Presented by Nicole Nisly, MD

Transcription

1 Presented by Nicole Nisly, MD

2 About Today s Presentation I will discuss osteoporosis and focus on causes, treatment options and prevention I will discuss medications and life style choices that can be of help I will discuss some treatments that are not FDA approved I have no conflict of interests to disclose

3 About Dr. Nisly Hello, my name is Dr Nicole Nisly, thank you for coming today I am a Professor of Internal Medicine and work at the University of Iowa Iowa River Landing Clinic (319/ ) My areas of expertise include Internal Medicine Primary Care, Complementary and Integrative Medicine, LGBTQ Health and Cultural Diversity in Health

4 How do we get osteoporosis? We reach our maximum bone mass normally by the age of 40 As we age, we tend to lose bone mass, especially after menopause Certain conditions make that loss happen faster

5 Risk Factors for Osteoporosis Age (most fractures of the hip occur after age of 80) Use of corticosteroids Low Body weight Smoking Excessive alcohol use Parental Hip Fx Rheumatoid arthritis Previous Fragility fractures Malabsorption Early menopause Hypogonadism Chronic liver disease Inflammatory Bowel disease

6 How do we know if we have osteoporosis? For most women, they should be screened with a DEXA scan at age 65 Sooner with increased risk factors (FRAX calculated risk of over 20% over 10 years) For men: less certain but around age 70, sooner if at risk

7 About DEXA Scan Results (Dual Energy X-ray Absorptiometry) This test measures bone mineral density (BMD). T score compares your BMD to that of a young women around age 25 Z score compares your BMD to someone of your age Osteoporosis: T score of 2.5 or less SD Osteopenia: T score between SD Z score of 2 or lower SD is abnormal

8 How often do you test? For women at average risk and T score between SD or any risk factors, repeat every 2 years T score between SD, repeat in 3-5 years T scores at SD, repeat in years Address risk and benefit, including cost. The purpose of testing is to help decide when to treat and reduce risks

9 Should I test early? If you have the risk factors indicated previously or fragility fracture: test women starting at age 50 and men around 70 Canadian osteoporosis Society recommends earlier testing for women and men between 50-65

10 How to test? DEXA scan of Hip and Lumbar spine preferred Peripheral measurements of heel or ultrasound measurements while more available do not correlate well with fracture risk Bone turnover markers are not cost effective in guiding evaluation or treatment

11 Other Tests Calcium Biochemistry profile including Albumin and protein and Alkaline Phosphatase 25-OH vitamin D Complete Blood Count Other tests in certain situations: Cortisol, parathyroid hormone, celiac disease screening, 24 hr urinary calcium

12 Pre-Menopausal Women & Children Bone density testing should only be done in very specific situations of very high risk Use Z scores instead of T scores to interpret test Usual WHO guidelines apply to post menopausal women

13 How about prevention? Increase exercise and weight lifting, aim at 3 times per week for 30 minutes Balance and fall prevention is important, exercises such as Tai-Chi may help Gluten Free Diet and Low or High protein diet are discussed for specific cases Vitamin D 3 in gel capsule: 600-4,000 IU daily (most people 600-1,000) Calcium: diet is best source. Supplements

14 The Issue of Calcium Dietary sources: one serving of dairy: 300 mg 1 oz hard cheese, 8 oz of milk, 6 oz of yogurt) Greens, non dairy drinks Supplements: calcium citrate absorbs better if using certain medications Goal: 500-1,000 mg of supplement if needed

15 Medications Biphosphanates such as Alendronate, Risendronate, Ibandronate and the I.V. form of Zoledronic Acid increase bone mass and reduce fracture SERM such as Raloxifene can decrease bone loss and reduce vertebral fracture Others: parathyroid hormone shots, Strontium (not available in the US), Denosumab shots, calcitonin

16 Natural Therapies Tai chi Soy protein Ipriflavone (unproven) Previously discussed life style changes Environmental modifications such as night lights, removing rugs, using walkers, exercising regularly QUIT SMOKING!! Reduce alcohol

17 What is CAM anyway? A wide range of practices, new and old, at times safe, other times dangerous, widely used by patients worldwide, however In general, safety and efficacy are not yet well established, Not commonly taught in medical schools and Not commonly utilized in U.S. hospitals

18 However Integrative Medicine and various Complementary or Holistic Therapies are making their way into the health care system in various formats Education: Core Curriculum, Electives, Resident electives, Fellowships are growing in the U.S.

19 Selected Alternative Medicine Systems and Techniques Mind-body interventions Alternative systems of medical practice Biologically based therapies Manipulative and body-based methods Energy therapies

20 Mind-body Interventions Art therapy Biofeedback Dance/movement therapy Hypnosis Imagery Meditation Music therapy Prayer and mental healing Self-help support groups Yoga

21 Alternative Systems of Medical Practice Acupuncture Ayurveda Community-based Latin American community healthcare Native American healthcare Homeopathy Naturopathic medicine Traditional Chinese medicine

22 Why bother telling your doctor or pharmacist what will they do with that information? Integrated care vs. uncoordinated care Potential for: Side-effects Drug-dietary supplement interactions Benefits

23 Herbal Medicines European Botanical Medicines Latin American Herbal Remedies Native American Herbal Agents Ayurvedic Herbal Agents Oriental Herbal Agents Chinese Japanese - Kampo

24 Medicine Derived From Plants Aspirin Atropine Belladonna Capsaicin Cascara Cocaine Colchicine Digoxin Ephedrine Ergotamine Ipecac Opium Physostigmine Pilocarpine Podophyllum Psyllium Quinidine Reserpine Scopolamine Senna Taxol Tubocurarine Vincristine Vinblastine Klepser, 2000

25 St. John s Wort Drug Interactions (P450 1A2, 2C9, 3A4) Activates a receptor, named PXR, in the liver and intestine, which accelerates drug metabolism. It may interact with over 80% of drugs available in the U.S. market.

26 I have a cold, allergy or something Mr. Sneezy comes in for refill of his allergy medication. Typically he has symptoms during the ragweed season. I have frequent colds, can I use Echinacea, he asks?

27 Where do I go for reliable information? NCCAM ( ODS ( NCI/OCCAM ( MD Anderson database ( Natural Medicine Comprehensive Database ( Micromedex Consumerlab.com

28 Talk to your Doctor Tell your health care providers about all the complementary and alternative practices you use. This will help ensure coordinated and safe care. Be proactive. Don't wait for your health care providers to ask about your CAM use. Make the most of the conversation. Bring a list of everything you use, keep a record of the information you receive, and ask questions if something is unclear.

29 Using Supplements Why I want to take the supplement How I found out about it Is it safe for me to take? Will it interact with any of my medications? Is it likely to help me? What else should I know about it? Where can I find more information? Should I try this? If not, why not? Might something else be better?

30 Keeping Track of Your Intake Name and company Dose Taken Dose Recomm ended Ingredie nts Why Gingko Nature Made 60 mg/day 120 mg/day Gingko Memory St John s wort, walmart 300 mg/day 900 mg/day SJW, Kava, valerian Mood

31 Conclusion Be an informed and empowered consumer: it is your health! The best patient is a well informed, interested, responsible and empowered patient, who actively and collaboratively participates in their health care.

32 Final Words & Questions