Via Christi Women's Connection April presentation on osteoporosis prevention and treatment by Dr. Rami Mortada, University of Kansas School of Medicine-Wichita.

1. Osteoporosis
The silent disease
Rami Mortada, MD
Assistant Professor
Division of Endocrinology
Kansas University – Wichita

2. Outline
• What is osteoporosis ??
• Why should you care ??
• Who is at risk ??
• How/who needs to be checked ??
• Treatment
– Ca and Vit D
– Medication

3. Osteoporosis: The silent disease

4. What is osteoporosis ?

5. Definition of Osteoporosis
Thin and brittle bone which make them more fragile with
increased risk of fractures
.
Normal Bone Osteoporotic Bone
NIH Consensus Development Panel on Osteoporosis. JAMA. 2001;285:785-795.

6. Bone is a living organ

7. Bone remodeling

8. Remodeling
Bone Remodeling Unit: 1. Activation
Average time to complete: 2. Resorption
~ 6 months 3. Reversal
4. Formation

9. Peak bone mass

10. Why do we get osteoporosis ??
X
X

11. Why do we get osteoporosis ??
+++ Resorption
+ Formation

12. How does osteoporosis happen ??

13. Why should you care ??

15. Fracture and risk of death
SITE INCREASE IN
MORTALITY RISK
Vertebrae 8.6
Hip 6.7
Any Clinical Fracture 2.2

16. Who is at risk ??

18. Risk Factors: female sex

19. Risk factors: smoking

20. Risk factors: Low body weight

21. Risk factor: Aging

22. Risk factor: Menopause
20% bone loss in the 5 years after menopause

23. Risk factor: fragility factor
• History of fragility fracture
• 1st degree relative with Osteoporosis or fragility
fracture

24. Other Risk Factors
• Absence of menstrual cycles
• Diet low in calcium, low Vitamin D
• Certain medications
• Hormone disorder: thyroid, parathyroid, prolactin…
24

25. How do you check for
osteoporosis ??

26. Bone density

27. Bone density: DEXA scan

28. Bone density images

29. Who needs a bone density ??
• Age 65 or older
• Previous fracture with little trauma or vertebral fracture
• Family history of osteoporosis
• Long term use of glucocorticoids (like prednisone)
• Early Menopause (before age 45)
• Alcohol
• Smoking

30. T-score

31. T score result
Status T-score
Normal +2.5 to −1.0, inclusive
Osteopenia Between −1.0 and −2.5
Osteoporosis ≤−2.5
Severe osteoporosis ≤−2.5 + fragility fracture

32. T score is not enough…
20 AGE
80 The relationship between BMD and
(% per 10 Years)
Hip fracture risk
15 fracture risk varies with age.
70
10
60
5
50
0
-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1
BMD T-score
Kanis et al, Osteopor Int 2001

33. Risk of Fractures Over 10 Years in Women
AGE T-Score T-Score
= -1.0 = -2.5
50 6% 11 %
60 8% 16 %
70 12 % 23 %
80 13 % 26 %

34. Who needs to get treated ??

35. Who needs to be treated ??

36. Sample FRAX Calculation:

37. What are the treatment options ??

38. Universal measurement for osteoporosis prevention
and treatment : Risk factor reduction

39. Universal measurement for osteoporosis prevention
and treatment : Risk factor reduction

40. Fall prevention: weight bearing exercise

41. Universal measurement for osteoporosis prevention
and treatment : Fall prevention
1. Make an appointment with your doctor
2. Keep moving
3. Wear sensible shoes
4. Avoid home hazard
5. Light up your living space
6. Use assistive devices

42. Treatment
Calcium 1200 mg / day is recommended

43. Treatment: Vitamin D

44. Medication for osteoporosis
• Anti resorptive-agents: Stop bone
loss
• Anabolic agent: Increase bone
formation

45. Bisphosphonates
• Fosamax, Actonel, Boniva, Reclast
• The big gun in osteoporosis treatment
Effects
• Significantly stop bone loss – anti-resorptive
• Reduce vertebral fractures 60%-70% at 3 years
• Reduce hip fractures 40%-50% at 3 years
• Pills: daily, monthly and weekly
• Intravenous: once yearly

46. Response to Long-term Alendronate
Subjects: Postmenopausal women with low BMD
BMD Urinary N-telopeptide
16 0
% Change from baseline
% change from baseline
Lumbar spine
12 -20
Placebo
-40
8
Femoral Neck -60 Alendronate 10 mg
4
-80
Alendronate 10 mg
0 -100
0 2 4 6 8 10 0 2 4 6 8 10
Years Years
Adapted with permission from Bone HG, et al. N Engl J Med. 2004;350:1189-1199.

47. Safety of bisphosphonate
• Reflux disease and ulcer
• Worsening of kidney disease
Osteonecrosis of the jaw Atypical femur fracture

48. How about a holiday ???

49. Raloxifene:
Estrogen Agonist/Antagonists
Effects
• Anti-resorptive: Stop bone loss
• Reduces spine fracture and increases BMD
• No hip fracture protection
• Breast cancer risk reduction
• No endometrial proliferation or cancer
Side effects
• Blood clots
• May increase hot flashes
Evista [package insert]. Indianapolis, IN: Eli Lilly and Company; 2007.

50. Estrogen
• Anti-resorptive: stop bone loss
– Risk reduction of 34% for vertebral and hip fractures after
5 years
• Indications
– Prevention of postmenopausal osteoporosis
– Long-term treatment not recommended
• Contraindications
– Thromboembolic disease, breast cancer, CVD, stroke,
abnormal genital bleeding, estrogen-dependent cancer

51. Denosumab
• Skeletal Effects – Anti-resorptive
– Risk reduction vertebral fracture 38%,
hip fracture 58% after 5 years
– Injection,
• Indications
– Severe osteoporosis
– Intolerance to bisphosphonate
• Side effects
– Decreasing Calcium level, increasing
infection ( maybe)
– No long term data about safety profile

52. Teriparatide
• Skeletal Effects –Anabolic
– Decrease vertebral fracture
68%, hip fracture 40%
– Daily injection x 3 years
• Indications
– Severe osteoporosis ( T -2.5-4)
• Best treatment available, must be
followed by a course of anti resorptive
therapy

53. Word of wisdom

55. Conclusion
• Osteoporosis is a serious but silent disease
• Due to decreased bone formation or increased bone loss
• Early prevention is the key element to prevent fracture
• Diet and exercise is the cornerstone for osteoporosis
prevention and treatment
• Screen with bone density at age 65, sooner if any risk factor
• Treatment is effective in decreasing fracture risks

57. Thank you