Case Study Mary 77 yo F Active w routine WB and resistance exercise No prescription mediation Healthy weight healthy diet She does have a disorder of proprioception and subjectively notes poor balance ID: 1046400
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1. Skeleton Keys: Unlocking the Secrets to Osteoporosis Care
2. Case Study: Mary77 y/o F. Active, w/ routine WB and resistance exercise. No prescription mediation. Healthy weight, healthy diet. She does have a disorder of proprioception and subjectively notes poor balance.PMHx breast ca 1983 (age 38) w/ mastectomy, chemotherapy, 5 years aromatase inhibitor & subsequent iatrogenic menopause1995: Right DR fx 2/2 GLF (age 50)1999: Osteoporosis dx per DXA (unavailable)1999-2009: Alendronate 75mg weekly1999-2022: OTC “Bone Health” Supplement containing calcium, Vit D, Mag, Vit K2, Strontium 2022: Left distal femur fx 2/2 GLF (exercising on tile in sock feet)
3. Case Study: MaryDXA 7/2022: L1-L2 BMD = 0.881 g/cm2 T-score of -0.9RTH BMD = 1.003 g/cm2 T-score of 0.5. LDR BMD = 0.568 g/cm2 T-score of -2.1. Trabecular Bone Score: (L1-L4) 1.409. T-score of -0.7The FRAX was not reported, because all T-scores for the spine, hip, and femoralneck are at or above -1.0.What is the dx?What, if any, tx would you recommend?
4. Down to the Bone:What is Osteoporosis?Chronic progressive disease of either quantity (BMD) and/or quality (microarchitecture) of skeletal bone resulting from disruption of normal balance of bone remodeling. Most commonly related to aging.Decreased bone anabolismAccelerated bone catabolismOsteoporosis is common, but not “normal.”Over 50% of women and 30-45% of men >50 y/o have either osteopenia or osteoporosis70% of adults >80 y/o have osteoporosisBone Strength = bone density + bone quality
5. A bone to pick:Care Gaps
6. Fractured Care:Conflicting guidelines: Who is right?
7. Skeletons in the closet…Common risk factors for primary and secondary Osteoporosis
8. A bare bones approach…Diagnosing OsteoporosisLaboratory analyses Primary utility is to exclude less common contributors:OsteomalaciaMultiple myelomaPrimary hyperparathyroidismAdynamic bone diseaseRare genetic disorders (x linked hypophosphatemia, hypophosphatasia, familial hypercalciuria)Always includes: CBC, CMP, PTHi, Vit D25-OHDMay include: Alk Phos, TSH, Free T4, LFTs, SPEP/UPEP, Bone specific Alk Phos, Celiac panel, U24Ca, Testosterone, female hormone panel, calcitonin. patient specific, per H&P and clinical judgement. Markers of bone turnover (CTX, P1NP, NTX): Limited diagnostic value more useful in monitoring effects of treatment than for diagnosis
9. Working our fingers to the bone…Imaging to evaluate osteoporosis
10. Weak in the knees…Utilizing BMD in clinical decision making BMD in clinical decision makingT score: For use >50SD score of BMD compared to the mean sex matched 20 y/oZ score: For use <50SD score compared to age matched controlsWHO Classifications: Osteopenia = T score -1 to -2.5Osteoporosis = T score <-2.5Clinical Pearls:For every SD decrease in T score, relative risk for fx increases 100%Regardless of BMD, those w/ prior osteoporotic fx have 5x > risk for recurrent fragility fracture!
11. With every bone in your body…Treating Osteoporosis
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21. Case Study: Mary77 y/o F. Active, w/ routine WB and resistance exercise. No prescription mediation. Healthy weight, healthy diet. She does have a disorder of proprioception and subjectively notes poor balance.PMHx breast ca 1983 (age 38) w/ mastectomy, chemotherapy, 5 years aromatase inhibitor & subsequent iatrogenic menopause1995: Right DR fx 2/2 GLF (age 50)1999: Osteoporosis dx per DXA (unavailable)1999-2009: Alendronate 75mg weekly1999-2022: OTC “Bone Health” Supplement containing calcium, Vit D, Mag, Vit K2, Strontium 2022: Left distal femur fx 2/2 GLF (exercising on tile in sock feet)
22. Case Study: MaryDXA 7/2022: L1-L2 BMD = 0.881 g/cm2 T-score of -0.9RTH BMD = 1.003 g/cm2 T-score of 0.5. LDR BMD = 0.568 g/cm2 T-score of -2.1. Trabecular Bone Score: (L1-L4) 1.409. T-score of -0.7“The FRAX was not reported, because all T-scores for the spine, hip, and femoral neck are at or above -1.0”Clinical QuestionsIs this a reliable DXA?Radiologist concluded “Osteopenia” Do you agree?What factors may have impacted this exam?What about TBS? What about FRAX?What are Mary’s ongoing risk factors?Would you tx May pharmacologically?If so, how & why?
23. If the bones are good, the rest don’t matter…UNM Bone Health and Fracture Liaison ServiceAdults >/= 50 with hx any low energy fracture (excluding digits/skull)Adults >/= 50 with vertebral or hip fracture via any MOIAdults >/= 50 requiring advanced tx that your clinic does not have on formularyAd Hoc temporarily closedSend PCO message to Sheila Acheson or Karen Reed