Treatment and Prevention Nahid Rianon MD DrPH The University of Texas Health Science Center at Houston UTHealth Module 3 of 3 LEARNING OBJECTIVES At the end of this presentation attendees will be able to ID: 932242
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Slide1
Osteoporosis Educational Series:Treatment and Prevention
Nahid Rianon, M.D., Dr.P.H.The University of Texas Health Science Center at Houston (UTHealth)
Module
3
of 3
Slide2LEARNING OBJECTIVES:
At the end of this presentation, attendees will be able to
Characterize the
pathophysiology of osteoporosisIdentify the clinical diagnosis of osteoporosisSummarize treatment and prevention options
Objectives
Slide3Pre QuizQuestion 1 of 5
Who needs to be treated for osteoporosis? (Choose one)T-score between -1.00 to -2.5 at femoral neck, total hip or spine AND a FRAX score showing 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% (FRAX) a) 10-yr probability of hip fracture ≥ 2% or any major osteoporosis-related fracture ≥ 20%
b) 10-yr probability of hip fracture ≥ 2% or any major osteoporosis-related fracture ≥ 10%
c) 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% d) 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 30%
Slide4Pre QuizQuestion 2 of 5
Which of the following may be interpreted as improved state of bone turnover after treatment for osteoporosis? (Choose one) A T-score of -1.5 in the spineSuppression of urine NTX
Improved DXA acquired BMD in both spine and femoral neck regions
Suppressed levels of bone formation and resorption markers
Slide5Pre QuizQuestion 3 of 5
Which of the following would indicate treatment failure, or need to consider alternate treatment for osteoporosis?BMD improved 1% since last DXA done 2 years ago
Fracture of femoral shaft while being treated with
bisphosphonate for 5 yearsIncreased levels of bone markers since last measure a year agoFemoral neck BMD did not change since last DXA 2 years ago
Slide6Pre QuizQuestion 4 of 5
An 80 year old Caucasian woman with dementia, falls and right hip fracture (1 year ago) while being on bisphosphonate, was referred for evaluation and treatment of osteoporosis. She had a mastectomy, followed by chemotherapy for breast cancer at age 66 and has been cancer free since then. Which of the following would be the best treatment option for her at this time? (Choose one)
a)
Ibandronateb) Calcitoninc) Teriparatided)
Denosumab
Slide7Pre QuizQuestion 5 of 5
Selective Estrogen Receptor Modulator (SERM) is one of the first options for osteoporosis treatment.TrueFalse
Slide8Today’s Outline
PathophysiologyDiagnosisTreatmentPrevention
Slide9Normal Bone Remodeling Sequence
Resorption = Formation No change in bone massPathogenesis of Osteoporosis
LEGEND: LC
= Lining Cells CL = Cement Line OS = Osteoid BRU = Bone Remodeling UnitOsteoclast
Precursor
Osteoclast
Osteoblast
Precursors
Osteoblast
Mononuclear
Cells
Slide10Net bone loss Unbalanced Remodeling and Osteoporosis
Resorption > Formation
Influencers:
Inadequate calcium or vitamin
D
Menopause
Aging
Medications
or diseases
Slide11High Bone Turnover State Unbalanced Remodeling
OsteoporosisBasic Pathology
Normal
Bone Structure
Osteoporotic
Bone Structure
Slide12Left hipA T- score of <-2.5 for BMD - considered osteoporosis
Lumber spineClinical Diagnosis of Osteoporosis
Slide13Formation
ResorptionSerum osteocalcinSerum bone specific alkaline
phosphatase
(BAP) Serum pro-collagen type 1 amino-terminal propeptide (P1NP)Serum C-terminal cross-linking telopeptide of type I collages (CTX)Urine N-terminal cross-linking telopeptide of type I collagen (NTX)
2
nd
void sample in the AM
Bone Markers
Slide14DXA Acquired BMD
Stable or improved BMD Loss of BMD <%CV showing no significant change over mechanical drift from QA report for DXA machineMonitoring Treatment Success
Bone Markers
Suppression of Bone markersBoth formation and resorption markers
Slide15Hx of hip fracture
Other prior fractures and T-score between -1.0 to -2.5 at femoral neck, total hip or spine
T-score ≤-2.5 at femoral neck, total hip or spine
T-score between -1.0 to -2.5 at femoral neck, total hip or spine
AND
secondary
cause ↑ risk of fracture
Steroid use, total immobilization
T-score between -1.0
to -2.5 at
femoral neck, total hip or spine
AND
10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% (FRAX)
Who Needs to be Treated?
Slide16Treatment Options
Bisphosphonates
Oral
Alendronate 10 mg daily or 70 mg weeklyRisedronate 5 mg daily or 35 mg weekly or 150 mg/moIbandronate 150 mg/moIntravenous
Zoledronic
acid 5 mg/yr
Calcitonin
Short-term for pain after vertebral fracture
Teriparatide
20 mcg sq daily
Recombinant human PTH
(
not >2 yrs)
Contra-indicated in cancer
patients
Denosumab
60
mcg sc/q 6
Humanized monoclonal antibody
Usually as a 2
nd
agent
Calcium
(1200-1500 mg) +
vitamin D
(800-1000 IU daily)
Slide17Adverse events (
mainly Bisphosphonates)Atypical fractureJaw necrosis
Severe GERD/gastritis or GI bleed
Unimproved BMD despite treatment (reassess risk and check bone markers)Fracture while being on txIntervention
Drug holiday
Monitor with DXA/2 yrs
Monitor bone markers/yr
Alternate options
Switch to other agents
ACEI/ARB* showed promise in observations studies – research continues
Adverse Effects or Treatment Failure
and Alternate
Tx
Options
Slide18Testosterone
If hypogonadism is the cause of osteoporosis
Hormones as Treatment Options
SERMRaloxifene
– not commonly used because it increases risk of DVT
Estrogen/Progestin
Not encouraged due to increased risk of breast cancer, stroke, DVT and coronary diseases
Slide19Weight bearing exerciseStimulates bone formation
2.5 to 4 hours/week of moderate to severe intensity physical activity*Calcium and Vitamin D
Regular supplemental required dose
Non-skeletalEnvironmental/BehavioralFall prevention
Improve balance
and gait-
PT/OT
Smoking cessation
Avoid risk level alcohol use
Avoid flexion in patients with risk of or
hx
of vertebral fracture
FLS
(Fracture Liaison Services) network within the clinic, or group of providers
Prevention
Slide20Osteoporosis is a progressive metabolic bone disease that decreases bone density with deterioration of bone structureDiagnosis = T- score of <-2.5 for BMD
Prevention and treatment should take comprehensive approachTake Home Message
Slide21Post QuizQuestion 1 of 5
Who needs to be treated for osteoporosis? (Choose one)T-score between -1.00 to -2.5 at femoral neck, total hip or spine AND a FRAX score showing 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% (FRAX) a) 10-yr probability of hip fracture ≥ 2% or any major osteoporosis-related fracture ≥ 20%
b) 10-yr probability of hip fracture ≥ 2% or any major osteoporosis-related fracture ≥ 10%
c) 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% d) 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 30%
Slide22Post QuizQuestion 2 of 5
Which of the following may be interpreted as improved state of bone turnover after treatment for osteoporosis? (Choose one) A T-score of -1.5 in the spineSuppression of urine NTX
Improved DXA acquired BMD in both spine and femoral neck regions
Suppressed levels of bone formation and resorption markers
Slide23Post QuizQuestion 3 of 5
Which of the following would indicate treatment failure, or need to consider alternate treatment for osteoporosis?BMD improved 1% since last DXA done 2 years ago
Fracture of femoral shaft while being treated with
bisphosphonate for 5 yearsIncreased levels of bone markers since last measure a year agoFemoral neck BMD did not change since last DXA 2 years ago
Slide24Post QuizQuestion 4 of 5
An 80 year old Caucasian woman with dementia, falls and right hip fracture (1 year ago) while being on bisphosphonate, was referred for evaluation and treatment of osteoporosis. She had a mastectomy, followed by chemotherapy for breast cancer at age 66 and has been cancer free since then. Which of the following would be the best treatment option for her at this time? (Choose one)
a)
Ibandronateb) Calcitoninc) Teriparatided)
Denosumab
Slide25Post QuizQuestion 5 of 5
Selective Estrogen Receptor Modulator (SERM) is one of the first options for osteoporosis treatment.TrueFalse
Slide26Thank YouQuestions?
Slide27ReferencesChodzko-Zajko
WJ et al., 2008Clinician's Guide to Prevention and Treatment of Osteoporosis http://www.nof.org/professionals/clinical-guidelinesPhotographs used for the cover slide are allowed by the MorgueFile free photo agreement and the Royalty Free usage agreement at Stock.xchng
. They appear on the cover slide in this order:
Wallyir at morguefile.com/archive/display/221205 Mokra at www.sxc.hu/photo/572286Clarita at morguefile.com/archive/display/33743
Slide28Brought to you by TEXAS. The Training Excellence in Aging Studies (TEXAS) program promotes geriatric training from medical school through the practicing physician level. This project is funded by the Donald W. Reynolds Foundation to the division of Geriatrics and Palliative Medicine within the department of Internal Medicine at The University of Texas Health Science Center at Houston (
UTHealth).TEXAS would also like to recognize the following for contributions:Houston Geriatric Education Center
Harris County Hospital District
Memorial Hermann FoundationHuffington Lecture SeriesThe TEXAS Advisory BoardOthello "Bud" and Newlyn HareUTHealth Medical School Office of the Dean UTHealth School of NursingUTHealth Consortium on Aging
UTHealth
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