A recording of this presentation is available HERE.
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Thanks so much to Dr. Kendal Hamann, SMGR Endocrinologist, for an outstanding Grand Rounds presentation on Osteoporosis. Dr. Hamann covered the basics and the nuances of osteoporosis diagnosis, reminded us that the DEXA scan results are only part of the clinical picture, and clarified when bisphosphonates should be first vs. second line.
Please watch the recorded version above if you want all the details.
4 clinical pearls:
- Use the FRAX score (10 year fracture score) to guide who should be treated for osteoporosis
- Even patients whose T score doesn't improve on bisphosphonates, there is a 30-50% decrease in fractures
- Rebound fractures are real. Never start denosumab (Prolia) without a plan for bisphosphonates after completion
- Check DEXA 2-5 years into treatment, at start of drug holiday (which is generally 5 years into bisphosphonates), then 2-5 years later
Osteoporosis= decreased BONE STRENGTH, which is a combination of Bone DENSITY (BMD) + Bone TURNOVER + Bone ARCHITECTURE
Normal BMD T>1.0, osteopenia BMD 1>T>-2.5, osteoporosis T<-2.5
Diagnosis of osteoporosis=- Fragility fracture (most commonly, fracture of wrist spine, hip from standing height)
- T-score of <-2.5 by DEXA scan.
- Of note, 50% of people with fragility fractures will NOT meet criteria by DEXA
Normal aging vs. Disease
Bone density peaks around 30 years in women and decreases p after that, with a particular drop after menopause. It is part of the normal aging process BUT also leads to significant morbidity and mortality.
- Vertebral fractures cause pain, loss of mobility, loss of height, even restrictive lung disease and abdominal issues. Plus, once you have a vertebral fracture, you have 20% risk of a second one in the next year.
- Hip fractures: 30% 1 year mortality (higher in men), 40% of people never walk independently after hip fx, 25% wind up needing care in long-term care facility
Bone density scan (i.e. DEXA) is a screening tool. But it only captures 60-80% of bone strength. You should be using the FRAX score (10 year risk of fracture) in addition to the T score to direct treatment
- FRAX: >3% risk of hip fracture, >20% risk of any fracture are indications for treatment
- Usng a T score of <-2.5, about 30% of menopausal women will qualify as having osteoporosis
- 1/2 of women with fragility fracture do not qualify as having osteoporosis on DEXA (i.e. T score will be >-2.5)
- Indications for DEXA:
- women and trans-people >65
- men >70
- any adult over 50 with a fragility fracture
- monitoring treatment
- lots of other people:
- primary hyperparathyroidism
- chronic steroids
- hypogonadism
- premature menopause
- longstanding hyperthyroidism
- celiac disease
- pregnancy w/fragility fracture
- people on GnRH agonists
Age
History of previous fracture
FALL risk
Family history
Cigarette smoking (1/8 people with hip fx are smokers see below)
ETOH >3 drinks/day
Immobilization
Inadequate Ca and Vitamin D (during childhood, leading to low peak in 30s)
Smoking!!!
Treatment:
Don't forget fall prevention!
Calcium and Vitamin D were given to every patient in every treatment arm of every trial for osteoporosis. They are still the mainstay of osteoporosis treatment and prevention. There is old data demonstrating they definitely decrease risk of fracture. Dosing is all over the place, but Dr. Hamann generally recommends 1000mg of Calcium and 800u of Vitamin D/day. It's fine to get your calcium through dietary means (particularly if you have a history of kidney stones and cannot tolerate supplements), just make sure you're getting 1000mg/day.
Who should receive treatment?
-anyone with T score <-2.5
-anyone with hx of vertebral/hip fracture from standing
-anyone with 10 year fracture risk (FRAX) > 20%
-anyone with 10 year hip fracture risk (FRAX) >3%
-clinical judgement
Bisphosphonates are the mainstay of osteoporosis treatment. They inhibit osteoclast. Data for fracture risk reduction is robust-- decreased fracture risk 30-50% reduction after about 6 months on bisphosphonates. Cost is low. We have 25+ years of experience now with these meds.
PO alendronate, ibandronate, risendronate
IV zoledronic acid, ibandronate
Risk of osteonecrosis of the jaw (ONJ) is low but real 1/10,000, risk of atypical femur fracture 1/50,000-1/100,000-- much lower than the number of fractures prevented by the medication.
Side effects: GI 10% (heartburn, upset stomach, nausea), aches (1%), hypocalcemia (check vitamin D and replete before starting), 1 in 5 people will get a flu-like infusion reaction to zoledronic acid. These should NOT be used in childbearing women.
Newer agents=Anabolic agents: Romozosumab (sclerostin inhibitor, sq monthly x 1 year, only approved in women), teriparatide & abaloparatide (parathyroid hormone agonists, sq daily x 2 years)
Costly, only approved for 1-2 years
Romozosumab: treat to target T>-2.5, should be used FIRST line for "severe osteoporosis" (T score <-3.0)
Order matters (see image below)-- these anabolic agentsshould be followed by bisphosphonates (not the reverse)
IN particular with denosumab (prolia), fragility fractures of the spine and rebound fractures are real. MUST always be followed by a bisphosphonate.
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| order matters!! |
Dr. Hamann's General Approach:
Drug holidays and repeat DEXA?
Consider drug holiday after 5 years on bisphosphonate (if not fracturing)
Check DEXA 2-5 years into treatment, at start of drug holiday, then 2-5 years later
When to consult endocrinology?
-intolerance of oral bisphosphonate
-severe osteoporosis (T<-3.0)
-multiple fractures despite treatment
-anyone needing to stop denosumab (prolia)
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