Osteoporosis Update

the Sam Andros Stein Institute for research on Aging is committed to advancing lifelong health and well-being through research professional training patient care and community service as a nonprofit organization at the University of California San Diego School of Medicine our research and educational outreach activities are made possible by the generosity of private donors it is our vision that successful aging will be an achievable goal for everyone to learn more please visit our website at aging dot UCSD edu [Music] so good evening again welcome back we are delighted to have all of you here tonight for our excellent lecture where dr. Gina Gina woods she's an associate professor of endocrinology and metabolism here at UC San Diego and bone health specialist she conducts research on bone marrow adiposity and its effects on skeletal health her own interest include calcium and vitamin D topics of which she has lectured at professional conferences she completed her residency in internal medicine and clinical and research fellowships and endocrinology at UC San Diego School of Medicine and earned her medical degree from Drexel University College of Medicine in Philadelphia she's board-certified in internal medicine endocrinology diabetes and metabolism please join me in welcoming dr. Gina woods Thank You Danielle it's a pleasure to be here this evening I have no disclosures really none so the objectives of the talk this evening are to understand what is osteoporosis but also to review normal age-related skeletal changes because these two are not one in the same well then talk about how to evaluate your fracture risk we'll talk about medical mindsets and approaches to osteoporosis prevention and treatment osteoporosis literally means porous bone it's a skeletal disease of compromised bone strength predisposing to fractures bone strength is a function of both bone density which can be easily measured and bone quality which is less completely understood and more difficult to ascertain but we know that bone strength depends upon geometry the size and shape of the bone the microarchitecture so you can see here these are called trabecular plates and rods so the architecture of the bone determines its strength and the rate of turnover so we tend to think of our skeleton as a fixed structure but actually we are building bone and breaking down bone throughout our entire life and in during adulthood 10% of our skeleton is remodeled each year and the rate of this turnover could influence bones strength and there are other factors that are not completely understood at this time but our active areas of research investigation osteoporosis has no symptoms unless a fragility fracture occurs and we define a fragility fracture as one which occurs with low trauma resulting from a standing height fall or less so slipping in the bathroom should not normally result in a fracture and if it does we would consider that to be a fragility fracture the three most common osteoporotic fractures are fractures of the spine hip and wrist so you can see a vertebral or spine fracture here these can present with sudden back pain with bending or lifting but they can also be asymptomatic and are sometimes diagnosed incidentally on an x-ray that was done for another purpose hip fractures are them have the most morbidity and mortality associated with them they almost always require surgery and individuals often don't recover their previous level of functioning after a hip fracture and wrist fractures are also common they usually result from a fall onto an outstretched hand other fractures that are commonly associated with osteoporosis include fractures of the upper arm her humerus the lower leg ribs and pelvis there are a few fractures that are generally not considered to be osteoporotic fractures and those include fractures of the fingers and toes and of the skull bones the consequences of fracture can include pain disability increased healthcare costs the need for rehabilitation or nursing care and fear or anxiety of a subsequent fracture or loss of Independence there are two ways to make the diagnosis of osteoporosis one is with the presence of a fragility fracture so if a fragile D fracture occurs we know the bone is weaker than it should be so regardless of the bone density that is a diagnosis of osteoporosis the other way to diagnose it is on a bone density scan which we will talk about more when we talk about assessing fracture risk so now we're going to briefly review what we know about normal musculoskeletal changes with aging and healthy adults this graph shows bone mass on the y-axis against age on the x-axis and we can see that when we're young we're building in a crewing bone bone mass Peaks between about the age of 20 and 30 and men achieve a higher peak bone mass than women bone mass is pretty stable in early adulthood particularly in women during the reproductive years but then it takes a steep decline around the time of menopause and there's a slow steady bone loss afterwards whereas in men it's more of a slow steady loss throughout throughout adult life and where our bone mass it ends up in our later years depends both on how much peak bone mass we acquire in our youth and the rate of bone loss with aging so a number of factors can influence peak bone mass there are genetic determinants there are ethnic differences and environmental factors are also important so physical activity and nutrition during childhood can play a role and the presence of childhood diseases or medications can impact peak bone mass acquisition factors contributing to bone loss are the main two are aging and sex steroid deficiency so the loss of estrogen and testosterone with aging contribute to bone loss there are probably other factors that are not completely understood and this is another area of active research investigation this data comes from a study out of Denmark where they looked at bone mass against age in healthy men and women who were not taking any medications for osteoporosis and this shows bone density as a function of age in women at four sites the circles represent pre menopausal women and the triangles are postmenopausal women so we can see that in premenopausal women bone mass is pretty stable the only site that showed any decline was the hip but after menopause there's a steady decline with age and in men there was more of a slow steady throughout life between the ages of 20 and 80 and when they compared the men and the women in this study the authors concluded that the overall percentage of bone loss was pretty similar in men and women at all of the different sites except for the forearm where women lost 50% more bone than the men this study looked a little more in depth at the rate of bone loss in women who were not taking bone bone medications so points along this dotted line indicate stable bone density so you can see in the 20s women are actually gaining bone density then it stays stable during pre menopause until around the age of 40 where it starts to decline the most rapid bone loss occurs during the menopause transition between the age of 45 and 60 and in postmenopausal life the rate of bone loss slows but there is still a steady bone loss this is another Scandinavian study I believe this one was from Sweden and they looked at the change in bone density muscle strength balance and gait speed in healthy adults men and women and they measured these four variables at two time points separated by ten years so I know this is a there's a lot of information on this slide I'll try to walk you through it here are the men and the women and they broke them into age groups between the age of 40 to 60 60 to 70 and 70 and older we can see that there was a loss of bone density and muscle strength during all three of these intervals so between age 50 and 60 both men and women were losing bone density and muscle strength and this loss continued throughout subsequent decades balance remained intact during the 50 to 60 timeframe but after age 60 we started to see balance declining and that continued into the 70s and gait speed was maintained in the 50 to 60 range 60 to 70 but over h7d gait velocity also did slow down so we talked about the definition of osteoporosis and we reviewed normal changes in bone and muscle and balance with aging so how do we assess our own fracture risk there are a number of tools we can use including clinical risk factors bone density or Dex's scanning something called TBS which is newer technology and the fracks which is an online fracture risk calculator the two strongest clinical risk factors for fracture are advancing age and having had a previous fracture beyond those two there are other factors that are important like the use of steroid medications for example prednisone having a parent who broke a hip is a risk factor having a low body weight less than 127 pounds current smoking or excessive alcohol intake which is considered greater than two drinks daily so two two or fewer drinks per day was not associated with increased fracture risk but intake above that was associated with greater fracture risk and that's independent of bone density the next tool is a DEXA or bone density scan this is there's two companies that make DEXA scans this is a whole logic there's there's also GE makes Texas scans but they're basically low radiation dose x-rays of the lower spine and hip sometimes of the wrist so who should be screened with a DEXA scan it depends in part upon who you ask so there are a number of medical societies that all have guidelines about screening bone density scans and they all are a little bit different but most experts would agree that most that all women should be screened starting at age 65 the experts disagree on whether or not men should be routinely screened some say men should be routinely screened starting at age 70 other groups say only men with risk factors but most agree that younger postmenopausal women and men over the age of 50 who have any of the following should be screened and these include radiographic osteopenia which means that you may get an x-ray for another and the radiologists comments that the bones appeared demineralized anyone with a low trauma fracture as I told you before that's a fracture occurring from a standing height fall or or less anyone who has lost more than one and a half inches from their peak adult height or who has any of the clinical risk factors that we previously reviewed this is a sample of a bone density report you can see there are images of the lumbar spine a 1 through 4 and the hip so the spine can be problematic for bone densities scanning a lot of us have arthritis in the spine and this can artificially elevate the bone density reading and occasionally can make the image uninterpretable on the DEXA scan and in that case we may need to get a image of the wrist and you'll see on your bone density report there are two scores the T score and the z score so the T score compares your bone density to the to a normal healthy young Caucasian female reference database and the T score is the number of standee standard deviations difference between your bone density and that reference database the z score compares your bone density to your peers so a reference database that's matched to you for age gender and race or ethnicity we make the diagnosis of osteoporosis based on the T score so a T score of minus 1 or higher is normal if it's between minus 1 and minus 2.5 that's called osteopenia or low bone mass and a T score of minus 2.5 or lower is considered osteoporosis severe osteoporosis is when the T score is minus 2.5 or lower and there has been a prior fragility fracture how frequently to get these bone density scans depends in part upon what your first scan shows so this data comes from a study called the study of osteoporotic fractures they enrolled over 9,000 women across the u.s. at four different sites and followed them for many years so you can see this data goes out to 18 years and in this particular study they were looking to see how long it would take for women who had normal bone mass or voseo Pinilla to develop osteoporosis and they determined that if the initial bone density scan showed normal bone density or mild osteopenia it takes quite a while so this hash the line here represents the point at which 10% of the group develops osteoporosis so those who started with normal bone density or mild osteopenia took about 17 years for 10% of that group to develop osteoporosis those who had moderate osteopenia it took about five years for 10% of them to develop osteoporosis but if you had advanced osteopenia a t-score between minus two and minus two point four nine it only took about one year for 10% of that group to develop osteoporosis so based on this data the authors of that study suggests that the repeat screening interval should depend upon your initial bone density score ranging from two years for those with more advanced osteopenia to up to ten to fifteen years if you're starting out with normal bone density or only mild osteopenia now if your initial scan shows osteoporosis that's a different story then we would suggest repeating the bone density at the soonest interval where we would expect to see a change so typically that's two years but if we're starting a treatment where we may see a change sooner it may be repeated after as little as one year the next tool we have is the fraks and I should mention that although we know that bone density screening is a very good predictor of fracture risk it does turn out that the majority of people who have osteoporotic fractures don't have osteoporosis on their bone density scan they have osteopenia and the reason for this is because so many more people fall into that osteopenia group it's a much larger group so the majority of fractures occur in that group so there's been a lot of interest in trying to determine how do we figure out who that has osteopenia is most likely to fracture so dr. John canis developed this fracture risk assessment tool he used cohorts from Europe North America Asia and Australia and it's been well validated in all these different populations and this is a free online calculator you can just Google fracks and you can't calculate your own frac score so you it asks you your country and your race your age sex weight and height and a number of questions including your bone density you can use this tool even if you don't have a bone density reading if you leave this blank it will still calculate a risk for you and and those that risk has been validated to be pretty accurate even without the bone density reading so then when you hit the calculate button it gives you two numbers a 10-year risk of having any major osteoporotic fracture and a 10-year risk for hip fracture so in this example those numbers are 21 and 6.2 percent so the experts recommend that we would treat someone who has a 10-year risk of at least 20% for major osteoporotic fracture or 3% for hip fracture and I should also mention that fracks is designed for patients with osteopenia so it is not intended for people who already have osteoporosis based on their bone density because we would already recommend treatment for those people also this is not recommended if you are on a medication for osteoporosis because the medications will reduce the fracture risk so the numbers that fracks gives you will be higher than the true risk because the medications reduce that risk even more so than what you would expect from the change in bone density you'll notice at the bottom it says if you have a TBS value click here so this takes us to our next topic which is the trabecular bone score so I told you that the spine can be problematic on DEXA scan because of the arthritis changes that can affect the reading so there was interest in trying to overcome this and out of that interest grew this trabecular bone score so it's a software package that analyzes the bone density images so it doesn't require any additional images and it looks at the pixelation and it gives you a score higher score means a healthier bone so you can see in this example this bone appears healthier and has a greater TBS score than this bone here which it this is considered a more degraded reading and would indicate a higher fracture risk so the TBS score is a good predictor of fracture fracture risk independent of bone density but if you use both your bone density reading and your to be a score that's the best way we think to predict fracture risk so we talked about osteoporosis what it is how to assess your fracture risk but before I go into the specifics of the treatments for osteoporosis I want to take a minute to talk about medical mindsets so I recently read this book by doctors Jerome groopman and Pamela Hart's band they're a husband-and-wife team from Harvard and they wrote this book called your medical mind how to decide what is right for you they interviewed many patients about their approaches to medical decision making and they came up with these six medical mindsets so I'm going to apply their algorithm to an example of osteoporosis so you can imagine that you have a bone density scan and your doctor tells you that your bone density is low and you have osteoporosis and it's time for medication so there may be some people out there who feel that they want to be proactive and do everything possible and more to achieve the perfect bone density reading whereas there may be other people who say well my bone density doesn't need to be absolutely perfect and I would prefer to be on the minimum number of medications possible so they refer to these mindsets as the maximalist or the minimalist then when you're offered a treatment there may be some people out there who would be more drawn to natural approaches letting the body heal itself or using treatments that are derived from nature whereas other people may be drawn toward the latest scientific advances so they refer to these as having a naturalism orientation or a technology orientation and when it's time to start taking a medication some people may undertake the treatment confident that they're on the right path whereas others may be more concerned read the package insert worried about all the side effects and wonder if they should really take the medication so they refer to these as believers or doubters so this is a interesting way to think about where you fall in these mindsets and maybe even a good conversation to have with your physician who has his or her own mindsets as well so now that we've talked about mindsets we can talk about the different options for approaching osteoporosis prevention and treatment the first thing I evaluate when assessing a patient for osteoporosis is nutrition so we want to make sure that the diet has adequate calorie and nutrient intake some older adults can be prone to weight loss and when we lose weight unfortunately we lose the things that we want to hold on to like bones and muscles and so making sure that we're getting enough calories protein and a variety of healthy foods particularly fruits and vegetables and then calcium and vitamin D are particularly of interest for bone health so we'll talk a little more about those so the current recommendations are for 1200 milligrams of calcium daily dietary sources are preferred rather than calcium supplements the reason for this is that we know that calcium supplements increase the risk for kidney stones and there have been some research groups that have reported that calcium supplements may increase the risk for cardiovascular events now that has not been shown in every study and it remains controversial but since it's out there we say we prefer dietary sources if possible luckily calcium comes in a lot of different foods and if you're getting at least one calcium rich food with each meal you're probably on the right track there are online calculators through the National Osteoporosis foundation to assess your daily intake and try to figure out if you're getting enough calcium through food vitamin D comes in two forms vitamin d2 is orgo Calcifer oh that's the kind that plants make and d3 is cholecalciferol that's the kind that comes from animal sources and the kind that we make in our skin when we're exposed to UVB radiation vitamin d3 is also available as an over-the-counter supplement whereas d2 is a prescription medication and d3 is found in a number of foods like salmon egg yolks and it's added to cereals and milk a number of factors can affect our skin's ability to produce vitamin G and these include our latitude the season of the year our skin tone the use of sunscreen and aging and unfortunately our skin becomes less efficient at producing vitamin D as we age the recommended intake of vitamin D again varies depending on who you ask the Institute of Medicine says between six and eight hundred international units a day is recommended other groups suggest more like The Endocrine Society says 1500 to 2000 international units per day the safe upper limit most people agree on 4000 as a safe upper limit The Endocrine Society has listed 10,000 but they've come under some scrutiny because there's been a study that shows that high intake of vitamin D does increase the risk for high calcium in the urine which could predispose to kidney stones so they now suggest that between four and ten thousand international units a day should be taken under medical supervision vitamin D is generally very safe minimal side effects it's hard to become developed vitamin D toxicity but the risk of taking too much could include high blood calcium or kidney stones the next thing we assess is physical activity we know that exercise weight-bearing exercise prevents or reverses bone loss by almost one percent per year and in this particular study they did not find a difference between aerobic weight-bearing exercise and muscle strength training exercise both were beneficial we also know that balance training may reduce Falls in particular there's good evidence for Tai Chi for falls prevention and preventing Falls obviously will help to prevent fractures there are a few exercises one might want to avoid if we have osteoporosis particularly osteoporosis in the spine we want to avoid forward spine movements like abdominal crunches because these can put pressure on the anterior spine and increase the risk for vertebral fractures so rather than doing situps you could consider doing something like a plank which also engages the core abdominal muscles but without putting any pressure on the spine Yoga has become very popular and can be part of a healthy lifestyle and can help balance however there was a recent case series out of the Mayo Clinic that showed a number of patients coming in with vertebral fractures that occurred during yoga so the experts who published this article suggest that poses to avoid if one has spine osteoporosis are ones that would involve a lot of flexion extension or torsion of the spine so you want to avoid those poses there on the left but the ones on the right are fine so anything where your spine is in a nice straight neutral position would be okay so the next step in osteoporosis prevention and treatment may involve getting a medical evaluation by your primary care physician or an osteoporosis specialist you this would include having your medical history reviewed and particularly with attention toward medical conditions or medications that may be associated with bone loss reviewing your family history performing an exam and in certain cases doing lab work to look for underlying causes of bone loss well now go into the section on osteoporosis medications and there's basically four classes the bisphosphonates rank ligand inhibitor there's only one in this class to Nasim AB anabolic agents there are two in this class and then the selected selective estrogen receptor modulators but before we talk about each of these drugs we're gonna just briefly talk about the bone remodeling cycle because this gives us a framework for understanding how these medications are working so this cell right here is called an osteoclast and its job is to resorb the bone so I told you that we're always building bone and breaking down bone throughout life this is the cell that breaks down bone and you can see it has this ruffled border it binds to the bone and releases enzymes that actually dissolve the bone releasing calcium into the bloodstream and it creates this little resorption pit and then the osteoblast is this cell here which comes along behind and lays down new bone initially it's protein mainly collagen which then becomes mineralized in new bone forms and these cells communicate with each other and this these activities usually go together it's coupled and it's called the bone remodeling cycle so the bisphosphonates inhibit bone breakdown they bind to the bone and are taken up by that osteoclast and they inhibit its ability to break down the bone they do have a long half-life so they they bind to the bone get taken up by this osteoclast and then are released and recycled within the bone so this long half-life can be a good thing or a bad thing depending on how you look at it and this class of medication has been on the market since the 1990s they've been around a long time there are a number of medicines within this class alendronate or Fosamax resonate or actonel i bandra nate or boniva and zoledronic acid which is reclass this one is an intravenous medication as a class these medications reduce hip and spine fractures overall by about 50% you can see the numbers ranging between maybe 40% and 70% for the different medications at the different different sites with one exception and that is that I Bandra Nate did not show a reduction in hip fracture risk this is a study that was just in the news about a week or so ago you may have heard about this it got a lot of coverage so this is looking at one of the bisphosphonates solid Ronnie or reclassed and the study was done in Australia and New Zealand and they gave Zola Johnny two women 65 or older who had osteopenia not osteoporosis and they wanted to see if this medication would prevent fractures and they gave four doses over six years so it was a dose every 18 months to half the women and the other half received saline infusions or placebo they found that reclassed improved bone density in the women who received the medication so bone density increased in the spine hip and total body compared to the women who received placebo where bone density declined and in on this graph you'll see the group who got the tree active treatment solid Ronnie are in blue the placebo group in red and these represent fracture rates so the fracture risk was reduced with the treatment in any fragility fracture non vertebral fracture and symptomatic fracture they were all reduced as was change in height so the women who received the zoledronic had less height loss compared to those who received placebo so this was an important study because previously this is a group of women that were where treatment would not necessarily have been recommended those in the osteopenia range but this study does show that these women may benefit and so we'll have to see how much practice patterns change based on this data so like all medications the bisphosphonates do have risks the IV zoledronic that we just discussed can cause an acute phase response which basically means flu-like symptoms for a few days following the infusion and this happens in one out of three patients usually after the first infusion if it doesn't happen with the first dose it's unlikely to happen with subsequent doses this these symptoms can be improved with tylenol and they usually don't last more than a few days but it is definitely a risk the oral forms can cause some GI upset but this can be reduced by taking the medication as directed which means taking it on an empty stomach with a full glass of water and then waiting 30 to 60 minutes before eating or taking other medications and you have to remain upright seated or standing during that time in frequently we see mild hypocalcemia and muscle pain with these medications and very rarely we see atypical femur fractures and osteonecrosis of the jaw but because these two are much feared and discussed I will go into these in a little more detail so atypical femur fractures are low tamo fractures of the mid shaft of the femur and they have a certain characteristic radiographic appearance they can be bilateral and they're usually associated with long term bisphosphonate use so most people who have had these fractures have been on the medication for over five years the estimated incidence ranges depending on which study you read from between one and one to five and 10,000 bisphosphonate users so they are very rare but they are much feared by patients and physicians because here we're giving a medication to prevent fracture and this different type of fracture is a possible risk so it is a big concern so this chart gives us some numbers doctors like to think in terms of numbers needed to treat or numbers needed to harm so this graph says that if we treated postmenopausal women for three years with a bisphosphonate how many women would we need to treat to prevent one fracture and how many women would we need to treat to cause one of these bad outcomes like an atypical fracture so the number needed to treat says that if we treated 14 women for three years we could prevent one vertebral fracture if we treated ninety women for three years we could prevent one hip fracture and if we treated 35 women for three years we could prevent any non vertebral fracture conversely we talked about the number needed to harm so if we and this depends upon as I mentioned there's various studies that give different estimates to the incidence of these atypical femur fractures so depending on what number you use to assess the risk we would have to treat between eight hundred and forty three thousand women for three years before we caused one atypical femur fracture so that can give you a sense of how the numbers play out there so because of this risk of atypical femur fractures we now limit the duration of treatment with bisphosphonates so we treat for a period of time and then we give a drug holiday so we think ten years is safe for most patients based on the studies that have been done but we individualize this based on the person's fracture risk so for those at lower risk of fracture we now tend to treat for between three and five years and then give a drug holiday however if someone is at very high risk for an osteoporosis related fracture we may consider recommending treatment for up to 10 years before we take a drug holiday the next side effect that will discuss is osteonecrosis of the jaw this is an exposed bone in the mouth that does not heal within eight weeks [Applause] it is estimated to occur in less than one out of 10,000 bisphosphonate users and many of the cases that have been reported were with the IV bisphosphonates that were given to patients that were receiving the medication for cancers that may have affected the bone so it's a different patient population and that the medication is given at a monthly interval instead of yearly so it's a little bit different in that situation but for osteoporosis treatment it seems to be very very rare but I will say that we often as asked about any plans for upcoming dental work and if they're because that could be a risk for this to occur so if there's a dental procedure planned we may hold off on treating the osteoporosis until after any kind of oral surgery is completed okay so now we're going to move to the next class of medication the rank ligand inhibitor denosumab or Prolia this is also an anti resorted agent so it acts on the osteoclast to inhibit this cells activity so that is acting similar to the bisphosphonates but by a different mechanism it's given as a twice-yearly subcutaneous injection and it's very potent at inhibiting bone resorption the freedom trial showed that denosumab reduces vertebral fractures by 68% non vertebral fractures by 20% and hip fractures by forty percent in postmenopausal women who are at high risk for fracture Dena Cemal also has some potential risks so atypical femur fractures and osteonecrosis of the jaw have also been seen with this medication skin infections were reported and hypocalcemia which can be severe so I didn't mention that the bisphosphonates are contraindicated in individuals with severe kidney impairment but Dena Sam AB is not soda Nasim AB is not cleared by the kidney and it is approved for use in those with kidney problems however in in that patient group in particular we monitor closely for hypocalcemia and the main difference to be aware of is that whereas with the bisphosphonates that have a long half-life we treat and then we give a drug holiday it's an awesome app there's no drug holiday it's very potent when it's active for six months but at the end of that six months the effect quickly wears off and so if one were to stop taking Dennis emmab we would want to do something else to protect the bones from from bone loss and fracture the next class we'll talk about are the anabolic agents and there are two medications in this class the first is teriparatide or Forteo this is an anabolic agent that stimulates the osteoblasts the cell that builds new bone so it increases bone formation it's given as a daily sub self-injection so it comes in a pen and patients give this to themselves every day at home as an injection we've learned that if it's used after an anti resorb t'v so if you take Fosamax first and then you switch to teriparatide the effects of teriparatide are slightly blunted so they're now the recommended the recommended way to do it would be to give the anabolic agent first and then follow it up with the anti resort of because similar to denosumab the effects of this medication wear off very quickly after you stop taking the medication teriparatide was shown to reduce 40 vertebral fractures by 65% and non vertebral fractures by 35 percent the risks include so there is a black box warning on this medication because in lab rats that were given about 30 times greater dose than we give to humans some of the rats developed osteosarcoma which is a type of bone tumor so because of that the FDA limits the duration of treatment to two years also this medication is contraindicated in anyone who's had prior radiation to the skeleton so radiation treatments for cancer that involved exposing the skeleton to radiation would be a contraindication for use of this medication and infrequently hypercalcemia has been reported the next anabolic agent is called a bala para tide or Tim loss it acts on the same receptor as teriparatide and this is the active trial which actually was a placebo controlled trial where they gave postmenopausal women either placebo or a Bala pair tied but then they also gave a group open-label teriparatide and it turns out there these two groups were very similar so teriparatide in a Bala pair tied were very similar in preventing fractures so they gave this part of the study lasted 18 months the placebo versus a Bala pair tied and then at the end of the 18 months they gave both groups alendronate and they found that during the first 18 months there was an 86 percent relative risk reduction in vertebral fractures in those who received below para tied and then this shows the part of the the two years of the study where both groups are now receiving alendronate and you can see the risk reduction was maintained so this also supports that we like to give the anabolic agent first and then follow it up with the anti resorbed of agent the risks of a below pair tied are similar to teriparatide we think but this medication was just approved last April so we don't have as much real-world experience it does have the same two-year limit and actually that applies to both drugs so if you've already had two years of teriparatide you would not be a candidate for a Bella pair time because of the same issue with the osteosarcoma in rats the next group that will discuss is estrogen and the selective estrogen receptor modulators so we know that estrogen inhibits bone resorption and maintains bone formation and in the Women's Health Initiative study that came out in 2002 we saw that estrogen reduced hip and spine fractures by 34 percent however estrogen is no longer recommended for the primary use of osteoporosis treatment due to the non skeletal risks which include breast cancer coronary events strokes and blood clots however estrogen is still used sometimes to treat menopausal symptoms in younger postmenopausal women so if if a woman is taking estrogen for menopausal symptoms she would be getting a benefit on her bones and may not require any additional treatment for osteoporosis raloxifene or Avista is a selective estrogen receptor modulator it has estrogen like activity in the bone but acts as an anti estrogen and other tissues like the breast raloxifene is approved for osteoporosis treatment there isn't one other drug it's conjugated estrogen plus Vasa Docs Athene that's a different selective estrogen receptor modulator this medicine is called do Ave and it's FDA approved for the treatment of menopausal symptoms and osteoporosis prevention it is not approved for osteoporosis treatment relaxed afine reduced vertebral fractures by 30 percent it comes in two convenient once-daily oral dosing and there's no limit on the duration of treatment and it's sort of in the same general family with tamoxifen although it's it's a different medication but raloxifene was looked at for breast cancer prevention in women who were at high risk for breast cancer and it did show that it decreased the risk of breast cancer in those women side-effects include hot flashes leg cramps and venous thromboembolism with rates similar to estrogen so if 170 women are treated with raloxifene one may develop a blood clot as a side effect so this table summarizes all of the available medications that are currently fda-approved for osteoporosis actually estrogen is not fda-approved for osteoporosis but this shows currently available medications there are additional medications in clinical trials so there may be more on this list in the very near future so that's something to look forward to so what approach is right for you for osteoporosis prevention and treatment the choice depends it depends upon your individual risk factors and also on your personal beliefs and medical mindset so with that I will thank you for your attention I'll be happy to take any questions yes yeah so the question was about infusion I'm assuming you mean a reclassed infusion zoledronic infusion yeah that's solid Ronnie so that yeah that's the one that the recent study last week came out showing benefits on fracture risk reduction prevention of height loss it it is effective for preventing fractures and preserving bone density you know there are risks as we reviewed so I guess it depends on if you're a believer or doubter sure here I can its vol ii dr o n8 ee sure yes yes so when you get a bone density scan they'll do your hip and your spine and at the hip they give two measurements one is femoral neck and one is total hip so yes you're very observant on fracks it asks specifically for the femoral neck bone density so if you have that information you can add it to fracks yes good question I know so many of the studies just enrolled women because fractures are more common in women but osteoporosis is a big problem for men as well I guess I would say that so the teeth score that you get even for men compares you to a female reference database so the T score is the number of standard deviations difference between your bone density and a thirty-year-old Caucasian female reference database and the reason we compare men to women is because men and women fracture at the same absolute bone density so men tend to have higher bone density but if their bone density is as low as a woman it would be they would have the same T score so the treatment is recommended based on the absolute bone density and the risk of fracture at that level one thing to note is the Ballou parrot ID the one that was just approved last year is currently not approved in men it's just approved in women and then the selective estrogen receptor modulators are approved in women but the other medications are approved in men the bisphosphonates and de Nasim AB and Forteo so fractured ad incidence of fracture so this the statistic is that one in two women over the age of fifty will develop a fracture in their remaining lifetime and one in four men so it's more common in women but affects a lot of men as well and yeah so and the screening guidelines would be for men starting at age 70 a lot of experts recommend routine screening at age 70 or earlier if there are additional risk factors yes sure any other questions yes so I frequently get asked about other supplements k2 or on other micronutrient supplements I would say there is evidence that some of those micronutrients are important for bone health however physicians like myself included tend to be reluctant to recommend those supplements because we just don't have the same studies that show that they prevent fractures so we don't have the same data for safety and efficacy so I prefer to recommend a healthy balanced diet and trying to get all of those micronutrients from food yes okay good question if you show no improvement in bone density with alendronate so even if your bone density stays stable we still know that fracture risk is reduced so some of the medications have a more dramatic effect on the bone density measurement than others but particularly some of the bisphosphonates even if the bone density stays stable fracture risk is reduced and you know you're not the you're not developing the age-related loss that would have maybe have otherwise occurred if you're on treatment and the bone density continues to decline then we may wonder if the medication is really getting in so Fosamax in particular may not be getting absorbed well and then maybe we would consider a different medication so the question was about ten years of fosamax with no improvement in bone density I would it would be hard for me without knowing the full medical history to really make a recommendation but I would say you know again this is where you have to individualize the treatment decision review the medical history have there been any fractures if not and everything else you know the person is otherwise healthy you know maybe take a drug holiday but that would have to be I would have to kind of do a full evaluation to make a firm recommendation yes so it slows them down too the question was what does what do the bisphosphonates do to the osteoblasts so as I showed you those cells communicate with each other and the when the activity of one is increased the activity of the other tends to be increased and vice versa so it basically kind of quiets down that bone turnover so the osteoblasts activity is also reduced and this can be measured with there's something called bone turnover markers so their blood tests that assess the activity of those cells and we know when people are on treatment that the the activity of both are suppressed yes good question question is about fracture healing with bisphosphonates there has been concerned about this and in particular in patients who come in with an osteoporosis fracture there was a question about should we initiate a bisphosphonate right away or wait and let the fracture heal the data suggests that there's no detrimental effect of putting someone on a bisphosphonate within a short timeframe after a fracture there is interest in looking at the anabolic agents the one that stimulate new bone to see if they promote fracture healing there's pretty good data in animals that that's the case the data in humans is less clear but there are people looking at that yes teriparatide possibly I mean that would be something to consider like I said if I think I would want to use an anabolic agent at any point we prefer to use it before the anti resort of because that seems to be the best sequence to do things in yes so I personally first question was about a website I don't have a website myself UCSD endocrinology we have a section on there about our osteoporosis clinic and the providers that see patients I do see patients in the Hillcrest clinic and La Jolla Clinic for osteoporosis so yes yes that's a good question I don't know I don't think so it's you know the older we get the higher the risk but it doesn't mean everyone is definitely going to get it no all right well thank you again [Applause] [Music] [Music]

Channel: University of California Television (UCTV)

Views: 63,966

Rating: 4.7711563 out of 5

Keywords: osteoporosis, bones, bone health

Id: IZYm8TfY7Ts

Length: 52min 27sec (3147 seconds)

Published: Mon Nov 05 2018