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

• 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

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(dual energy xray absorptiometry)

• 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

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 mg1 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 Name and and companycompany

Dose Dose TakenTaken

Dose Dose RecommRecommendedended

IngredieIngredientsnts

WhyWhy

Gingko Gingko Nature Nature MadeMade

60 60 mg/daymg/day

120 120 mg/daymg/day

Gingko Gingko MemoryMemory

St John’s St John’s wort, wort, walmartwalmart

300 300 mg/daymg/day

900 900 mg/daymg/day

SJW, SJW, Kava, Kava, valerianvalerian

MoodMood

In conclusion: be an informed and empowered consumer: it is your

health!

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

Final Words & Questions