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Osteoporosis By Kimberley Guida, MD Pullman Family Medicine, LLP

Case Presentation Aunt Minnie is a 72 year old white female who lives alone.  She walks 2 miles per day, doesn’t smoke, and has an active social life.  Her sister June has suffered a hip fracture and now lives in a nursing home.  Minnie has rheumatoid arthritis which has mostly affected her hands.  She occasionally needs a short course of steroids to control flare-ups. Other than that, she takes no medications.

Case Presentation Two days ago, Minnie was out grocery shopping. She remembers that her granddaughter Martha told her she should get more calcium in her diet.  She decides to try the calcium-fortified orange juice.  While reaching into the cooler for the juice, which of course, is located on the top shelf in the back, she slips on a wet spot on the floor and falls, breaking her left hip.

What Happens to Minnie? Minnie is admitted to the hospital, where she undergoes surgery to repair her hip.  Her recovery is slow.  She joins her sister in the nursing home for rehabilitation.  Due to terrible pain with walking since the surgery, Minnie stays in her wheelchair much of the day.

What Happens to Minnie? Minnie slowly becomes more forgetful.  She cries much of the time. She has chronic pain and needs to take pain medication frequently.  Her depression worsens when her sister dies of a heart attack.  Need I go on?

What Is Osteoporosis? The word osteoporosis means “porous bone,”  or low bone density. Porous bone is weak bone. Weak/fragile bones  are more likely to fracture. Osteoporosis is a silent disease- many people do not know they have it until they sustain a fracture. Most common fractures occur in the spine, hip, and wrist.

What Is Osteopenia? Osteopenia means less bone mass than normal, but it is not quite “porous” enough to be called osteoporosis Osteopenia, untreated, often becomes osteoporosis over time

Scope of the Problem 28 million Americans have osteoporosis 1 out of 2 white women will suffer from an osteoporotic fracture in their lifetime 1.5 million fractures due to osteoporosis 24% of patients older than 50 will die the year following an osteoporotic fracture Other consequences- depression, physical limitation, chronic pain, poor quality of life

Economic Burden Direct cost of osteoporotic fractures is estimated at 38 million dollars PER DAY 180,000 nursing home admissions/year 432,000 hospitalizations per year 2.5 million physician visits per year

Topics of Discussion Risk factors for osteoporosis Screening for osteoporosis Treatment Prevention

Risk Factors Age over 65 White/Asian race Non-use of HRT Family history of fractures over age 50 Low level of physical activity Low body weight (< 127 lbs)

More Risk Factors Smoking Low calcium intake Medications (steroids, anti-convulsants, lithium, coumadin) Other diseases (RA, multiple myeloma, renal failure, etc) History of fracture with minimal trauma under age 40 Eating disorders

Risks for Falls Poor vision Arthritis Poor strength Poor balance Dementia Obstacles in the home

Prevention of Osteoporosis Nutrition Exercise Consider Hormone Replacement therapy at menopause

Nutrition Calcium intake- 1000-2500 mg/day Vitamin D- 400-600 IU/day to help with absorption of calcium Protein-if you don’t eat enough, your body may leach it out of the bone Avoid excessive coffee intake Avoid heavy alcohol use

Exercise Weight-bearing aerobic exercise Weight training with resistance builds more bone mass Recommend 30 minutes at least 3 times weekly

Screening for Osteoporosis DEXA-Scan- a special x-ray of lumbar spine, wrist, and hip to measure bone density Other bone density devices- heel, finger- 85% correlation with Dexa

Who Should Be Screened? All women age 65 or older Women under age 65 with other risk factors Men with risk factors

What Do the Results Mean? T-score- measures how your bone density compares to young healthy women Z-score- measures how your bone density compares to women your age

What the Numbers Mean Normal bone density = T-score less than or equal to 1 SD below the mean Osteopenia= 1.0 to 2.5 SD’s below the mean Osteoporosis= more than 2.5 SD’s below the mean

Treatment for Osteoporosis Hormone replacement therapy Bisphosphonates SERM’s (raloxifene) Calcitonin Phytoestrogens Anabolic agents (PTH)- still under investigation

Hormone Replacement Therapy Benefits Decreases fracture risk Maintains bone density- prevents the normal decline in bone density that occurs with menopause Decreases flushing, sweats, mood swings associated with menopause Prevents vaginal atrophy Lowers LDL (bad cholesterol) Heart disease?

HRT Side Effects Small increase in risk of breast cancer Increased risk of blood clots Gallbladder disease Breast tenderness Vaginal bleeding Heart disease?

Bisphosphonates Alendronate(Fosamax) and risedronate(Actonel) Increase the bone mineral content of existing bone- they do not help form new bone Proven to decrease fractures at the hip and spine Side effects: heartburn, ulcers, abdominal pain

Raloxifene (Evista) A SERM (selective estrogen receptor modulator), ie a “designer” estrogen Increases bone mineral density and decreases fractures in the first 12-18 months of therapy No vaginal bleeding May CAUSE hot flashes May reduce risk of breast cancer Same risk of blood clots as estrogen

Calcitonin A naturally occurring hormone that regulates calcium in the body. Decreases bone loss at the spine. Helps decrease the pain of vertebral fractures. Two forms- nasal spray and injection.

Phytoestrogens Recent trial showed no benefit for bone density or fracture prevention May help with vasomotor symptoms of menopause

PTH (Parathyroid Hormone) Anabolic agent- actually can help to form new bone, not just increase mineral content of existing bone Still under investigation, but a major new advance for the future

Cost of Preventing Fractures HRT= $25,800 per fracture prevented Raloxifene= $69,400 per fracture prevented Fosamax= $58,000 per fracture prevented

In Summary Osteoporosis is a silent disease that affects a large portion of our population EARLY prevention is the key Start an exercise program Make sure you are getting enough calcium and Vitamin D Talk with your doctor about your risk factors

Thank You For more information on Osteoporosis or to refer back to this presentation, visit our website at www.pullmanfamilymed.com