Osteoporosis – 2010 Guideline CMAJ

Focus on preventing fragility fracture

Osteoporosis – T scoare <= -2.5

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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/#

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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.

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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

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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)

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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

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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

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Antiresoprtive agents

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

1. Bisphosphonates: Alendronate, risedronate, zoledronic acid
   • Men and Women
2. RANKL inhibitor – Denosumab (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. SERM –Raloxifene 

Bone-forming agent 

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

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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

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>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

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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

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Reference:

• http://www.cmaj.ca/content/early/2010/10/12/cmaj.100771.full.pdf+html?ijkey=edc6c6048e7d4acdc41368fe3f1e622bf5a2deac&keytype2=tf_ipsecsha