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Osteoporosis, Part 1

Heidi James, MD and Sylvie Ouellette, MD
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Who should care about osteoporosis? Everybody. It affects 1 in 3 women and 1 in 5 men. Dr. Heidi James and Dr. Sylvie Ouellette discuss the evaluation and treatment of patients at risk for, and who have, osteoporosis.

 

Pearls:

  • Osteoporosis is decreased bone mass associated with impaired bone quality that leads to increased risk of fractures. Of those who have a hip fractures aged > 50, 25% die within 6-12 months.

  • Risk factors include age, female sex, Caucasian, prior hip fractures, glucocorticoid use, smoking, alcohol use, inflammatory disease (diabetes, rheumatoid arthritis, Crohn’s) and meds (PPIs, SSRIs).

  • Calcium and vitamin D supplementation is a gray area. Probably not a lot of benefit for average individual with reasonable North American diet but consider in the frail  nursing home population. Current Canadian guidelines are 1200mg of calcium per day in diet or through supplementation. Risks of calcium supplementation include cardiovascular events, renal calculi and constipation.

  • The DEXA scan is the screening method of choice with guidelines varying by provider and region. Generally, screen women > 65 and maybe men > 70, and earlier if they are high risk. The CAROC and FRAX score can help you risk stratify.

  • Measure height in all patients yearly, especially those at risk of osteoporosis because a >6cm discrepancy in height of what a patient reports and their measured height OR a >2cm loss of height is highly predictive of a vertebral compression fracture.

  • Treatment consists of bisphosphonates, denosumab and raloxifene. Bisphosphonates are the most commonly use but associated with GI upset, esophagitis, osteonecrosis of the jaw, and atypical femoral neck fractures.

  • Duration of treatment with bisphosphonates is not well established. The following are general guidelines:

    • For those who are low risk and are/were treated, stop the med. Follow their heights and repeat bone density in 3 years.

    • If pt is high risk, leave them on it and monitor closely for side effects like atypical femoral neck fractures.

    • If pt is of moderate risk, has been on the bisphosphonate for at least 5 years, or IV bisphosphonate for at least 3 years, hasn’t had any new fractures, and bone density is stable but still not > -2.5, consider holding the bisphosphonate. Follow closely and repeat bone density scan in two years. However, if they’ve had a fracture or bone density is worsening, then keep them on therapy.

 

  • What is osteoporosis? Decreased bone mass associated with impaired bone quality that leads to an increased risk of fractures.

    • 1 in 3 women affected

    • 1 in 5 women affected

    • Fractures in individuals > 50, 80% of those caused by osteoporosis

    • ~25% of patients > 50 yrs of age who have hip fractures  die within 6 - 12 months and have a 5-9% chance of breaking the other hip

  • What is the physiology of osteoporosis?

    • OsteoClasts resorption bone

    • OsteoBlasts rebuild bone

    • As people age, the process goes from being pretty balanced to speeding up where the osteoblasts can’t keep up → net deficit of bone.

    • Accelerates in women 10  years post menopause

    • Accelerated in men around age of 50 but bone strength has a slower rate decline because men don’t have the sudden change in sex hormones that women do.

  • Risk factors?

    • Age

    • Women > men (sex hormone differences and women have smaller bones)

    • Prior fragility fractures

    • Parents who had hip fractures

    • Prior glucocorticoid use

    • Smokers

    • > 3 servings of alcohol per day

    • Rheumatoid arthritis

    • DM1

    • Crohn’s disease

    • Meds: anticoagulants, anticonvulsants, PPI, SSRI

      • Unclear how significant the increased risk of osteoporosis with a PPI

    • Caucasian

      • As Asian women adopt more western diets, seeing increased rates of osteoporosis and hip fractures

  • Prevention? Bone mass doubles from puberty to mid-20’s  making adequate vitamin D and calcium intake, weight bearing exercise, and avoidance of smoking very important during that time.

  • Other factors which impact bone

    • Eating disorders, which are common during this time frame, can be very detrimental due to  losing bone mass secondary  to nutritional deficiency.

    • Depo-Provera

      Studied in Europe and is available everywhere except North America because of licensing idiosyncrasies. It promotes both bone remodeling and resorption. It seems to be very effective. Some patients are getting it from compounding pharmacies in the form of strontium citrate but we have no data if it’s effective or what side effects it will bring. Furthermore, strontium is incorporated into the bone and affects bone density due to its higher molecular weight. As a result, it impairs our ability to meaningfully follow their bone density. So while it may make the numbers look better, unclear what that means clinically.

  • Who should be referred to a specialist?

    • Those who are fracturing despite clear adherence.

    • Those who have a very low bone mass (t-score <-3.5)

    • Those who present with atypical femoral neck fractures

    • Those who are <50 and having fragility fractures

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Bones Lose Their Autonomy Full episode audio for MD edition 193:25 min - 91 MB - M4AHippo Primary Care RAP January 2017 Summary 329 KB - PDF

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