Osteoporosis Acove - Medical University of South Carolina

Report
Aging Q3 ACOVE #9
Osteoporosis
Jay Brzezinski, MD
Medical University of South Carolina
2011
Osteoporosis ACOVE Work Group
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Dr. Jay Brzezinski, Chair
Dr. Bill Moran
Dr. Pam Pride
Dr. Leonard Lichtenstein
Dr. Amy Thompson
Dr. Brad Keith
Dr. Lara Hourani
Tamela Sill, RN
Burden
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25 million Americans have osteoporosis
½ of all post-menopausal women will have
an OP related fracture
Up to 20% of hip fracture patients die in one
year
Usually asymptomatic until fracture occurs
BONE
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Trabecular bone
Also called Cancellous bone
Vertebral body bone
Bone near joint lines
Has bone marrow
Light weight
Has spiculated pattern
BONE
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Cortical bone
Compact bone
Long bones
Dense
Stiff
hard
heavy
BONE
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Trabecular bone, 25% replaced per year
Cortical bone, 3% replaced per year
Osteoporosis occurs in both
It makes sense that trabecullar bone
fractures easier?
RISK FACTORS
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Age
Gender
Prior fracture
Family history
Exercise
Smoking
RA
ETOH
Drugs….steroids
NON-RISK FACTORS??
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Obesity?
Athletic childhood?
Osteoarthritis?
Diet??
Family history?
SCREENING( i.e. asymptomatic)
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All women at age 65
Women under 65 with FRAX score >9.3%
9.3% is risk of asymptomatic woman age 65
A previous fracture? We are not screening
now!
How to Screen
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DEXA is best
Heel quantitative ultrasound??
DEXA
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Dual energy x-ray absortiometry
One x-ray beam is absorbed by soft tissue
One x-ray is absorbed by everything
Subtract the two and get bone
Problem with ordering a screening BMD on
PP???
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Diagnosis: “Pre Menopausal”
T-SCORE
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-1.0 or better is normal
Lower than -2.5 is osteoporosis
-1.0 to -2.4 is osteopenia
What if I have had a compression fracture?
What if I had a hip replaced?
FRAX
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www.sheffield.ac.uk/FRAX/tool.jsp
Treatment
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Calcium
Vitamin D
Should I measure
What does it mean
Will replacement help
Exercise??
Bisphosphonates
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alendronate (Fosamax®) 70 mg qweek
Ibandronate (Boniva®) 150 mg qmonth
risedronate (Actonel®) 5 qday,35 qweek, 150
qmonth
Zoledronic acid (Reclast®) qyear IV
Forteo®
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Teriparitide sq qday times 2 years
Risk…osteosarcoma
Used to treat osteoporosis with prior fracture
or high risk who cannot take
bisphosphonates
How long to Treat?
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5 years?
7 years?
Life?
Until BMD better?
Bisphosphonates accumulate in bone and
after stopping leach out over 1-2 years
Expert Opinion
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Mild risk: rx 5 years and follow BMD
High risk: rx 10 years and do 1-2 year drug
holiday
When to rescan
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Normal with no risks: 3-5 year
Risk factors that persist: 2 years
High risk after menopause: 2 years
Treated patients: 2 years than less if
responding
Risks
NNH
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Osteonecrosis of jaw=>60,000 and most
occurred in cancer patients treated with very
high dose zoledronic acid
Atypical femur fracture=? 25,000?
Benefits
NNT
Prior Fracture
No Prior Fracture
Any Fracture = 21
100
Vertebral Fracture = 8
29
Hip Fracture = 35 - 46
4.5 - 66
Other Fracture = 21 - 43
35 – 66
Osteoporosis Blue Sheet
Osteoporosis
Aging Q3 ACOVE # 9
PCT Ask:
PCT
CIRCLE:
MD ACTION:
YES or
NO
1. Have you ever had a DXA scan (bone
density) for osteoporosis?
YES
YES
1a. If YES,
Is the DXA documented in
Practice Partner?
NO
1b. If NO,
Was the patient referred for a
DXA?
2. Was the patient’s risk of fracture
(FRAX) calculated?
3. Did the patient’s FRAX score
influence any clinical decisions in
today’s visit?
4. Have you ever had a fractured bone?
YES
MD
CHECK:
4. If YES,
4a. Did you do a fracture history?
4b. Did the fracture history indicate
any need for change in
medications or further treatment?
NO
If NO – No further action needed
NO
o
s
Osteoporosis Detailing Sheet
Aging Q3
Osteoporosis and Aging
ACOVE #9
An estimated 25million Americans have osteoporosis. It affects elderly people of all races and
ethnicities. 20-25% of persons with a hip fracture are unable to return to independent living
and 12-20% die within 1 year.
Risk Factors
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Screening
DXA for all Women 65+ years
Diagnosis
T-Score
 Osteoporosis
≤ -2.5
 Osteopenia
-1.0 to - 2.4
 Normal
> -1.0
Age
Gender
Previous fracture
Family history
Low BMI
Physical activity
Currently smoking
Rheumatoid arthritis
Alcohol use
Steroid use *
False Positives with Compression
Fractures
*Note: If patient uses >5 mg/day
Prednisone or equivalent
< 3 months: Warning
> 3 months: Rx Bisphosphonate
65+ Female
Fracture
(Major trauma NA)
DXA (Baseline)
No Fracture
DXA and FRAX
Treat
>-1.0 DXA
No Treatment
< -2.5
Treat
-1.0 to - 2.4 DXA
Look for the FRAX at:
http://www.shef.ac.uk/FRAX/tool.jsp?country=9
≥ 3% FRAX (Hip
Fracture)
Treat
≥ 20% FRAX
(Osteoporotic
Related Fracture)
FRAX should not be used with persons on treatment for
osteoporosis.
Treat
Practice Partner Template
Progress Notes
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If patient is age 65 or over and female, has
the patient ever had a DXA scan?
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If patient is 65 or over and female, has the
patient’s risk of fracture (FRAX) been
calculated?
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Does the patient report ever having a
fractured bone?
Osteoporosis ACOVE begins in
clinic Thursday, July 21, 2011
Thanks for supporting Aging Q3

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