Osteoporosis Update DR. SYLVIE OUELLETTE RHEUMATOLOGIST
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1 Osteoporosis Update DR. SYLVIE OUELLETTE RHEUMATOLOGIST
2 Disclosures! Speaker programs! AbbVie, Amgen! Research! Amgen, Novartis! Education/ conference support! Amgen, Roche! Advisory Boards! AbbVie, Amgen, UCB, Roche
3 Objectives! By the end of this presentation, you will be able to:! Effectively counsel patients regarding Calcium and Vitamin D supplementation! Counsel patients regarding risk of atypical femoral fractures with osteoporosis therapy! Have a plan for when and how to consider treatment interruption for patients who have received anti-resorptives for osteoporosis
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5 Key Changes from to Osteoporosis Canada! Higher daily vitamin D supplementation (D3) 3! IU for individuals < 50 years! IU for individuals > 50 years! Lower daily calcium intake (from all sources): 1200 mg! Updated evidence-based approach to therapies 1. Brown JP, Josse RG. CMAJ 2002; 167(10 Suppl):S Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print]. 3. Hanley DA, et al. CMAJ 2010; 182: E610-E618.
6 Calcium - What I used to do! Concerns of calcium supplement! Kidney stones! Cardiovascular events! GI intolerance! Favour dietary Calcium (3-4/d)! Milk! Yogurt/ cottage cheese! Block cheese! Calcium fortified orange juice, soy milk, almond milk
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8 Calcium - What I do now! Community dwelling individuals! No demonstrated benefit to promoting dietary Calcium or supplements! Benefits likely = harm! Frail, institutionalized patients! Encourage Calcium to 1000 mg/d! Diet first! Then supplement! Supported by! Weaver CM et al, OI 2016, 27:367! Chapuy MC et al, NEJM 327(23):1637
9 Vitamin D! Essential for Calcium homeostasis! Vitamin D receptors in muscle! Vitamin D deficiency associated with muscle weakness! Studies suggested! Decreased incidence of falls, fractures! Improved lower extremity function in high risk seniors
10 Vitamin D Hansen KE JAMA Int Med 2015;175(10): ! 3 year DBRCT of 230 post-menopausal women less than 75 yo! Vitamin D 800 IU daily + twice monthly placebo! Daily placebo and twice monthly Vitamin D IU! No difference in:! BMD! Muscle mass! Timed Up and Go! Number of falls! Functional status
11 Vitamin D Bischoff-Ferrari HA, JAMA Int Med 2016;176(2): ! 1 year, DBRCT! 200 men and women over 70 yo with prior fall (community-dwelling)! Low-dose control group Vitamin D IU monthly! Vitamin D IU monthly! Vitamin D IU mcg of calcifediol monthly! Despite improved Vitamin D levels,! No benefit on lower extremity function! INCREASED falls with higher doses
12 Vitamin D what I do now! Community-dwelling adults (with no other health issues)! No benefit to greater than IU/d Vitamin D3! Institutionalized patients! Consider supplement IU/d! Can consider pooled weekly dose, but not monthly or greater interval
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14 Drug holiday
15 Risk of Fractures Adler et al JBMR, 31(1), 16-35
16 Fracture risk of bisphosphonates N Engl J Med 2016;374: DOI: / NEJMcp
17 NNT 90 Weighing the risks and benefits of bisphosphonate treatment Based on treatment for 3 years - Black DM, Rosen CJ. N Engl J Med 2016;374: NNH 800
18 Drug Holiday! Task Force of the American Society for Bone and Mineral Research! JBMR 2016, 31(1): 16-35! Treatment decisions MUST be individualized
19 Drug holiday - Exclusions! 2014, Epidemiology/Quality of Life Working Group of the International Osteoporosis Foundation! HIGH risk patients! Lowest T-score < -3.5! Glucocorticoids >5 mg/d! History of multiple fractures
20 Adler et al JBMR, 31(1), 16-35
21 Summary! In high risk patients, treatment with bisphosophonates out-weighs risks of atypical femoral fractures! May consider halting therapy with bisphosphonates after 5 years (3 yrs if IV)! Community-dwelling individuals probably don t need Calcium supplements or advice about dairy! High dose Vitamin D is unlikely to confer much benefit
22 How much Calcium supplement would you recommend to a 65 yo woman?! A mg/d as supplement! B mg/d (including her diet AND supplement)! C- none, if she is community dwelling
23 How much Calcium supplement would you recommend to a 65 yo woman?! A mg/d as supplement! B mg/d (including her diet AND supplement)! C- none, if she is community dwelling
24 How long should patients continue on anti-resorptive therapy?! A it depends on fracture risk! B 5 to 10 years! C indefinitely
25 How long should patients continue on anti-resorptive therapy?! A it depends on fracture risk! B 5 to 10 years! C indefinitely
26 Questions?
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