures can lead to decreased mobility and an additional risk of deep venous thrombosis and/or pulmonary embolism. •Vertebral fractures can lead to severe chronic pain of neurogenic origin, which can be hard to control.

Prognosis

Although osteoporosis patients have an increased mortality rate due to the complications of fracture, most patients die with the disease rather than of it.