The first of the newsletters on these Qs and As should include a refresher on the Virtual Forums what they are, how they work, etc. The fact is that less than 5% of COPN members tune in for any given Forum. Many new members will not understand what they are or how they work and with a bit of education we could bump the numbers up substantially. We should also include a reminder that it s not too late to view the Forums and then include a link to the archives. New Osteoporosis Guidelines: What you and your health provider need to know QUESTION & ANSWER Wednesday, December 1, 2010 1:00 p.m. to 2:00 p.m. ET 1. I m 55 years old. I ve been taking Fosavance (70mg 5600 Vit.D/week) for about 2 years. Before that I was taking Actonel (32 mg/week) for about 5 years. I was told by the doctor that I also should take calcium. My supplement gives me about 650 mg of calcium alone other microelements. Question: Why should I take calcium if I am taking bone building drug Fosavance? In order for medications like bisphosphonates to increase bone density and reduce fractures individuals still need to have adequate calcium and vitamin D from diet and supplements. All of the studies that have shown benefit of drug therapy for osteoporosis have included calcium and vitamin D supplements. It is important to know whether the supplement contains 650 mg of elemental calcium or 650 mg of the calcium salt (e.g., calcium carbonate has 250 mg elemental calcium in each 650 mg tablet). The recommended calcium intake is for elemental calcium from all sources (diet and supplements) and should be 1200 mg per day after age 50. If your diet and supplement do not provide this dose than you may wish to increase your intake. There is no evidence that taking more than 1200 mg of elemental calcium offers any additional advantage. 2. Is there an easy and inexpensive test to measure absorption of vitamin D? Inability to absorb vitamin D is uncommon, and is usually only an issue in individuals with conditions known to interfere with digestion and absorption (bowel resection, gastrectomy, celiac disease, Crohn s disease, pancreatic disease, biliary disease). In the absence of these conditions, it can be assumed that an individual will absorb vitamin D normally.
3. If a person has had a bone mineral density test within the past year or two, would you suggest her physician review the risk factor based on the new system to evaluate medication need. Do physicians at this point have access to the FRAX calculator? How recent should the BMD test have been to properly use the FRAX tool? The FRAX calculator is available online (www.shef.ac.uk/frax) and also available as an iphone application and on some BMD machines. The CAROC system was published in the CMAJ and does not require computer based calculations. There will be available on the Osteoporosis Canada website an APP for CAROC in the future. Either of these could be used to assess 10-year fracture risk for individuals that have had previous BMD testing. The risk assessment is most accurate when the BMD test is recent (within the last 3 years) and becomes less useful over time as BMD may have changed. It is also important to be aware that the risk calculation does not apply to individuals receiving drug therapy for osteoporosis since it will overestimate fracture risk in individuals on treatment. 4. Why is only the BMD from femoral neck used in risk calculation, and not the BMD from spine? The World Health Organization (WHO) selected the femoral neck as the reference site for osteoporosis diagnosis and fracture risk assessment based upon the large number of studies that have collected data on the femoral neck, and since this is the best site for prediction of hip fracture risk which is the fracture site responsible for the greatest cost, morbidity and mortality. The Osteoporosis Canada guidelines note that when the risk assessment is in the moderate range based upon the femoral neck (10-20% fracture risk over ten years) then the lumbar spine may be helpful in deciding which individuals require treatment. Specifically, if the lumbar spine measurement is much lower than the femoral neck measurement in a moderate risk patient then treatment would be reasonable. There is ongoing research from the WHO on how best to include the lumbar spine measurement in fracture risk assessment, and this will likely be incorporated in future versions of FRAX. 5. Could you define hip BMD? Is it total hip or femoral neck density? The WHO FRAX system and CAROC systems as used in the 2010 Osteoporosis Canada guidelines are based upon the femoral neck bone density measurement. 6. Did you consider eating disorders as a risk factor? Although eating disorders are not specifically listed as a risk factor in the 2010 Osteoporosis Canada guidelines, these often produce menstrual irregularities
(hypogonadism) in younger women and low body weight in older women. The guidelines include both of these as indications for BMD testing (hypogonadism prior to age 50; body weight less than 60 kg or major weight loss greater than 10 % of body weight at age 25 after age 50). 7. Does a lumbar fracture show up on a BMD or is another x-ray recommended? Most lumbar spine fractures are not detected by a BMD test even when this examines the lumbar spine. Occasionally, severe fractures can be suspected on the scan but these need X-ray confirmation. Vertebral fracture assessment (VFA) can be done with some BMD scanners and is a relatively new technique for imaging the thoracic and lumbar spine to identify fractures. The 2010 Osteoporosis Canada guidelines make recommendations on the role of VFA in fracture risk assessment and patient management. An xray of the thoracic (mid) and lumbar spine ( lower) is recommended if there has been measured height loss greater than 2 cm as this may be due to a spine fracture. 8. Many older people are still on Didrocal. Is that medication considered to be of benefit? Why, in the list of drugs, is Didrocal never included? Is it because it isn't very effective? The 2010 Osteoporosis Canada guidelines still include Didrocal (etidronate) which is still available. Many patients have been successfully treated with this medication and continue to tolerate it quite well. However it has not been shown to prevent hip fractures. It is considered a second line agent as there are newer agents which have stronger evidence of fracture prevention. Etidronate can be considered for prevention of vertebral fractures in menopausal women and long term glucocorticoid users intolerant of first line therapies. 9. Do the additional factors that warrant consideration for therapy in patients at moderate risk for fracture make these patients at high risk for fracture? The additional factors that warrant consideration for therapy in patients at moderate risk helps to identify those in whom treatment may be warranted. These individuals are at higher risk than those without additional risk factors. Some (but not all) of these individuals would fall in the high risk range (>20% 10- year fracture risk). 10. Is it helpful to have a follow up BMD tests to monitor effectiveness of treatment or is the test's value limited to helping assess osteoporosis risk and diagnosis?
The 2010 Osteoporosis Canada guidelines provide information in terms of BMD monitoring. This remains an area of controversy as no randomized trials have directly assessed the value of repeat BMD testing on persistence with treatment or reduction of fractures. If performed, repeat measurement of BMD should initially be performed after 1 to 3 years; the retesting interval can be increased once therapy is shown to be effective. If BMD has improved or remains unchanged, the patient is considered to have had a good response to therapy. 11. So if I tripped and fell and had a hair line fracture in my 5th metatarsal of my foot, it is not due to Osteoporosis? Fractures of the head/face, hands, ankles and feet are not usually related to osteoporosis. This would include fractures of the metatarsal. These are not included as fragility fractures in the 2010 Osteoporosis Canada guidelines. 12. Does osteoporosis or the pharmacological treatment of osteoporosis affect the healing potential of bone following a fracture? There is no evidence that current medications approved for treatment of osteoporosis adversely affect bone healing after a fracture or surgery. There has been a large clinical trial after recent hip fracture that showed pharmacologic therapy not only reduced future fractures but also mortality. 13. Why is smoking considered an increased risk factor for osteoporosis? Smoking increases the risk for osteoporosis and fracture through a number of mechanisms, and is therefore considered multifactorial. In part, these effects are through a reduction in body weight (smokers tend to be thinner) and reduced physical activity. Smoking may also further reduce the low levels of circulating estrogen in post menopausal women. Smokers with lung disease may also be treated with intermittent glucocorticoids. 14. I've read most cost effective drug with low risk are thiazide diuretics. Please comment. There is some evidence that thiazide diuretics reduce calcium loss from the kidneys which may be beneficial in terms of preserving BMD and reducing fracture risk. These medications have not been tested in randomized clinical trials for osteoporosis and fracture reduction, and therefore cannot be recommended as a treatment for osteoporosis. 15. Which is better for managing my pain, ibuprofen or aspirins? I have broken both ankles, wrist and leg in three places. I am 53 years old and do not have high blood pressure.
Over the counter pain medications (aspirin or ASA, ibuprophen, Tylenol or acetaminophen, etc) are equally effective for fracture related pain. Gastric upset is the major side effect of anti-inflammatories (ASA, ibuprophen), and some individuals may find that they tolerate one of these better than another