Osteoporosis - New Guidelines Michelle Glass B.Sc. (Pharm) June 15, 2011
Outline What is Osteoporosis? Who is at risk? What treatments are available? Role of the Pharmacy technician
Definition of Osteoporosis Bone disorder characterized by low bone strength resulting in bone fragility and an increased risk of fractures Bone strength depends upon two features: Bone density Bone quality Occurs when the rate of bone loss exceeds the rate of bone formation over an extended period
The bone remodeling cycle. Derived from Roodman GD. N Engl J Med. 2004;350:1655-1664.
Assessment for Osteoporosis Who should be assessed? Women and men over 50 to identify those at high risk Anyone over 50 who has experienced a fragility fracture How is the Assessment Done? Detailed history to identify risk factors for low BMD, future fractures and falls: Prior fragility fracture Parental hip fracture Glucocorticoid use Current smoking High alcohol intake (3 or more drinks per day)
Assessment for Osteoporosis Rheumatoid arthritis Inquire about falls in past 3 months Inquire about gait and balance Physical examination Measure weight Screening for vertebral fractures: Measure height annually Measure rib to pelvis distance Measure occiput-to to-wall distance Spinal x-ray x indicated if there is evidence of vertebral fracture Assess fall risk by using Get-Up Up-and-Go Test
(CAROC) CAROC) - Canadian Association of Radiologists and Osteoporosis Canada Other factors in addition to (hip) BMD results are used to determine 10-year fracture risk These factors are age, sex, fracture history and glucocorticoid use FRAX Tools for Assessment In 2008, the World Health Organization (WHO) launched FRAX, a web-based based fracture risk assessment tool. In 2010 Canadian data were added. In addition to femoral neck (hip) BMD, age, gender, fracture history and steroid use, FRAX also takes into account other risk factors to calculate the absolute 10-year risk of a hip fracture or other major osteoporotic fracture (spine, forearm, upper arm).
Goal of drug treatment: Prevention of osteoporosis in high risk people Prevention of further bone loss Rebuild healthy bone Fracture prevention Fall prevention
Medications Associated with Increased Risk of Osteoporosis Oral steroids (e.g. Prednisone, Dexamethasone) Depo-Provera Anti-seizure drugs (e.g. Phenytoin, Carbamazepine, Phenobarbital) Cyclosporin Lithium SSRI s s (implicated) Anti-estrogen drugs (e.g.?tamoxifen, Anastrozole, Letrozole, Exemestane)
Disorders Associated with an Increased Risk of Osteoporosis Irritable Bowel Syndrome Celiac disease Rheumatoid arthritis Ankylosing Spondylitis Lymphoma Leukemia Pernicious Anemia Multiple Sclerosis Breast Cancer...
Drug categories Bisphosphonates Etidronate/Didronel tm Alendronate/ Fosamax tm Risedronate/ Actonel tm Zoledronic acid /Aclasta Ibandronate/Boniva Denosumab SERMs Raloxifene - Evista tm Calcitonin /Miacalcin tm HRT PTH (Forteo) Fluoride Vitamin D Calcium Strontium ranelate/ Protos tm
Medication activity Bone resorption inhibitors Bisphosphonates SERM s HRT Calcitonin Bone formation stimulators Parathyroid hormone Fluoride Monoclonal antibody
Bisphosphonates Bind to bone and slow down bone-eroding eroding cells (osteoclasts) Alendronate (Fosamax ), Risedronate (Actonel ), Etidronate (Didrocal ) Pamidronate (Aredia ), Zoledronate (Zometa )Zoledronic Acid (Aclasta) Can be used for both prevention and treatment of osteoporosis
Bisphosphonates: Mechanism of Action Roger M. Bone 1999,24, 739
Treatment Controversies Jaw Necrosis pamidronate and zolendronate IV in patients treated for cancer and not osteoporosis; This side effect is rare, but a concern nevertheless since it is thought to affect all bisphosphonates. Rare reports have been described with alendronate Text (Fosamax ) ) or risedronate (Actonel ). Increased Risk of Atypical Fractures long-term alendronate use further studies needed to establish whether a clear association exists thigh fracture associated with bisphosphonate use is extremely rare, on the other hand, fractures due to osteoporosis are extremely common
Lifestyle Changes Increase physical activity (weight-bearing exercise) Reduce/eliminate tobacco Reduce/eliminate caffeine intake Reduce/eliminate alcohol intake Minimize risk of falling ENSURE ADEQUATE CALCIUM AND VITAMIN D INTAKE...
Diet and Bone Health Calcium: Bone is really a bank,, or place where the body can store and retrieve calcium - the mineral that makes bone hard. Vitamin D: Is needed to make sure the body can absorb calcium from food.
Age Calcium Needs 1-3 yrs 500 mg 4-8 800 mg 9-18 1300 mg 19-30 1000 mg 31-50 1000 mg 51+ 1200 mg Nat l l Academy of Sci 1997 OSC 2001
Vitamin D House bound elderly at greatest risk of deficiency Sun exposure is not enough to replace ingested Recommendations by age: AGE DAILY INTAKE 19 to 50 400-1000 IU 50 + 800-2000 IU
Pharmacy Technicians role Patient education Know required amounts of calcium and Vitamin D at various stages in life Know correct amounts of Ca not more than 500mg at one time Watch for patients on any of the potential bone- loss medications and advise accordingly Be attentive to pt s s complaining of falling or dizziness and refer patient to the pharmacist pt s s refusing to take Ca supplements due to media reports of it causing heart attacks should be referred to the pharmacist