Osteoporosis and Bone Health. Heather Schickedanz, MD Geriatric Knowledge Network, 08/10/16

Transcription

1 Osteoporosis and Bone Health Heather Schickedanz, MD Geriatric Knowledge Network, 08/10/16 1

2 Learning Objectives Recognize the risk factors for osteoporosis Diagnose and treat osteoporosis Reduce the risk of falls and fractures in patients with osteoporosis Promote bone health in all of your patients 2

3 Why care? Common: 54 million Americans have OP and osteopenia. 1:2 women and 1:4 men age 50 and older will break a bone due to OP. Contributes to: depression, mobility imp, fractures. Costly: OP 2 million broken bones and $19 billion in related costs every year. By 2025, ~3 million fractures and $25.3 billion annually due to OP. 3

4 The Case of Mr. Caderas 55 year old man, retired car mechanic and long time heavy smoker. PMH: DJD and severe OA in both knees, DM, GERD, COPD, depression. Meds: Beclomethasone INH, Omeprazole, Glimiperide, Pioglitazone, and Fluoxetine. Falls screen: Positive for 1 fall 3 months ago, tripped. 4

5 Risk Factors for Osteoporosis Non-modifiable Risk Factors >age 50. Female. Post-Menopause. Family history of osteoporosis. Low body weight/bmi<20. History of fractures or height loss. Medical comorbidities: GI, Autoimmune, Endo, HemeOnc 5 Modifiable Risk Factors >3 alchoholic drinks per day. Sedentary lifestyle. Cigarette smoking. Low calcium intake. Low vitamin D level. Steroid therapy.

6 6 Medications that increase risk Aluminum-containing antacids Antiseizure medicines (only some) such as Dilantin or Phenobarbital Aromatase inhibitors such as Arimidex, Aromasin and Femara Cancer chemotherapeutic drugs Cyclosporine A and FK506 (Tacrolimus) Gonadotropin releasing hormone (GnRH) such as Lupron and Zoladex Heparin Lithium Medroxyprogesterone acetate for contraception (Depo-Provera ) Methotrexate Proton pump inhibitors (PPIs) such as Nexium, Prevacid and Prilosec Selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac and Zoloft Steroids (glucocorticoids) such as cortisone and prednisone Tamoxifen (premenopausal use) Thiazolidinediones such as Actos and Avandia Thyroid hormones in excess

7 Diagnose Osteoporosis Who to screen with DEXA Women >age 65yo or postmenopausal and >50yo with risk factors Men with risk factors and/or >70yo Dx of Osteopenia: rescreen in 3-5 years to monitor for progression Diagnosis of Osteoporosis T-score > -2.5 by DEXA scan (vertebra or hip) Fragility fracture (hip or vertebral clinical or morphometric fx) When to treat Diagnosis of Osteoporosis based on above, OR FRAX 10-year probability of hip fraxture >3% or OP-related fx >20% 7

8 When to treat? 8

9 Treat Osteoporosis Diet, Exercise, Rx: Replete and supplement low Calcium or Vitamin D >30 Recommend weight bearing exercise, PT and/or home eval for falls. 1 st line: bisphosphonate therapy (e.g. alendronate, zoledronic acid) 2 nd line: hormonal therapy (e.g. calcitonin, raloxifene, estrogen, teriparatide) Pro tips: Bisphosphonates are not consistently associated with serious adverse events; Raloxifene and estrogen increase VTE and stroke risk Estrogen with progestin increases CAD and breast cancer After 10 years of therapy, no guidelines as to whether to continue 9

10 Preventing Falls and Fractures = Promoting Mobility and Health! Gait and balance evaluation Vision evaluation Appropriate footwear Healthy diet Exercise and/or Tai Chi program Home safety evaluation and modification: Adequate lighting and removal of clutter No loose rugs or excessive furniture Grab bars, shower chair, toilet seat raiser PT/OT eval and appropriate mobility device 10

11 Back to Mr. Caderas Risk Factors? 11

12 Mr. Caderas 55 year old man, retired car mechanic and long time heavy smoker. PMH: DJD and severe OA in both knees, DM, GERD, COPD, depression. Meds: Beclomethasone INH, Omeprazole, Glimiperide, Pioglitazone, and Fluoxetine. Falls screen: Positive for 1 fall 3 months ago, tripped. 12

13 Next steps for Mr. Caderas You counsel Mr. Caderas on his risk for OP, and order a DEXA scan The T-score is -2.1 (osteopenia) You check labs to evaluate for secondary causes of bone demineralization (CMP, RF, TSH, PTH, vitamin D3 level) and they are all normal Should you start therapy for OP? 13

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15 Mr. Caderas: Case concluded You prescribe alendronate 70mg po q week with instructions You counsel Mr. Caderas on smoking cessation, weight bearing exercise, falls prevention, and request a PT evaluation for mobility device You prescribe calcium and vitamin D supplement You increase glimiperide, discontinue pioglitazone, and switch his PPI to an H2-receptor blocker 15

16 Recap: Learning Objectives Recognize the risk factors for osteoporosis Diagnose and treat osteoporosis Reduce the risk of falls and fractures in patients with osteoporosis Promote bone health in all of your patients 16

17 Questions/Discussion? Thank you! Heather Schickedanz, MD Geriatric Knowledge Network, 08/10/16 17

18 Case #1 18

19 Case #2 19