Marcy B. Bolster, MD Associate Professor of Medicine Division of Rheumatology Endocrine Associates Massachusetts General Hospital

Marcy B. Bolster, MD Associate Professor of Medicine Division of Rheumatology Endocrine Associates Massachusetts General Hospital

What is Osteoporosis? Osteoporosis causes bones to lose density, become weak, and fracture easily Osteoporosis affects the entire skeleton Osteoporosis predicts fracture risk

Osteoporosis Normal Spine Osteoporotic Spine Source: National Osteoporosis Foundation, 2000

DXA Oral bisphosphonates FRAX Fall Risk Assessment Denosumab (Prolia) Teriparatide (Forteo) Risk factors Exercise Calcium/Vitamin D IV bisphosphonates Raloxifene (Evista)

Why Do We Care About Osteoporosis? Osteoporosis is common - 44 million Americans have either osteoporosis or low bone mineral density 10 million with osteoporosis Osteoporosis is serious - Osteoporotic fractures cause disability and increased mortality Osteoporosis is easy to diagnose - Bone density testing can detect osteoporosis before the first fracture occurs Good treatments are available- Fracture risk can be reduced by 50-70%

Facts about Fractures Most osteoporotic fractures occur in the spine, hip, and wrist 2/3 of spine fractures are painless Fractures lead to disability and increased mortality Up to 20% increased mortality as early as one year after a hip fracture

Impact of Osteoporosis 40% of women over 50 will suffer an osteoporosisrelated fracture in their lifetimes. Each year, the risk of suffering a fracture from osteoporosis is greater than the combined risk of suffering a heart attack, stroke, or breast cancer in women.

Societal Impact Two million osteoporotic fractures occur each year Morbidity Functional impairment and quality of life Mortality associated with hip fractures 5-8x (first 3 months) 20-25% one-year mortality Cost for all fractures $17 billion in direct medical costs (2005) 17x cost of congestive heart failure (CHF) Projected $25 billion (2025) LeBlanc et al, Arch Int Med, 2011; Haentjens P et al, Ann Int Med, 2010; Brauer CA et al, JAMA, 2009; Boonen S et al, Osteoporosis Int, 2004; Hall Se et al, Aust NZ Med J, 2000; Cummings SR et al, Lancet, 2002; Liu Z et al,

Fractures Lead to Fractures 1 in 5 patients with a fragility fracture will sustain a 2 nd fracture in the next 5 years 50% of patients presenting with a hip fracture have had a prior fragility fracture 1 in 10 patients with a hip fracture will have a repeat hip fracture within 5 years Johnell O et al, Osteoporos Int, 2004;Akesson K et al, Osteoporos Int, 2013; Solomon DH et al, J Bone Min Res, 2014

Who is at Risk for Developing Osteoporosis? Post-menopausal women; increasing age Caucasian or Asian Small body stature Family history (especially hip fracture in a parent) Personal history of fractures as an adult (non-traumatic) Inactive lifestyle Cigarette smoking Alcohol use (> 3 drinks/day) Inadequate calcium intake Rheumatoid arthritis Medications: prednisone, breast cancer treatment, seizure medications, progesterone birth control

What is Meant by a Fragility Fracture? A fracture sustained from a fall from a standing height or less

Or a Fracture Sustained with a Fall from Which a Fracture Ought Not be Expected 21 yo woman 62 yo woman Google Images, 2016

Fragility Fractures 81 yo W Left hip fx 85 yo M L1 Vert fx 62 yo W Wrist fx 71 yo W Humerus fx

Lifetime Risk of Fractures: Age 50 60.0% 53.0% 50.0% 40.0% 30.0% 21.0% 20.0% 11.4% 16.6% 13.1% 10.0% 3.1% 2.9% 1.2% 0.0% Lifetime Risk of Fracture Fracture: Hip Fracture: Wrist Fracture: Clinical Vertebral 50 yr-old females 50 yr-old males Eisman JA et al. ASBMR Task Force Report on Secondary Fracture Prevention, 2012.

Diagnosis: Bone Densitometry

How to Detect Osteoporosis DXA (dual-energy x-ray absorptiometry) Gold standard Measures hip and spine (sometimes forearm) Compares bone mineral density to that of a young adult (T-score) Peripheral measures (ankle, hand, finger) A screening tool Indicate possible risk of future fracture Do not confirm the presence of osteoporosis Not approved to make the diagnosis

Who Should Get a Baseline Bone Density Test? All women 65 years old or older All women with a history of a fragility fracture Postmenopausal women with at least one risk factor Adults with a disease or medication history associated with bone loss Prednisone Breast cancer medications Seizure medications Progesterone birth control

Interpretation: T-score is key The most clinically relevant value on the bone density report The T-score compares the bone density of the patient to that of peak bone density (approximately age 30)

The T-Score Bone density compared to that of a healthy young adult World Health Organization (WHO) defined Normal: > -1.0 Osteopenia: -1.0 to -2.5 Osteoporosis: -2.5 or lower The lower the T-score, the higher the risk of fracture

Fracture Risk Doubles With Every Standard Deviation Decrease in Bone Density 35 30 25 RR for 20 Fx 15 10 5 0-5.0-4.0-3.0-2.0-1.0 0.0 1.0 T-score

What About Osteopenia 50% of post-menopausal women age > 50 who fracture have osteopenia T-score between -1.0 and -2.5 How do we determine which patients with osteopenia are at increased risk for fracture? FRAX score

Using the FRAX Tool to Help Determine Fracture Risk in Treatment-Naïve Patients With Low Bone Mass

Weight-bearing Exercise Consult your doctor first

Role of Exercise in Prevention and Treatment Decreased risk of falling Improved bone mass and strength Enhanced muscle strength Improved balance, better posture Increased flexibility of soft tissues Improved cardiovascular fitness Improved depression

Fall Prevention In The Home Use handrails on stairs, bathroom Keep rooms free of clutter Keep floors clean but not slippery Wear supportive, low-heeled shoes. Don t walk in socks; floppy slippers Use 100 watt bulbs in all rooms Install ceiling lighting in bedrooms Use rubber mat in shower/tub Keep a flashlight at bedside Check posture in mirror often

Management Exercise Modification of environment for safety Medications

What Are the Treatment Options? Exercise Fall Prevention Calcium + Vitamin D Daily Estrogen Raloxifene Teriparatide Weekly Alendronate Risedronate Monthly Risedronate Ibandronate Quarterly Ibandronate IV Twice yearly Denosumab Yearly Zoledronic acid

How Much Calcium is Enough? Varies for age 1,200-1,500 mg every day after age 50 From diet or supplement or both It is ideal to obtain calcium from diet as much as possible Good Sources of Calcium Milk-300 mg/glass (includes soy and almond) Yogurt-400 mg/cup Broccoli-180 mg/cup Sardines-370 mg/3 oz

How Much Vitamin D? 800-1000 IU every day From fortified foods or supplements or both Higher doses if Vitamin D deficient Good sources of Vitamin D Milk (100 IU per glass) Multivitamins (most have 400 IU) Over the counter vitamin D tablets

Medications Available for Treating Post-Menopausal Osteoporosis Tablets Calcium and Vitamin D supplementation Estrogen Raloxifene (Evista ) Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Intravenous yearly Zoledronic Acid (Reclast ) Subcutaneous injection Teriparatide (Forteo ) daily Denosumab (Prolia ) twice yearly

Concerns about Medication-Related Adverse Events Bisphosphonates (alendronate, zoledronic acid) Esophageal discomfort Osteonecrosis of the jaw Atypical femoral fractures Teriparatide (Forteo ) Black box warning Leg cramps Dizziness Denosumab (Prolia ) Eczema? Osteonecrosis of the jaw, atypical femoral fractures

Concerns about Medication-Related Adverse Events Bisphosphonates Esophageal discomfort Osteonecrosis of the jaw Atypical femoral fractures

Osteonecrosis of the Jaw Woo and colleagues, May 2006 Review of published literature 368 cases of osteonecrosis of the jaw Treated predominantly for metastatic disease and hypercalcemia of malignancy Breast, prostate, lung, renal cell cancer, multiple myeloma Majority received high dose IV bisphosphonate Woo S-B, et al, Ann Intern Med, 2006

Osteonecrosis of the Jaw Risk factors Intravenous bisphosphonates Dosage used (up to 12x dosage used for osteoporosis) History of dental trauma or surgery Includes dentures History of dental infection Woo S-B, et al, Ann Intern Med, 2006

Osteonecrosis of the Jaw Recommendations Complete all dental invasive work prior to or within 1-2 months of initiating IV bisphosphonate treatment Once on IV bisphosphonates maintain good dental care If already on treatment then seek conservative procedure management Appropriate timing of dosing and procedures if possible If ONJ develops treat conservatively Antibiotics, oral rinses Woo S-B et al, Ann Intern Med, 2006

Atypical Femoral Fractures Fragility of thigh bone (femur) Association determined (but not causal) with long term bisphosphonate use Important to consider how long a course of therapy should be Studies show benefit with 3-6 years of treatment (depends on which medication) Alendronate (Fosamax) 5 years Zoledronic acid (Reclast) 3 or 6 years Some patients at very high risk warrant a longer treatment course

Medication Adverse Events Begging the Question Who should receive a drug holiday? When should the holiday begin? How long should it last?

Consider Drug Holiday

The Drug Holiday: Following a Sufficient Treatment Course Many patients take a drug holiday Bone turnover can resume Awareness of fracture risk prevention Careful monitoring for ongoing bone loss Continue calcium and vitamin D intake

How Long is the Holiday?

The Drug Holiday: What is the Duration? Taking into account Patient age Risk factors History of fracture Other medical illnesses 1-2 years OR 3-4 years

Drug Holiday Considerations Individualize the decision with each patient Reconsider this regularly

Benefits Outweigh Risk Risks Benefits Timing and Therapy Duration

Fracture Prevention Primary vs. Secondary Prevention

Fracture Prevention: Primary Preventing the first fracture Appropriate screening (DXA scan) Risk assessment Utilization of the FRAX tool Risk factor modification Falls assessment Treatment regimen Ensuring correct administration Ensuring compliance Determining plan for therapy duration

Fracture Prevention: Secondary Treatment of osteoporosis after a fragility fracture is sustained Appropriate screening (DXA scan) Risk assessment Utilization of the FRAX tool Risk factor modification Falls assessment Treatment regimen Initiating treatment Ensuring correct administration Determining plan for therapy duration IN ADDITION TO REDUCING FRACTURE RATES, BISPHOSPHONATES DECREASE MORTALITY RATES

The Osteoporosis Challenge To educate all patients on measures to maintain good bone health To identify patients at high risk for osteoporosis To use bone densitometry to detect low bone density BEFORE a fracture occurs To educate patients about treatment options taking into account the risks and benefits To use risk factor reduction, medications and exercise to treat patients for osteoporosis Consider appropriate duration of therapy

CALCIUM AND BONE HEALTH Why take calcium? Most adults do not get all the calcium they need from their diet. Calcium is necessary for bone structure and strength. A long-standing calcium deficiency may result in weakened bones or osteoporosis. How much calcium do I need? Adults 50 years and older typically need 1200 mg calcium/day. Both dietary calcium (from food) and calcium from supplements count towards your daily requirement. What about calcium supplements? Calcium supplements are available without a prescription. The dose of calcium supplements varies widely by manufacturer, and the advertised dose on the front of the bottle may be confusing. Be sure to check the nutrition label on the back of the bottle to determine exactly how much calcium is in each pill. What are the different types of calcium supplements? Calcium carbonate is the most commonly found type of calcium supplement, and is best absorbed with a meal. Examples of brands: o Caltrate: 600 mg elemental calcium per pill o OS-CAL: 500 mg elemental calcium per pill o TUMS: 200-400 mg elemental calcium per pill o Viactiv: 500 mg elemental calcium per chew o Calcium gummies: 250mg per gummy Calcium citrate is absorbed more easily, but each pill contains less calcium than most calcium carbonate pills, and therefore you need to take more pills for the equivalent calcium dose. It may also be more expensive than calcium carbonate. Examples of brands: o Citracal: 315 mg elemental calcium per pill o Citracal slow release: 600mg elemental calcium per pill (combination of calcium citrate and calcium carbonate) What is the calcium content of common foods? Please see reverse of this sheet for table Developed for MGH Endocrine Associates 2013 Source: USDA

CALCIUM CONTENT OF FOODS Dairy and Soy Amount Calcium (mg) Milk (skim, low fat, whole) 1 cup 300 Buttermilk 1 cup 300 Cottage Cheese 0.5 cup 65 Ice Cream or Ice Milk 0.5 cup 100 Sour Cream, cultured 1 cup 250 Soy Milk, calcium fortified 1 cup 200 to 400 Yogurt 1 cup 450 Yogurt drink 12 oz 300 Carnation Instant Breakfast 1 packet 250 Hot Cocoa, calcium fortified 1 packet 320 Nonfat dry milk powder 5 Tbsp 300 Brie Cheese 1 oz 50 Hard Cheese (cheddar, jack) 1 oz 200 Mozzarella 1 oz 200 Parmesan Cheese 1 Tbsp 70 Swiss or Gruyere 1 oz 270 Tofu, firm, calcium set 4 oz 250 to 750 Tofu, soft regular 4 oz 120 to 390 Vegetables Amount Calcium (mg) Arugula, raw 1 cup 125 Broccoli, cooked 1 cup 180 Chard or Okra, cooked 1 cup 100 Collard greens 1 cup 50 Kale, raw 1 cup 55 Mustard greens 1 cup 40 Other Foods Amount Calcium (mg) Figs, dried, uncooked 1 cup 300 Orange juice, calcium fortified 8 oz 300 Cereals (calcium fortified) 0.5 to 1 cup 250 to 1000 Bread, calcium fortified 1 slice 150 to 200 Oatmeal, instant 1 package 100 to 150 Almonds, toasted unblanched 1 oz. 80 Sesame seeds, whole roasted 1 oz. 280 Mackerel, canned 3 oz. 250 Salmon, canned, with bones 3 oz. 170 to 210 Sardines 3 oz. 370 Molasses, blackstrap 1 Tbsp 135 Developed for MGH Endocrine Associates 2013 Source: USDA