Talking to patients with osteoporosis None about initiating therapy - - PowerPoint PPT Presentation

Page 1

Talking to patients with osteoporosis about initiating therapy

Deborah Sellmeyer, MD Professor of Medicine Division of Endocrinology, Gerontology, and Metabolism Stanford University, School of Medicine

Disclosure

• None

General Approach: Assessment of Risk

• H & P

– assess for patient specific risk factors – assess patient preferences – factors that affect medication choices

• Walk the patient through DXA results

– spine – hip – forearm – FRAX

Developing a Plan

• Assess for causes of secondary osteoporosis
• Nutrition

– Calcium – Vitamin D – Protein (0.8g/kg/day) – Overall good nutrition: lean protein/meet goals for fruit and vegetables

• Exercise: weight bearing activity, resistance training,

posture, balance

• Does patient meet guidelines to consider medication

– BMD – bone loss – FRAX – fragility fracture

Page 2 Medication

• Need hip/non-spine protection

– bisphosphonates – denosumab – anabolic

• Risk limited to spine

– calcitonin – raloxifene

• Particularly high risk/fractured on treatment

– teriparatide – abaloparatide – romosozumab

• Glucocorticoids

– bisphosphonate – denosumab – teriparatide

Medication specifics

• calcitonin

– 25%  spine fractures, no data for other fractures – early agent—clinical trials less robust than other

• ptions

– 6% mild nose irritation

• raloxifene

– 35%  spine fractures, does not reduce fx at other sites –  risk invasive breast CA – risk of thrombosis similar to OCP –  risk of death due to stroke in postmenopausal women with CAD – hold for 72 hrs prior to air travel/immobility – hot flashes – need to take continuously; no ONJ or AFF

Medication specifics

• Bisphosphonates

–  fracture risk 50-60% spine, 40-50% hip – Oral

• ~20% of pts UGI side effects
• difficult to absorb: review dosing instructions

– IV

• 25% acute phase reaction after 1st dose
• may be reduced with acetaminophen pre-tx
•  mortality after hip fracture

– Both

• <0.5% risk of ONJ
• 1:30,000 risk atypical fracture with long term treatment
• protection after stopping—medication holidays

Medication specifics

• denosumab

–  fracture risk 60% spine, 40% hip – skin side effects

• rashes, eczema
• <0.5% increased risk of serious skin infections

– UTI risk may be increased – similar risk of rare side effects to bisphosphonates

• <0.5% risk of ONJ
• 1:30,000 risk atypical fracture with long term treatment

– unlike bisphosphonates, rapidly reversible

• need to receive doses on schedule
• need to change to bisphosphonate prior to medication

holiday or use continuous therapy

Page 3 Medication specifics

• teriparatide/abaloparatide

– 70-80% reduction vert fxs – 50% reduction non-vert fxs – side effects: injection site reactions, hypercalcemia/uria, nausea, dizziness

• romosozumab

– 50% (vs. aln) - 70% (vs. pbo) reduction vert fx – 20% reduction non-vert (vs. alendronate) – vascular risk (MI, CVA)

• No difference vs. placebo (0.8% both groups)
• 2.0% romosozumab vs. 1.1% alendronate

– one ONJ and one AFF (n>11,000)

Case #1

• 70 y/o woman, known low bone density for 8 years,

concerned about medication side effects

• No fractures
• No family history of osteoporosis or hip fracture
• + celiac disease, on gluten free diet, + reflux,

constipation

• Consumes 2-3 servings Ca rich food/day
• Walks 10,000 steps/day
• Meds: Vit D 2000 IU, statin, H2 blocker, ASA
• PE: mild thoracic kyphosis

Case #1

• DXA

– Lumbar spine T-score -3.1 – Femoral neck T-score -2.0 – Total hip T-score -1.6 – FRAX hip fracture risk = 1.6%

• Recommendations?

Case #1

• Nutrition:

– Calcium: OK – Vitamin D: OK – Protein: OK – Gluten free: OK

• Physical activity:

– Weight bearing activity: OK – Consider adding resistance activities – Exercise program to reduce kyphosis

• Stand Tall: (415) 514-4816 or wellness@ptrehab.ucsf.edu
• PT referral
• Assess for secondary osteoporosis, ensure TTG IgA low
• Vertebral imaging

Page 4 Case #1: Medication?

• Meets guidelines for pharmacologic therapy based on

lumbar spine T-score of -3.1

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

Case #1: Medication?

• Meets guidelines for pharmacologic therapy based on

lumbar spine T-score of -3.1

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

• Vertebral imaging: no

fractures

• Labs normal, TTG IgA neg
• Added resistance and

posture training

• Raloxifene

Case #2

• 60 y/o woman, low bone density dx 2009
• risedronate 2009-2011, stopped due to concern about side effects
• no fractures
• type 1 DM, insulin pump, A1C 7.8%, + nephropathy
• frequent UTIs, one episode nephrolithiasis
• FH: maternal aunt kyphosis, ? vert fx
• Meds: vitamin D 1000-2000 IU/day, calcium 500 mg bid, insulin,

ACE inhibitor

• 1-2 servings calcium rich food/day
• Body Pump class at gym three times/week
• PE: unremarkable

Case #2

• DXA

– Lumbar spine T-score -0.5 – Femoral neck T-score -2.5 – Total hip T-score -1.9 – FRAX:

• Major osteoporotic fx: 11%
• Hip fx: 2%
• Recommendations?

Page 5 Case #2

• screen for causes of secondary osteoporosis

– urine calcium 172 mg/24 hrs – serum Cr 0.78, eGFR 83 – Ca 9.2, phos 3.7 – PTH 53

• Nutrition:

– calcium: high, decrease suppl to 500 mg/day – vitamin D: OK – protein: OK – glycemic control: review with diabetologist

• Physical activity: consider 30 mins walking on

days not at the gym

Case #2: Medication?

• Meets guidelines for pharmacologic therapy

based on femoral neck T-score of -2.5

• FRAX estimated risk low

– uses femoral neck BMD – does not include DM as a risk factor

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

Case #2: Medication?

• Meets guidelines for pharmacologic therapy

based on femoral neck T-score of -2.5

• FRAX estimated risk low

– uses femoral neck BMD – does not include DM as a risk factor

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

• Increased weight bearing

activity

• Improve glycemic control
• Hold on pharmacologic

therapy for now

• Assess DXA in one year

Case #3

• 88 y/o woman, known low bone density since 2001
• previously tried alendronate and risedronate—

discontinued due to UGI symptoms

• no fractures
• no FH osteoporosis or hip fracture
• PMH: GERD, CAD, HTN, arthritis, glaucoma
• meds: vitamin D 600 IU, calcium 500 mg, MVI, beta

blocker, eye drops

• participates in senior exercise class 2-3x/week
• 1 serving calcium rich food/day
• PE: unremarkable

Page 6 Case #3

• DXA:

– Lumbar spine not available due to DJD – Femoral neck T-score -3.3 – Total hip T-score -2.4 – 1/3 forearm T-score -4.2

• Recommendations?

Case #3

• Nutrition:

– Calcium: prob OK, check calcium content of MVI – Vitamin D: OK – Protein: OK – Review general goals for fruit/veg

• Physical activity:

– Encouraged continued participation in Senior exercise classes – Fall prevention strategies

• Assess for causes of secondary osteoporosis,

particularly PTH given 1/3 forearm BMD

Case #3: Medication?

• Meets guidelines based on femoral neck and 1/3

forearm BMD values

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

Case #3: Medication?

• Meets guidelines based on femoral neck and 1/3

forearm BMD values

• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

• Labs: 25 OH vitamin D 28,

PTH 63

• Increase vitamin D to 1500

IU/day

• Needs agent with both

spine and non-spine/hip protection

• Denosumab—largest effect
• n 1/3 forearm BMD

Page 7 Case #4

• 59 y/o woman, low bone density since 2006
• wrist fracture 2016 with fall from standing height
• hx breast CA, on aromatase inhibitor, 3 more years of tx
• GERD
• vegetarian, consuming 1 serving Ca fortified almond milk, 3-4

servings/day cruciferous vegetables

• +FH osteoporosis: mother, no fractures
• Meds: vitamin D 2000 IU, calcium 500 mg, aromatase inhibitor, H2

blocker

• Torn meniscus—limited weight bearing activity
• Tooth being watched, may need procedure/extraction
• PE: unremarkable

Case #4

• DXA:

– lumbar spine T-score -2.1 ( 6% over 2 years) – femoral neck T-score -2.8 ( 8% over 2 years) – total hip T-score -2.2 ( 8% over 2 years)

• Recommendations?

Case #4

• Nutrition:

– Calcium: OK – Vitamin D: OK – Protein: low—recommended increased protein to meet RDA of 0.8 g/kg/day – Vegetarian/vegan: ensure B12 adequate

• Physical activity: limited at present, recommended walking

program and resistance exercises as able

• Assess for causes of secondary osteoporosis, B12 level,

24 hour urine calcium, PTH

• Follow up with dentist regarding need for dental work

Case #4: Medication?

• Meets guidelines for pharmacotherapy by BMD, also

has ongoing bone loss

• Needs to continue aromatase inhibitor
• Possible dental procedure
• GERD
• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

Page 8 Case #4: Medication?

• Meets guidelines for pharmacotherapy by BMD, also

has ongoing bone loss

• Needs to continue aromatase inhibitor
• Possible dental procedure
• GERD
• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

• Dental: no immediate

procedure, but prob w/i 6-12 months

• Oral vs. IV bisphosphonate
• IV ibandronate

Case #5

• 54 y/o woman, low bone density on screening DXA 2019
• bilateral cuboid fractures, hiking out of Grand Canyon 2016
• PMH: lactose intolerance, migraines
• Menarche age 16, amenorrhea for two years in HS while

running cross country, min weight 100 lbs (BMI 18.9), no disordered eating, purging

• meds: vitamin D 5000 IU/day, calcium 600 mg twice/day,

eletriptan

• FH: mother with osteoporosis, wrist, hip fractures
• PE: BMI 19.8, unremarkable

Case #5

• DXA

– Lumbar spine: T-score - 3.9 – Femoral neck: T-score - 3.8 – Total hip: T-score - 3.7

• Recommendations?

Case #5

• Nutrition:

– Calcium: OK – Vitamin D: prob OK, check level – Protein: OK – Review general recommendations for fruit/veg – Review energy intake goals/healthy weight

• Physical activity: walking program, resistance exercises

as tolerated

• Assess for causes of secondary osteoporosis

Page 9 Case #5: Medication?

• Meets criteria for medication based on osteoporosis
• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

Case #5: Medication?

• Meets criteria for medication based on osteoporosis
• Options:

– calcitonin – raloxifene – oral bisphosphonate – IV bisphosphonate – denosumab – anabolic

• Needs agent with both spine and non-

spine/hip protection

• Eval for secondary osteoporosis neg
• Strong family history osteoporosis
• No CV risk factors
• Anabolic: romosozumab

Questions?