Presented by

Nicole Nisly, MD

About Today’s Presentation

• I will discuss osteoporosis and focus on causes,

treatment options and prevention

• I will discuss medications and life style choices that

can be of help

• I will discuss some treatments that are not FDA

approved

• I have no conflict of interests to disclose

About Dr. Nisly

• Hello, my name is Dr Nicole Nisly, thank you for

coming today

• I am a Professor of Internal Medicine and work at

the University of Iowa Iowa River Landing Clinic

(319/467-2000)

• My areas of expertise include Internal Medicine

Primary Care, Complementary and Integrative

Medicine, LGBTQ Health and Cultural Diversity in

Health

How do we get osteoporosis?

• We reach our maximum

bone mass normally by the

age of 40

• As we age, we tend to lose

bone mass, especially

after menopause

• Certain conditions make

that loss happen faster

Risk Factors for Osteoporosis

• Age (most fractures of the

hip occur after age of 80)

• Use of corticosteroids

• Low Body weight

• Smoking

• Excessive alcohol use

• Parental Hip Fx

• Rheumatoid arthritis

• Previous ‘Fragility” fractures

• Malabsorption

• Early menopause

• Hypogonadism

• Chronic liver disease

• Inflammatory Bowel disease

http://www.shef.ac.UK/FRAX

How do we know if we have osteoporosis?

• For most women, they should be screened with a

DEXA scan at age 65

• Sooner with increased risk factors (FRAX

calculated risk of over 20% over 10 years)

• For men: less certain but around age 70, sooner if

at risk

About DEXA Scan Results

• This test measures bone mineral density (BMD).

• T score compares your BMD to that of a young

women around age 25

• Z score compares your BMD to someone of your

age

• Osteoporosis: T score of 2.5 or less SD

• Osteopenia: T score between 1-2.5 SD

• Z score of 2 or lower SD is abnormal

(Dual Energy X-ray Absorptiometry)

How often do you test?

• For women at average risk and T score between 2-

2.49 SD or any risk factors, repeat every 2 years

• T score between 1.5-1.99 SD, repeat in 3-5 years

• T scores at 1-1.49 SD, repeat in 10-15 years

Address risk and benefit, including cost. The purpose of

testing is to help decide when to treat and reduce risks

Should I test early?

• If you have the risk factors indicated previously or

fragility fracture: test women starting at age 50 and

men around 70

• Canadian osteoporosis Society recommends

earlier testing for women and men between 50-65

How to test?

• DEXA scan of Hip and Lumbar spine preferred

• Peripheral measurements of heel or ultrasound

measurements while more available do not

correlate well with fracture risk

• Bone turnover markers are not cost effective in

guiding evaluation or treatment

Other Tests

• Calcium

• Biochemistry profile including Albumin and protein

and Alkaline Phosphatase

• 25-OH vitamin D

• Complete Blood Count

• Other tests in certain situations:

• Cortisol, parathyroid hormone, celiac disease

screening, 24 hr urinary calcium

Pre-Menopausal Women & Children

• Bone density testing should only be done in very

specific situations of very high risk

• Use Z scores instead of T scores to interpret test

• Usual WHO guidelines apply to post menopausal

women

How about prevention?

• Increase exercise and weight lifting, aim at 3 times per

week for 30 minutes

• Balance and fall prevention is important, exercises

such as Tai-Chi may help

• Gluten Free Diet and Low or High protein diet are

discussed for specific cases

• Vitamin D 3 in gel capsule: 600-4,000 IU daily (most

people 600-1,000)

• Calcium: diet is best source. Supplements

The Issue of Calcium

• Dietary sources: one serving of dairy: 300 mg

1 oz hard cheese, 8 oz of milk, 6 oz of yogurt)

Greens, non dairy drinks

• Supplements: calcium citrate absorbs better if

using certain medications

• Goal: 500-1,000 mg of supplement if needed

Medications

• Biphosphanates such as Alendronate,

Risendronate, Ibandronate and the I.V. form of

Zoledronic Acid increase bone mass and reduce

fracture

• SERM such as Raloxifene can decrease bone loss

and reduce vertebral fracture

• Others: parathyroid hormone shots, Strontium (not

available in the US), Denosumab shots, calcitonin

Natural Therapies

• Tai chi

• Soy protein

• Ipriflavone (unproven)

• Previously discussed life style changes

• Environmental modifications such as night lights,

removing rugs, using walkers, exercising regularly

• QUIT SMOKING!!

• Reduce alcohol

What is CAM anyway?

• A wide range of practices, new and old, at times

safe, other times dangerous, widely used by

patients worldwide, however…

• In general, safety and efficacy are not yet well

established,

• Not commonly taught in medical schools and

• Not commonly utilized in U.S. hospitals

However…

• Integrative Medicine and various Complementary

or Holistic Therapies are making their way into the

health care system in various formats

• Education: Core Curriculum, Electives, Resident

electives, Fellowships are growing in the U.S.

Selected Alternative Medicine Systems

and Techniques

• Mind-body interventions

• Alternative systems of medical practice

• Biologically based therapies

• Manipulative and body-based methods

• Energy therapies

Mind-body Interventions

• Art therapy

• Biofeedback

• Dance/movement therapy

• Hypnosis

• Imagery

• Meditation

• Music therapy

• Prayer and mental healing

• Self-help support groups

• Yoga

Alternative Systems of Medical Practice

• Acupuncture

• Ayurveda

• Community-based

– Latin American

community healthcare

– Native American

healthcare

• Homeopathy

• Naturopathic medicine

• Traditional Chinese

medicine

Why bother telling your doctor or pharmacist

what will they do with that information?

• Integrated care vs. uncoordinated care

• Potential for:

– Side-effects

– Drug-dietary supplement interactions

– Benefits

Herbal Medicines

• European Botanical Medicines

• Latin American Herbal Remedies

• Native American Herbal Agents

• Ayurvedic Herbal Agents

• Oriental Herbal Agents

– Chinese

– Japanese - Kampo

Medicine Derived From Plants

• Aspirin

• Atropine

• Belladonna

• Capsaicin

• Cascara

• Cocaine

• Colchicine

• Digoxin

• Ephedrine

• Ergotamine

• Ipecac

• Opium

• Physostigmine

• Pilocarpine

• Podophyllum

• Psyllium

• Quinidine

• Reserpine

• Scopolamine

• Senna

• Taxol

• Tubocurarine

• Vincristine

• Vinblastine

Klepser, 2000

St. John’s Wort

• Drug Interactions (P450 1A2, 2C9, 3A4)

• Activates a receptor, named PXR, in the liver and

intestine, which accelerates drug metabolism.

• It may interact with over 80% of drugs available in

the U.S. market.

I have a cold, allergy or something…

• Mr. Sneezy comes in for

refill of his allergy

medication.

• Typically he has symptoms

during the ragweed

season.

• I have frequent colds, can

I use Echinacea, he asks?

Where do I go for reliable information?

• NCCAM (http://nccam.nih.gov/)

• ODS (http://ods.od.nih.gov/index.aspx)

• NCI/OCCAM (http://www3.cancer.gov/occam/)

– MD Anderson database (http://www.mdanderson.org/departments/CIMER/)

• Natural Medicine Comprehensive Database (www.naturaldatabase.com)

• Micromedex

• Consumerlab.com

Talk to your Doctor

• Tell your health care providers about all the complementary and alternative practices you use. This will help ensure coordinated and safe care.

• Be proactive. Don't wait for your health care providers to ask about your CAM use.

• Make the most of the conversation. Bring a list of everything you use, keep a record of the information you receive, and ask questions if something is unclear.

Using Supplements

• Why I want to take the supplement

• How I found out about it

• Is it safe for me to take? Will it interact with any of my medications?

• Is it likely to help me?

• What else should I know about it? Where can I find more information?

• Should I try this? If not, why not? Might something else be better?

Keeping Track of Your Intake

Name and company

Dose Taken

Dose Recommended

Ingredients

Why

Gingko Nature Made

60 mg/day

120 mg/day

Gingko Memory

St John’s wort, walmart

300 mg/day

900 mg/day

SJW, Kava, valerian

Mood

Conclusion

The “best patient” is a well informed, interested, responsible and empowered patient, who actively and collaboratively participates in their health care.

Be an informed and empowered consumer:

it is your health!

Final Words & Questions