1 J.J. Jones, DNP, ANP-BC, ACNP-BC Tracey Anderson, MSN, CNRN, FNP-BC, ACNP-BC JJ Jones, no financial disclosures to reveal Tracey Anderson, clinical faculty for Codman Neuro Advanced Practice Provider Course Disclosures Summarize the elements of osteoporosis prevention Discuss emerging and novel medications for the use in osteoporosis management in primary care Identify pharmacological and non-pharmacological treatment modalities following fragility fracture Objectives
Transcript
1
J.J. Jones, DNP, ANP-BC, ACNP-BC
Tracey Anderson, MSN, CNRN, FNP-BC, ACNP-BC
JJ Jones, no financial disclosures to reveal
Tracey Anderson, clinical faculty for Codman Neuro Advanced Practice Provider Course
Disclosures
Summarize the elements of osteoporosis prevention
Discuss emerging and novel medications for the use in osteoporosis management in primary care
Identify pharmacological and non-pharmacological treatment modalities following fragility fracture
Objectives
2
Affects more than 44 million individuals in the US and
over 200 million worldwide, annually (Kastner & Straus, 2008)
Effects of low bone mass often result in:
fragility fractures
disability
decreased quality of life and increased morbidity/mortality
Hip fractures are associated with a mortality rate as high as 36% (National Osteoporosis Foundation, 2013)
Background
Mean rate of osteoporosis screening among providers is 56% (Cohen, 2008)
Average lifetime risk for development of fragility fractures:
40% for both men and women (Gibson, 2008)
Background
432,000 hospital admissions
2.5 million office visits
180,000 nursing home admissions
2008: $17 billion spent on treating osteoporotic related fractures
2025: Estimated to exceed $25 billion (Blume, 2011)
Costs of Osteoporosis
3
Idiopathic
PMP Osteoporosis (Type I)
Age associated or senile OP (Type II)
Juvenile Osteoporosis (onset 8-14 yr)
Primary Causes
Secondary Causes
Adrenal d/o
DM
Hyperparathyroidism
COPD
Osteogenesis Imperfecta
Chronic hepatic d/o
Gastrectomy
Bariatric surgery
Malabsorption syndromes
CKD
ESRD
RA
Leukemia
Parkinson’s
SCI
CHF
High Risk Medications
Anticoagulants
Anti-neoplastics
Corticosteroids
Depo-Provera
Cyclosporin A/Tacrolimus
PPI
Immunosuppressives
Loop Diuretics
Methotrexate
Thiazolindinediones
Thyroid Hormone therapy
SSRI’s
Anti-convulsants
Cytotoxic Drugs
4
Retrieved from www.sci.washington.edu
Normal vs. Osteoporotic Bone
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP, ACNP- BC, 2016)
Bone Density screening is the gold standard for
osteoporosis diagnosis
Recommended to begin in women age 65 or selectively in those younger than 65 based on risk
Screening Recommendations
5
Must use screening code + reason OP is suspected
Cannot code for s SUSPECTED condition
If a patient is on therapy, can code as drug monitoring: V58.83
Screening code: Z13.820 (Primary)
Osteoporosis: M81.8
Asymptomatic Post-menopausal Status: Z78.0
Ovarian Failure: E28.39
ICD-10 Codes
Bone Mineral Density Test 77078
CPT Codes
Normal Bone: T score of +1 to -1
Osteopenia: T score of -1 to -2.5
Osteoporosis: T score of -2.5 or lower
Understanding Bone Density
6
T-score of -2.5 or less
T-score of -1 to -2.5 AND
FRAX score of > 3% for hip fracture or > 20% risk of major osteoporotic fx within 10 years (forearm, hip, shoulder, or spine)
History of fragility fracture
When do we treat?
Prediction tool for assessing an individual’s risk for
fracture
Useful in providing general guidance for treatment decisions
Incorporates non-BMD clinical risk factors Ht/Wt
Previous Fx
Family hx
Smoking status
Glucocorticoids
ETOH consumption
FRAX Score
NOF recommends treating when:
10-year risk of >3% for hip fracture or > 20% major osteoporotic fracture
Raloxifene (Evista)—Estrogen agonist in bone, decreases
bone resorption and turnover Daily dosing Half-life 32.5 hr 60 mg PO $229 (www.goodrx.com)
Denosumab (Prolia)—Inhibit osteoclast formation,
maintenance, and survival and reducing bone resorption and turnover—RANKL Inhibitor Q 6 mo dosing, SC Half-life 25.4 days 60 mg SQ $1119 (www.goodrx.com)
Treatment Recommendations
Calcitonin (Micalcin Nasal)—inhibits osteoclasts and
may increase osteoblast activity Daily dosing, nasal spray
Half-life 43 min
200 units/spray $122 (www.goodrx.com)
Teriparatide (Forteo)—regulates bone metabolism Daily dosing, SC or IV
Impression: Hx Breast CA, DM, borderline HTN, Osteopenia
Recommendations: Continue current medications
Increase exercise—recommended 10# weight loss
Case Study: 2003
Bisphosphonate tx for 4 years for Osteopenia
Life line Screening for osteoporosis:
Results of osteoporosis screening fall outside normal range according to WHO guidelines.
Ordered BMD study
Increased Fosamax to 70mg po weekly and considered changing to Reclast infusion.
Case Study: 2007
12
Bisphosphonate Therapy 7 years
BMD Study No evidence of osteoporosis or osteopenia of left
femur
Osteopenia of the lumbar spine
No FRAX score reported
Recommendations: No change in treatment documented
Case Study: 2010
Bisphosphonate therapy 8 years
Admitted to ED with c/o R hip pain.
Was drying off after a shower and had her right leg elevated on the side of the tub, felt a snap in the thigh area. Severity was moderate, quality sharp.
Current osteoporosis medications:
Alendronate 35 mg weekly
Calcium 600mg po BID
Case Study: July, 2011
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
13
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
Closed, displaced, angulation right subtrochanteric
femur fracture
Orthopedic Consultation
Intramedullary Rod placement
Post-op course was unremarkable
Case Study: July, 2011
14
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
Concern for pathologic bone fracture secondary to
metastatic malignancy vs. atypical fx secondary to long-term bisphosphonate use
X-ray Left lower extremity
CT Scan
Bone Scan
Pet Scan
July 2011
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
15
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
Moderate increased uptake in the proximal half of
the right femur and adjacent soft tissues could be secondary to neoplasm
recent fracture
post-operative changes
A focus of abnormal uptake in the proximal left femur seen on recent bone scan corresponds to an area of cortical thickening on CT
probably benign
Otherwise, negative study
PET Scan
16
Osteoporosis medications
Calcium 600 mg + Vitamin D 200 IU BID
Alendronate discontinued
Activity
WC and weight bearing on right side for transfers only
Non-weight bearing on the left
PT was felt to be premature but likely ordered at a later date
Discharged
Readmitted for elective intramedullary nailing left femur utilizing long trochanteric fixation nail with bx of intramedullary reaming's and open cortical pathologic lesion
Case Study: Sept, 2011
(Images used with permission from personal patient file, J.J. Jones, DNP, ANP-BC, ACNP- BC, 2016)
17
No evidence of malignancy
Pathology
Indications:
Bilateral Hip/knee pain
Findings:
Slight increased uptake seen in the proximal femurs secondary to previous surgery. No indication of surgical complication. Remainder of bony skeleton is unremarkable.
3-Phase Bone Scan, March 2012
Indications: Screening
Findings:
Normal BMD of the lumbar spine and left distal forearm. No change in bone density of the lumbar spine compared to prior exam.
BMD: Aug, 2013
18
No further fractures
Remains on Calcium 600 mg + Vitamin D BID
Lost to relocation
Follow-up, 2014
73 year old female who presented to ED with acute
back pain after ground level fall
Referred from ED for T12 compression fracture (4/18/2015)
MRI without evidence of ligamentous injury or cord/nerve compromise
Placed in Jewitt brace in ED
Case Study #2
COPD (current smoker, on oxygen)
CAD
Lumbar degenerative disc disease
Psoriasis
PE in 2013 – on lifelong warfarin after recurrence when stopped
Medical Issues
19
MRI done 4/18/2015 in ED with acute T12 compression fracture
First Follow Up
Seen in office 4/22/2015 for intractable pain
Sent back to Orthotist for brace refit
Discussed OIC and meds (colace, laxative)
Plan to follow up in 1 month with x-ray
Seen May 20, 2015
T12 compression fracture stable
Pain control improved
Jewett brace when out of bed
Follow up in 1 month with x-ray
2nd Follow Up
20
Patient having trouble with Jewett
Decided to switch to Aspen Back Pack Style TLSO (done 6/17/2015)
Brace Issues
3rd Follow Up
Seen June 23, 2015
Pain improving
X-ray shows T12 stable but now with new SPONTANEOUS L4 fracture
Continue TLSO brace
3 month time period starts again
PCP contacted re: osteoporotic fractures
(Images used with permission from personal patient file, Tracey Anderson, NP)
21
Seen July 22, 2015
T12 fracture stable, L4 fracture stable, now with new SPONTANEOUS L3 fracture
Saw PCP after last visit to discuss Forteo but called out of town for 3 weeks as she had death in family
Kyphoplasty risks/benefits discussed again
4th Follow Up
AKA Percutaneous vertebral augmentation
Vertebroplasty Done in USA since 1995
Treats fractures caused by:
Osteoporosis
Metastatic tumors
Multiple myeloma
Vertebral hemangiomas
Typically reserved for patients refractory to conservative measure
Done by radiologist, uses biplanar fluoro
“Cemento”-plasty
Kyphoplasty
Done in USA since 1998
Similar to vertebroplasty but can provide fracture reduction and partial reversal of skeletal deformity
Indications same as vertebroplasty
May be of greatest benefit in very kyphotic spine due to acute fracture
“Cemento”-plasty
22
Kyphoplasty media images from Kyphon representative, 2002)
Stable T12 fracture
Stable L4 fracture
NEW L3 fracture
(Images used with permission from personal patient file, Tracey Anderson, NP)
5th Follow Up
Seen August 25, 2015
Stable fractures T12, L4 & L3
New fracture L5
Has since seen rheumatologist who wants to start Reclast
Now with acute foot drop
Urgent MRI
23
Confirms active fractures T12, L3, L4 and L5
No nerve root compression seen to explain left foot drop
Urgent referral sent for LLE EMG
MRI Results (8/25/2015)
(Images used with permission from personal patient file, Tracey Anderson, NP)
Electrodiagnostic evidence of severe left Peroneal
neuropathy
No electrodiagnostic evidence of lumbar radiculopathy or plexopathy
Sent for AFO
Again referred for PT, recommend e-stim trial
Continue TLSO
EMG Results
24
Seen September 29, 2015
Has had a fall and broken right patella
X-ray shows all fractures stable
Has started Reclast
Continues to take Calcium + Vitamin D
6th Follow Up
Seen November 23, 2015
X-ray shows all fractures stable
Foot drop improving with PT
Decision made to wean from TLSO
She is definitely less mobile than in April – patellar fracture, foot drop and back pain all factors
Patient died 2/11/2016 at another hospital of unknown cause
Last Follow Up
Stable fractures 11/23/2015
(Images used with permission from personal patient file, Tracey Anderson, NP)
25
Serial vertebral fractures common in osteoporosis
Compression/Pathologic fractures have similar radiographic appearances – need clinical work up
Treatment of underlying issue imperative but inadequate to help with healing of acute fractures
Cementoplasty can worsen problem in setting of severe osteoporosis
Pearls
References
Blume, S. and Curtis, J. (2011). Medical Costs of Osteoporosis in the Elderly Medicare Population. Osteoporosis International, 22 (6): 1835-1844. Doi: 10.1007/s00198-010-1419-7. Cohen, K. (2008). Osteoporosis: Evaluation of Screening Patterns in a Primary-Care Group Practice. Journal of Clinical Densitometry, 11(4): 498-502. Doi: http://dx.doi.org/10.1016/j.jocd.2008.08.104 Gibson, M. V. (2008). Evaluation and treatment of bone disease after fragility fracture [Entire issue]. Geriatrics, 63(7) 21-30. Kastner, M., & Straus, S. E. (2007). Clinical decision support tools for osteoporosis disease management: a systematic review of randomized controlled trials. Journal of General Internal Medicine, 23(12), 2095-2105. Doi.10.1007/s11606-008-0812-9 National Osteoporosis Foundation. (2013). Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation. Retrieved from: www.nof.org/files/nof/public/content/resource/913/files/580.pdf Xing D, Ma JX, MA XL, et al. A meta-analysis of balloon kyphoplasty compared to percutaneous vertebroplasty for treating osteoporotic vertebral compression fractures. J Clin Neurosci 2013: 20:795.
References
Dohm M, Black CM, Dacre A, et al. A randomized trial comparing balloon kyphoplasty and vertebroplasty for vertebral compression fractures due to osteoporosis. AJNR AM J Neuroradiol 2014; 35: 2227.
