Osteoporosis Case Studies

March 2012

Ronald C. Hamdy, MD, FRCP, FACP

Professor of Medicine

Director, Osteoporosis Center

Professor/Chair, Geriatric Medicine

East Tennessee State University

Editor-in-Chief, Journal of Clinical Densitometry

Osteoporosis Case Studies

March 2012

Ronald C. Hamdy, MD, FRCP, FACP

Professor of Medicine

Director, Osteoporosis Center

Professor/Chair, Geriatric Medicine

East Tennessee State University

Editor-in-Chief, Journal of Clinical Densitometry

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Asymptomatic Natural menopause 2 years ago Exercises regularly – strenuous routine Good dietary calcium and vitamin D intake Family history: negative for osteoporosis No prescribed medications OsCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 121 pounds; height 64”

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Asymptomatic Natural menopause 2 years ago Exercises regularly – strenuous routine Good dietary calcium and vitamin D intake Family history: negative for osteoporosis No prescribed medications OsCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 121 pounds; height 64”

Area BMD T-score

L1 9.9 1.419 + 2.4

L2 11.4 1.445 + 2.9

L3 13.9 1.483 + 2.4

L4 14.1 1.494 + 1.7

L1-4 48.8 1.463 + 2.6

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Area BMD T-score

L1 9.9 1.419 + 2.4

L2 11.4 1.445 + 2.9

L3 13.9 1.483 + 2.4

L4 14.1 1.494 + 1.7

L1-4 48.8 1.463 + 2.6

RIGHT HIP BMD T-score Femoral Neck 1.081 + 0.8Trochanter 0.773 - 0.2Total Hip 1.047 + 0.4LEFT HIPFemoral Neck 1.016 + 0.3Trochanter 0.818 + 0.3Total Hip 1.047 + 0.4

RIGHT HIP BMD T-score Femoral Neck 1.081 + 0.8Trochanter 0.773 - 0.2Total Hip 1.047 + 0.4LEFT HIPFemoral Neck 1.016 + 0.3Trochanter 0.818 + 0.3Total Hip 1.047 + 0.4

Lunar, ProdigyLunar, Prodigy

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Diagnosis: Normal bone density (WHO criteria)Diagnosis: Normal bone density (WHO criteria)

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Diagnosis: Normal bone density (WHO criteria)Diagnosis: Normal bone density (WHO criteria) Management recommendations: Management recommendations:

Maintain Bone Mass – Healthy lifestyleMaintain Bone Mass – Healthy lifestyle

Repeat DXA scan 2 yearsRepeat DXA scan 2 years

Mrs. MB, 51 years old WW, Concerned about Osteoporosis

Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSCRIGHTFem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.4 0.078 0.050

LEFTFem Neck 1.016 + 0.3 0.945 - 0.3 - 7.0 0.071 0.031Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.3 0.068 0.042Total Hip 1.0471.047 + 0.4+ 0.4 0.966 - 0.3 0.966 - 0.3 - 7.7 0.0810.081 0.022

L1-L4 1.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028

Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis

Baseline 2-years BMD change Region BMD T-score BMD T-score % Abs LSCRIGHTFem Neck 1.081 + 0.8 0.985 + 0.0 - 8.9 0.096 0.034Trochanter 0.773 - 0.2 0.732 - 0.5 - 5.3 0.041 0.053Total Hip 1.047 + 0.4 0.969 - 0.3 - 7.4 0.078 0.050

LEFTFem Neck 1.016 + 0.3 0.945 - 0.3 - 7.0 0.071 0.031Trochanter 0.818 + 0.3 0.750 + 0.1 - 8.3 0.068 0.042Total Hip 1.0471.047 + 0.4+ 0.4 0.966 - 0.3 0.966 - 0.3 - 7.7 0.0810.081 0.022

L1-L4 1.463 + 2.6 1.394 + 1.8 - 5.0 0.069 0.028

Laboratory investigations: Blood Chemistry profile, Vit. D, PTH: Within normal limits.Laboratory investigations: Blood Chemistry profile, Vit. D, PTH: Within normal limits.

Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis

Normal BMDNormal BMD

Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis

Normal BMDNormal BMD

Mrs. MB, 53 years old WW, Second visit Concerned about Osteoporosis

Bone loss sustained: Expected Post-menopausal loss

Management recommendation: Maintain Bone massRepeat DXA scan 1 year

Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis

Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis

VERY VERY

VERYVERY

Mrs. MB, 54 years old WW, Third visitVERY concerned about Osteoporosis

Base 2-yrs % 1-yr BMD change 04-05

Region BMD BMD Diff. BMD T-score % Abs LSC

RIGHT

Fem Neck 1.081 0.985 - 8.9 0.977 - 0.1 - 0.8 0.008 0.034

Trochanter 0.773 0.732 - 5.3 0.713 - 0.5 - 0.3 0.019 0.053

Total Hip 1.047 0.969 - 7.4 0.958 - 0.3 - 0.8 0.011 0.050

LEFT

Fem Neck 1.016 0.945 - 7.0 0.938 - 0.3 - 0.7 0.007 0.031

Trochanter 0.818 0.750 - 8.3 0.739 - 0.1 - 1.5 0.011 0.042

Total Hip 1.0471.047 0.966 0.966 - 7.7 0.9480.948 - 0.3- 0.3 - 1.8- 1.8 0.0180.018 0.022

L1-L4 1.463 1.394 - 5.0 1.374 + 1.7 - 1.4 0.020 0.028

Bo

ne

Mas

sB

on

e M

ass

ActiveGrowt

h

SlowLoss

RapidLoss

ContinuingLoss

Age in YearsAge in Years

50501010 2020 4040 6060 7070 8080 90903030

MENOPAUS

E

Peak Bone MassPeak Bone Mass

1- 5% annually1- 5% annually

Age-associated Changes in Bone Mass

1- 2% annually1- 2% annually

Low back pain , gradually worsening

Episode of very severe pain, incapacitating, 3 weeks ago

Positive family history;

Sister 85 yrs, died after hip fracture

Daily calcium intake: about 1500 mg

CBC, CMP, TSH; within normal limits

Meds: NSAID, calcium supplements

Weight 130 pounds, height 64”

X-ray evidence of vertebral compression fracture

Mrs. MRW, 76 years WW

Low back pain , gradually worsening

Episode of very severe pain, incapacitating, 3 weeks ago

Positive family history;

Sister 85 yrs, died after hip fracture

Daily calcium intake: about 1500 mg

CBC, CMP, TSH; within normal limits

Meds: NSAID, calcium supplements

Weight 130 pounds, height 64”

X-ray evidence of vertebral compression fracture

Mrs. MRW, 76 years WW

Low back pain , gradually worsening

Episode of very severe pain, incapacitating, 3 weeks ago

Positive family history;

Sister 85 yrs, died after hip fracture

Daily calcium intake: about 1500 mg

CBC, CMP, TSH; within normal limits

Meds: NSAID, calcium supplements

Weight 130 pounds, height 64”

X-ray evidence of vertebral compression fracture

Mrs. MRW, 76 years WW

Mrs. MRW, 76 years WW

Area BMD T-score

L1 12.65 0.849 - 0.69

L2 11.80 1.012 - 0.15

L3 15.55 0.920 - 1.49

L4 11.61 1.123 + 0.06

L1-4 51.61 0.969 - 0.71

Mrs. MRW, 76 years WW

Area BMD T-score

L1 12.65 0.849 - 0.69

L2 11.80 1.012 - 0.15

L3 15.55 0.920 - 1.49

L4 11.61 1.123 + 0.06

L1-4 51.61 0.969 - 0.71

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Vertebral compression fracturesVertebral compression fractures

Mrs. MRW, 76 years WW

Area BMD T-score

L1 12.65 0.849 - 0.69

L2 11.80 1.012 - 0.15

L3 15.55 0.920 - 1.49

L4 11.61 1.123 + 0.06

L1-4 51.61 0.969 - 0.71

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Vertebral compression fracturesVertebral compression fractures

Diagnosis: Osteoporosis

10-years % # probability:

Hip # 33

Other # 50

Diagnosis: Osteoporosis

10-years % # probability:

Hip # 33

Other # 50

Mrs. MRW, 76 years WW

Area BMD T-score

L1 12.65 0.849 - 0.69

L2 11.80 1.012 - 0.15

L3 15.55 0.920 - 1.49

L4 11.61 1.123 + 0.06

L1-4 51.61 0.969 - 0.71

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip

Vertebral compression fracturesVertebral compression fractures

Diagnosis: OsteoporosisDiagnosis: Osteoporosis

Mrs. MRW, 76 years WW

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Vertebral compression fracturesVertebral compression fractures

Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip

Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, Prolia

Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, Prolia

Risk for hip fractures relative to placebo for participants who are at high risk for fracture, by agent

MacLean, C. et. al. Ann Intern Med 2008;148:197-213

FDA Approved Medication –Hip Fractures

StudyStudy NumbersNumbers Duration Duration yearsyears

risk risk reductionreduction

AlendronateAlendronate FITFIT 2,0272,027 33 YesYes

RisedronateRisedronate HIPHIP 5,4455,445 33 YesYes

IbandronateIbandronate BONEBONE 2,9462,946 33 NoNo

ZoledronateZoledronate HORIZONHORIZON 7,7367,736 33 YesYes

RaloxifeneRaloxifene MOREMORE 7,7057,705 33 NoNo

CalcitoninCalcitonin PROOFPROOF 1,2551,255 55 NoNo

DenosumabDenosumab FREEDOMFREEDOM 7,7367,736 33 YesYes

TeriparatideTeriparatide 1,6371,637 1.51.5 **

* Study aborted 18 months

Mrs. MRW, 76 years WW

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Vertebral compression fracturesVertebral compression fractures Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, Prolia

Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, Prolia

Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip

Diagnosis: OsteoporosisDiagnosis: Osteoporosis

Mrs. MRW, 76 years WW

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

RIGHT HIP BMD T-score Femoral Neck 0.557 - 2.6Trochanter 0.535 - 1.7Total Hip 0.736 - 1.7LEFT HIPFemoral Neck 0.554 - 2.7Trochanter 0.516 - 1.8Total Hip 0.724 - 1.8

Vertebral compression fracturesVertebral compression fractures

Goal: Reduce Fracture Risk especially hipGoal: Reduce Fracture Risk especially hip

Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, Prolia

Bisphosphonates:

Alendronate, Fosamax, generics Risedronate, Actonel, Atelvia Ibandronate, Boniva Zoledronate, Reclast

Raloxifene, Evista

Calcitonin, Miacalcin

Teriparatide, Forteo

Denosumab, ProliaDiagnosis: OsteoporosisDiagnosis: Osteoporosis

Mrs. MRW, 76 years WW

CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES

Mrs. MRW, 76 years WW

CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW • ATYPICAL FEMORAL SHAFT FRACTURES

Probability:

1:10,000 to 1:100,000

Probability:

1:10,000 to 1:100,000

Probability #:

Hip # 33 % 1:3

Other # 50 % 1:2

Probability #:

Hip # 33 % 1:3

Other # 50 % 1:2

Mrs. MRW, 76 years WW

CONCERNED ABOUT:• OSTEONECROSIS OF THE JAW (ONJ)• ATYPICAL FEMORAL SHAFT FRACTURES (AFSF)

Probability:

1:10,000 to 1:100,000

Probability:

1:10,000 to 1:100,000

Atypical femoral shaft fracturesAtypical femoral shaft fracturesProdromal symptoms/signsProdromal symptoms/signs

Clinical:Clinical:

Pain, localised tendernessPain, localised tenderness Imaging:Imaging:

X-rays, technetium scan, MRI, CT-scans, MRIX-rays, technetium scan, MRI, CT-scans, MRI Laboratory:Laboratory:

Bone turnover markers: N-TX, C-TXBone turnover markers: N-TX, C-TX

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0 6 12 18 24

Control Group67 hip fractures

Hip Protectors13 hip fractures

CumulativeHazard of

Hip Fractures

Months

54%*

Kannus P, et al. N Engl J Med 2000; 343:1506-1513

Prevention of Hip fracture with Hip Prevention of Hip fracture with Hip ProtectorsProtectors

*P=0.008

1801 elderly men and women in long stay or supported home care

Bisphosphonates:

alendronate, risedronate,

ibandronate zoledronate

Raloxifene

Calcitonin

Teriparatide

Denosumab

Bisphosphonates:

alendronate, risedronate,

ibandronate zoledronate

Raloxifene

Calcitonin

Teriparatide

Denosumab

? Kyphoplasty

?? Vertebroplasty

? Kyphoplasty

?? Vertebroplasty

Mrs. MRW, 76 years WW

Bisphosphonates:

alendronate, risedronate,

ibandronate zoledronate

Raloxifene

Calcitonin

Teriparatide

Denosumab

Bisphosphonates:

alendronate, risedronate,

ibandronate zoledronate

Raloxifene

Calcitonin

Teriparatide

Denosumab

? Kyphoplasty

?? Vertebroplasty

? Kyphoplasty

?? Vertebroplasty

Mrs. MRW, 76 years WW

Calcium/vitamin DCalcium/vitamin D

DAILY CALCIUM INTAKE Elemental Calcium (mg)

Postmenopausal:Postmenopausal: 1,5001,500 Premenopausal:Premenopausal: 1,0001,000 Pregnant/nursing:Pregnant/nursing: 1,200 - 1,5001,200 - 1,500 Men < 65 years:Men < 65 years: 1,0001,000 Men Men >> 65 years: 65 years: 1,5001,500

Mrs. IB, WW, 56 years

Asymptomatic Surgical menopause when 41 years Exercises regularly Good dietary calcium and vitamin D intake Family history: positive for osteoporosis No prescribed medications CitraCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 175 pounds; height 64” – No height loss

Mrs. IB, WW, 56 years

Asymptomatic Surgical menopause when 41 years Exercises regularly Good dietary calcium and vitamin D intake Family history: positive for osteoporosis No prescribed medications CitraCal 500 mg + Vitamin D twice daily Multivitamins once a day Weight 175 pounds; height 64” – No height loss

Mrs. IB, WW, 56 years

Area BMD T-score

L1 11.1 0.910 - 1.8

L2 11.3 0.914 - 1.8

L3 11.5 0.922 - 2.3

L4 12.3 0.927 - 2.6

L1-4 46.2 0.925 - 2.1

RIGHT HIP BMD T-score Femoral Neck 0.887 - 1.2Trochanter 0.713 - 0.9Total Hip 0.925 - 0.9LEFT HIPFemoral Neck 0.910 - 1.1Trochanter 0.755 - 0.7Total Hip 0.961 - 0.8

RIGHT HIP BMD T-score Femoral Neck 0.887 - 1.2Trochanter 0.713 - 0.9Total Hip 0.925 - 0.9LEFT HIPFemoral Neck 0.910 - 1.1Trochanter 0.755 - 0.7Total Hip 0.961 - 0.8

Diagnosis: OsteopeniaDiagnosis: Osteopenia

WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –

• AgeAge

• WeightWeight

• HeightHeight

• AgeAge

• WeightWeight

• HeightHeight

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –

• AgeAge

• WeightWeight

• HeightHeight

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

Femoral neck

T-score

or

Z-score

Femoral neck

T-score

or

Z-score

WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –

• AgeAge

• WeightWeight

• HeightHeight

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

Femoral neck

T-score

or

Z-score

Femoral neck

T-score

or

Z-score

10-year probability of fracture (%)

Hip

Others

10-year probability of fracture (%)

Hip

Others

WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –

• AgeAge

• WeightWeight

• HeightHeight

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

• Previous fracture

• Parent fractured hip

• Current smoking

• Glucocorticoids

• Rheumatoid arthritis

• Secondary osteoporosis

• Alcohol > 3/day

Femoral neck

T-score

or

Z-score

Femoral neck

T-score

or

Z-score

10-year probability of fracture (%)

Hip

Others

10-year probability of fracture (%)

Hip

Others

NOF Guidelines

Hip > 3%

Others > 20%

NOF Guidelines

Hip > 3%

Others > 20%

WHO – Fracture Risk Assessment Tool – FRAX – WHO – Fracture Risk Assessment Tool – FRAX –

• Diagnosis: Osteopenia (WHO criteria)Diagnosis: Osteopenia (WHO criteria)

• 10-year % fracture probability10-year % fracture probability• HipHip 1 1

• OthersOthers 2626

Mrs. IB, WW, 56 years

NOF Guidelines

Hip > 3%

Others > 20%

NOF Guidelines

Hip > 3%

Others > 20%

Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?

What is the goal of treatment ?What is the goal of treatment ?

Mrs. IB, WW, 56 years

Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?

What is the goal of treatment ?What is the goal of treatment ?

Fracture Risk Reduction Fracture Risk Reduction

Mrs. IB, WW, 56 years

Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?

What is the goal of treatment ?What is the goal of treatment ?

Fracture Risk Reduction Fracture Risk Reduction

Mrs. IB, WW, 56 years

10-year probability Hip # 1

Other # 26

10-year probability Hip # 1

Other # 26

Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel) Risedronate (Actonel) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? HRT ? ?? ? HRT ? ?

What is the goal of treatment ?What is the goal of treatment ?

Fracture Risk Reduction Fracture Risk Reduction

Mrs. IB, WW, 56 years

10-year probability Hip # 1

Other # 26

10-year probability Hip # 1

Other # 26

FDA Approved Medication – Vertebral Fractures

StudyStudy NumbersNumbers Duration Duration yearsyears

risk risk reductionreduction

AlendronateAlendronate FITFIT 2,0272,027 33 YesYes

RisedronateRisedronate VERTVERT 2,458 2,458 1,1161,116

33 YesYes

IbandronateIbandronate BONEBONE 2,9462,946 33 YesYes

ZoledronateZoledronate HORIZONHORIZON 7,7367,736 33 YesYes

RaloxifeneRaloxifene MOREMORE 7,7057,705 33 YesYes

CalcitoninCalcitonin PROOFPROOF 1,2551,255 55 YesYes

DenosumabDenosumab FREEDOMFREEDOM 7,7367,736 33 YesYes

TeriparatideTeriparatide 1,6371,637 1.51.5 YesYes

Hormonal Replacement Therapy - WHI

Alendronate (Fosamax)Alendronate (Fosamax) Risedronate (Actonel, Atelvia) Risedronate (Actonel, Atelvia) Ibandronate (Boniva)Ibandronate (Boniva) Zoledronate (Reclast)Zoledronate (Reclast) Raloxifene (Evista)Raloxifene (Evista) Calcitonin (Miacalcin)Calcitonin (Miacalcin) Teriparatide (Forteo)Teriparatide (Forteo) Denosumab (Prolia)Denosumab (Prolia) ? ? Hormonal Replacement Therapy ? ?? ? Hormonal Replacement Therapy ? ?

Mrs. IB, WW, 56 years

Calcium

Vitamin D

Calcium

Vitamin D

Diagnosed with osteoporosis about 9 years agoDiagnosed with osteoporosis about 9 years ago

Based on fragility fracture T10: moderate wedgeBased on fragility fracture T10: moderate wedge Secondary causes excluded.Secondary causes excluded. Started risedronate (Actonel) 35 mg weekly, then Started risedronate (Actonel) 35 mg weekly, then

converted to 150 mg once a monthconverted to 150 mg once a month No adverse effects, taking it as directed, own routineNo adverse effects, taking it as directed, own routine Good complianceGood compliance Good daily calcium/vitamin D intakeGood daily calcium/vitamin D intake

Mrs. PRP, WW, 82 years

Scan Date

Age BMD T-scores % BMD Change

Baseline Previous

2001 73 0.700 - 2.0

2003 75 0.721 - 1.8 + 3.0 + 3.0

2004 76 0.724 -1.8 + 1.8 + 1.3

2006 78 0.757 - 1.5 + 6.1 + 4.3

2007 79 0.747 -1.6 + 6.3 - 0.2

2010 82 0.771 - 1.4 + 9.2 + 2.9

Mrs. PRP, WW, 82 yearsRight Total Hip

Scan Date

Age BMD T-scores % BMD Change

Baseline Previous

2001 73 0.700 - 2.0

2003 75 0.721 - 1.8 + 3.0 + 3.0

2004 76 0.724 -1.8 + 1.8 + 1.3

2006 78 0.757 - 1.5 + 6.1 + 4.3

2007 79 0.747 -1.6 + 6.3 - 0.2

2010 82 0.771 - 1.4 + 9.2 + 2.9Should risedronate (Actonel) be continued ?

Mrs. PRP, WW, 82 yearsRight Total Hip

Atypical femoral shaft #

Delayed # healing

Bisphosphonate therapy

Oversuppressed bone turnover

Fracture Risk Reduction

Osteo-necrosis Jaw

Bisphosphonate therapy & Bone Turnover

Suppress, but not

Over-suppress !

COLLAGEN CROSS LINKSCOLLAGEN CROSS LINKS

CTxNTx

N-TELOPEPTIDEREGION

HELICAL REGION C-TELOPEPTIDEREGION

PyrDpd

C-Telopeptide or C-Tx C-Telopeptide or C-Tx

C-Telopeptide or C-Telopeptide or C-Tx C-Tx

1000 pg/mL

100 pg/mL

200 pg/mL

Mrs. PRP, WW, 82 yearsRight Total Hip

Scan Date

Age BMD T-scores % BMD Change

Baseline Previous

2001 73 0.700 - 2.0

2003 75 0.721 - 1.8 + 3.0 + 3.0

2004 76 0.724 -1.8 + 1.8 + 1.3

2006 78 0.757 - 1.5 + 6.1 + 4.5

2007 79 0.747 -1.6 + 6.4 - 0.3

2010 82 0.771 - 1.4 + 9.2 + 3.0Continue risedronate (Actonel)C-Tx 320 pg/mL

Mrs. RV, 60 years, WW, Second visit

2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3

LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2

L1-L4 Cannot be interpreted: scoliosis and artifacts

2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3

LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2

L1-L4 Cannot be interpreted: scoliosis and artifacts

Prescribed alendronate in 2008

Mrs. RV, 60 years, WW, Second visit

Did not refill her second prescription

of Alendronate

2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3

LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2

L1-L4 Cannot be interpreted: scoliosis and artifacts

2008 2010 % Change RIGHT HIP BMD T-score BMD T-score BMDFem Neck 0.676 - 1.6 0.655 - 1.7 - 3.3Total Hip 0.750 - 1.6 0.688 - 2.1 - 8.3

LEFT HIPFem Neck 0.609 - 2.2 0.597 - 2.3 - 2.0Total Hip 0.735 - 1.7 0.646 - 2.4 - 12.2

L1-L4 Cannot be interpreted: scoliosis and artifacts

Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in

Known to have osteoporosis

CBC, Blood Chem. Profile, TSH: within normal limits.

Prescribed a bisphosphonate.

Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in

Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in

DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD

Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2

Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8

Lumbar Vertebrae Multiple vertebral compression fractures

DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD

Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2

Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8

Lumbar Vertebrae Multiple vertebral compression fractures

Complete blood picture

Blood chemistry profile Normal

Thyroid stimulating hormone

Complete blood picture

Blood chemistry profile Normal

Thyroid stimulating hormone

Bisphosphonates, good complianceBisphosphonates, good compliance

Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in

Mrs. WF, 68 yrs, Wt: 140 lbs Ht: 62 in

DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD

Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2

Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8

Lumbar Vertebrae Multiple vertebral compression fractures

DXA Scan Baseline 2 yrs later % Change LSC Results BMD T-score BMD T-score BMD

Right Total Hip 0.721 -2.5 0.689 - 2.9 - 4.5 2.2

Left Total Hip 0.688 -2.7 0.657 - 2.9 - 5.1 2.8

Lumbar Vertebrae Multiple vertebral compression fractures

Complete blood picture

Blood chemistry profile Normal

Thyroid stimulating hormone

Complete blood picture

Blood chemistry profile Normal

Thyroid stimulating hormone

Bisphosphonates, good complianceBisphosphonates, good compliance

25(OH) Vitamin D 12 ng/mL

25(OH) Vitamin D 12 ng/mL

Non-response to oral bisphosphonatesNon-response to oral bisphosphonates

• ComplianceCompliance

• Inadequate Calcium/vitamin DInadequate Calcium/vitamin D

• Secondary osteoporosis Secondary osteoporosis

OsteoporosisOsteoporosis

Diagnosis:Diagnosis:

Fragility fracturesFragility fractures

DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis < - 1.0 to – 2.5: Osteopenia< - 1.0 to – 2.5: Osteopenia >> - 1.0: Normal - 1.0: Normal

OsteoporosisOsteoporosisDiagnosis:Diagnosis:

Fragility fracturesFragility fractures

DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis < - 1.0 to – 2.5: Osteopenia< - 1.0 to – 2.5: Osteopenia >> - 1.0: Normal - 1.0: Normal

Management strategy:

WHO FRAX 10 year # probability %

NOF guidelines: Hip # > 3.0

Other # >20

Management strategy:

WHO FRAX 10 year # probability %

NOF guidelines: Hip # > 3.0

Other # >20

OsteoporosisOsteoporosis

Diagnosis:Diagnosis:

Fragility fracturesFragility fractures

DXA - WHO Guidelines:DXA - WHO Guidelines: << -2.5 Osteoporosis -2.5 Osteoporosis OsteopeniaOsteopenia >> - 1.0: Normal - 1.0: Normal

Medications:

Alendronate (Fosamax, generics)

Risedronate (Actonel, Atelvia)

Ibandronate (Boniva)

Zoledronate (Reclast)

Raloxifene (Evista)

Calcitonin (Miacalcin)

Teriparatide (Forteo)

Denosumab (Prolia)

HRT ??

Medications:

Alendronate (Fosamax, generics)

Risedronate (Actonel, Atelvia)

Ibandronate (Boniva)

Zoledronate (Reclast)

Raloxifene (Evista)

Calcitonin (Miacalcin)

Teriparatide (Forteo)

Denosumab (Prolia)

HRT ??

Management strategy:

WHO FRAX 10 year # probability %

NOF guidelines: Hip # > 3.0

Other # >20

Management strategy:

WHO FRAX 10 year # probability %

NOF guidelines: Hip # > 3.0

Other # >20

FDA Approved Medication for Osteoporosis# Risk Reduction# Risk Reduction

Calcium

Vitamin D

Diet

Exercise

No smoking

Calcium

Vitamin D

Diet

Exercise

No smoking

VertebraeVertebrae HipsHips

AlendronateAlendronate YesYes YesYes

RisedronateRisedronate YesYes YesYes

IbandronateIbandronate YesYes NoNo

ZoledronateZoledronate YesYes YesYes

RaloxifeneRaloxifene YesYes NoNo

CalcitoninCalcitonin YesYes NoNo

TeriparatideTeriparatide YesYes

Denosumab YesYes YesYes

WHO – FRAX

NOF – Guidelines

Hip > 3% Others > 20%

WHO – FRAX

NOF – Guidelines

Hip > 3% Others > 20%

Management Of

Osteoporosis

Management Of

Osteoporosis

MedicationsMedications

Lifestyle changesLifestyle changes

Calcium & Vitamin DCalcium & Vitamin D

Fall PreventionFall Prevention

DiseasesDiseases

Medications causing bone loss

Medications causing bone loss

Reduce impact of fallsReduce impact of falls

Early diagnosis Prevention

Early diagnosis Prevention

OsteoporosisOsteoporosis

It is never too early or too late to prevent or treat

osteoporosis !