Talk for primary care illustrating current hot topics in osteoporosis management

2. 70 year old Woman
I only smoke when I drink
I like a glass of wine
with my dinner Doctor

5. But Calcium supplements
cause Heart attacks!

6. •Suggests 20-30% increased risk of myocardial infarction
in patients taking Calcium supplements
•No significant increase in CVA’s

7. • Meta-analysis
• Excludes patients taking Ca and Vit D
supplements
• At odds with results of WHI study
• Could there be something there?

8. Possible reduction of risk of MI with higher dietary Ca
Small increased risk of MI with supplements only

11. My nephew is a dentist.....

12. Osteonecrosis of the jaw

13. Rare in bisphosphonate doses used in OP
1:100,000
More common with IV bisphosphonates (but still rare)

14. • Discuss potential risks and symptoms with
patient
• Encourage good dental hygiene
• Pretreatment dental visit not necessary

15. • < 3yrs treatment with BP
• Dental extractions and implants as normal
• > 3 yrs treatment
• Stop BP for 3 months before treatment
• Restart when bone healed

16. Has the treatment worked
Doctor?

17. Least Significant Change

18. 3.5% Lumbar Spine
2.2% Hip

19. What do the changes mean?
Fracture risk %
Adapted from Chapurlat RD et al Osteoporosis Int 2005:16. pp 842848

20. How much change is
significant?
Ideal is increase in BMD
Patients with static BMD still have reduced
risk of fracture
Only worry about Decrease

22. Alternatives to bisphosphonates
Vertebral Hip
(Protelos)
Yes Yes/No*
Strontium
(Forsteo)
Yes No
Teriparetide
(Evista)
Yes No
Raloxifene
Denosumab
Yes Yes
(Prolia)
* >75yrs osteoporosis femoral neck

23. Do we need to treat
everybody?

24. I’m 51
and
healthy
T Scores
LS- -2.6
Hip -2.6

26. Google ‘FRAX’

27. How long do I need
to be on treatment?

28. Do Bisphosphonates
work in long term?

30. After 5 years little to support continued
benefit on fracture risk
Possibility of drug holiday in some (low risk
pts)
Change to alternative agent

32. Drug holiday?
• Patients with lower risk
• May stop for up to 2 years
• Possible small drop in BMD
• No increased risk of fracture
• Avoid in high risk patients

33. I’m 51
and
healthy
T Scores
LS- -2.6
Hip -2.6

34. Summary
• Encourage Dietary Ca
• For most Single dose Ca supplement plenty
• Not essential to treat everybody!
• Use FRAX to help aid decision
• Monitor for Bone loss (2 yrs)
• Consider revise Bisphosphonates at 5-7yrs
• Consider Drug holiday