Osteoporosis – 2010 Guideline CMAJ

Focus on preventing fragility fracture

Osteoporosis – T scoare <= -2.5


Indications for measuring BMD with dual-energy x-ray absorptiometry

  1. Age >= 65
  2. Clinic risk factors for fracture (menopausal women, men 50-64yo)
    1. Fragility # after age 40yr
    2. High risk medications – aromatase inhibitors, androgen deprivation Tx, Prolonged use of glucocorticoids (> 3/12 of >= 7.5mg daily)
    3. Parental hip #
    4. Vertebral # or osteopenia on x-ray
    5. high alcohol intake
    6. Current smoking
    7. low body weight (<60kg) or major wt loss (>10% at 25yo)
    8. RA
    9. Disorders associated with osteoporosis:
  3. Younger adults (<50yo)
    1. Fragility #
    2. High risk medications. eg. Prolonged use of glucocorticoids
    3. Hypogonadism or premature menopause (<45yo)
    4. Malabsorption syndrome or chronic inflammatory conditions
    5. Primary hyperparathyroidism
    6. Other disorders associated with rapid bone loss/#

Recommended biochemical tests for pt being assessed for osteoporosis:

  1. Calcium, corrected for albumin
  2. CBC
  3. Creatinine
  4. Alkaline phosphatase
  5. TSH
  6. SPEP (for pt with vertebral #)
  7. 25-hydroxyvitamin D –
    • measure after 3-4/12 of adequate supplementation.
    • Don’t repeat if an optimal level (>75nmol/L) is achieved.

Vertebral # unrelated to trauma
  1. Defined as vertebral ht loss >=25%. 5x increase in the risk of future vertebral #
  2. Perform lateral T & L spine x-ray or dual-energy x-ray absorptiometry

Assess 10yr # risk – use FRAX

Low <10%, Moderate 10-20%, High >20%

Uses

  1. sex, age, BMI, prior #, parental hip #
  2. Prolonged glucocorticoid use, RA (2o causes of osteoporosis), current smoking, EtOH intake (>= 3unit/day)
  3. Bone mineral density of femoral neck (optional)

Tx
  1. Exercise
    • Weight-bearing, balance & strengthening exercise
  2. Smoking cessation
  3. Fall Prevention
  4. 1200mg Calcium for >50yo
  5. Vit D supplementation
    • 400-1000IU for healthy adult
    • 800-1000IU  for >50yo at moderate risk of Vit D deficiency
    • up to 2000IU is safe

Pharmacologic Tx
  1. High risk pt
  2. >50yo with fragility # of hip or vertebra or >1 fragility #
  3. Mod risk – consider lateral thoracolumar x-ray (T4-L4) or vertebral # assessment & Tx if
    • Additional vertebral fracture(s)
    • Previous wrist # in individuals >65yo
    • T score <-2.5
    • Lumbar spine T score << femoral neck T score
    • rapid bone loss or disorders contribute to bone loss
    • Men undergoing androgen-deprivation Tx for prostate ca
    • Women undergoing aromatase inhibitor Tx for breast Ca
    • Long-term or repeated use of glucocorticoids
    • Recurrent falls (>2 in 12mo)
    • Reassess BMD in 1-3 yr and reassess risk
  4. Low risk – not req, reassess risk in 5yr

Antiresoprtive agents

1st line for vertebral, nonvertebral, and hip # prevention

  1. Bisphosphonates: Alendronate, risedronate, zoledronic acid
    • Men and Women
  2. RANKL inhibitorDenosumab (C/I: hypocalcemia, hypersensitivity, pregnant or nursing)
  3. Hormone therapy – only for menopausal women requiring Tx for vasomotor symptoms as well
    • Second Line – Calcitonin or etidronate
    • Testosterone not recommended

1st line for vertebral # prevention

  1. SERMRaloxifene 

Bone-forming agent 

  1. Teriparatide
    • Calcitonin and Teriparatide reduce the pain associated with vertebra #

S/E
  1. Calcium supplementation
    • renal calculi & CV events
  2. Bisphosphonates (benefits >>>>>>harm)
    • self-limited flu-like symptoms
    • Osteonecrosis of the jaw – (aveolar bone in the mandible or maxilla doesn’t heal after 8 weeks)
      • <1/10000, Increase with
        • XRT, ChemoT
        • high-dose for bone metastases / glucocorticoids,
        • DM, poor dental hygiene or tooth extractions/implants
    • Atypical # of the femur (subtrochanteric / diaphysieal regions)
      • More common in long-term Tx
      • Clean transverse / oblique chalk-like breaks
      • Prodromal thigh or groin pain
    • esophageal ca or A fib – conflicting results
  3. Denosumab
    • cellulitis
  4. Raloxifene & hormone Tx
    • thromboembolic events
  5. Teriparatide
    • hypercalciuria & hypercalcemia

>50yo on Glucocorticoid (>3mo >7.5mg/day)
  1. Tx with Bisphosphonate (alendronate, risedronate, zoledronic acid) at the onset or Teriparatide
  2. second line: calcitoin or etidronate
Women on aromatase inhibitor
  • Tx with Bisphosphonate or denosumab

Monitor:
  • Initially, BMD 1-3 yr after Tx – good response if unchanged or improved
  • If good response, BMD in 5-10yr
  • Ref to specialist if poor response despite good compliance

Reference:

 

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Posted in 69 Osteoporosis, 99 Priority Topics, Endo, FM 99 priority topics

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