{"id":3406322,"date":"2022-07-30T18:17:31","date_gmt":"2022-07-30T22:17:31","guid":{"rendered":"https:\/\/myendoconsult.com\/learn\/?p=3406322"},"modified":"2023-03-16T04:58:28","modified_gmt":"2023-03-16T09:58:28","slug":"management-of-osteoporosis","status":"publish","type":"post","link":"https:\/\/myendoconsult.com\/learn\/management-of-osteoporosis\/","title":{"rendered":"Management Of Osteoporosis"},"content":{"rendered":"

Osteoporosis is a condition in which the bones become weak and brittle, making them more susceptible to fractures. While osteoporosis can affect people of any age, it is most commonly seen in older adults. There are a number of different treatments available for osteoporosis<\/a>, and the best course of treatment will vary depending on the individual. In general, however, medical treatment for osteoporosis focuses on two main goals:\u00a0increasing bone density<\/strong>\u00a0and\u00a0reducing the risk of fractures<\/strong>. Important clinical pearls in the management of osteoporosis will be briefly reviewed next.<\/p>\n

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Understanding Basic Osteoporosis Terminology<\/h2>\n

DEXA:<\/strong> Bone density should be performed in women age 65 and older and men age 70.\u00a0 In post-menopausal women and men age 50-69, bone density could be done if risk factors present.\u00a0 In patients with fracture, bone density should be performed.\u00a0\u00a0 A significant change in bone mineral density is variable from one machine to the next and radiologist should comment if change meets statistical significance (2-3% is common).<\/p>\n

ESTIMATION OF RISK: <\/strong>A fracture risk calculator is available online.\u00a0 Patient\u2019s individual risk can be calculated based upon age, weight, height, bone density (at the femoral neck only), and medical history as well.\u00a0\u00a0 This tool is helpful in estimating risk for future fracture.\u00a0 This tool is valid for patients who are treatment na\u00efve.\u00a0 The calculator is available at http:\/\/www.shef.ac.uk\/FRAX\/<\/a>\u00a0 (Please note that the DEXA machine utilized at Sanford in Fargo and Bemidji is a GE Lunar machine and that the database used for establishing risk is variable based upon location and ethnicity.)<\/p>\n

Nutrition Counseling<\/h2>\n

CALCIUM:<\/strong>\u00a0 Recommend that patients obtain at least 1200mg daily in total.\u00a0 Additional calcium <\/a>may be necessary for patients with malabsorption and other disorders, and less may be necessary for patients with certain other medical conditions.\u00a0 High doses risk kidney stone development.\u00a0 It is best to get calcium from dietary sources if possible.\u00a0 For patients who have undergone gastric bypass<\/a> or for patients on proton pump inhibitors who require supplemental calcium, calcium citrate is preferred to calcium carbonate for absorption.<\/p>\n

VITAMIN D:<\/strong>\u00a0 Recommend vitamin D level of 30ng\/dL as lower limit of acceptable values, though some physicians recommend levels between 40-60ng\/dL.\u00a0 Typical safe daily intake is 800-1000 units cholecalciferol daily for patients 50 and older.\u00a0 Many patients require more than this to maintain normal levels of vitamin D.\u00a0 Some patients may not require any, and risks are present with high doses. All patients are different and these recommendations may or may not apply to individual patients. <\/strong><\/p>\n

Physical Activity Counseling<\/h2>\n

WEIGHT-BEARING ACTIVITY:\u00a0 <\/strong>When possible, patients should participate in weight-bearing exercise, such as walking.\u00a0 Physical therapy is encouraged for patients at risk of falls.\u00a0 Fall prevention should be emphasized along with safety of the living environment (avoiding throw rugs, electric cords, small pets, etc).<\/p>\n

Lifestyle Counseling<\/h2>\n

All patients should be encouraged to stop smoking and to avoid excessive alcohol intake.<\/p>\n

Pharmacology<\/h2>\n

Treatment is indicated if hip or vertebral fracture (clinical or morphometric).\u00a0After a thorough history and physical examination, secondary cause evaluation of bone loss\/bone health may be reasonable.\u00a0\u00a0 Appropriate testing may include: complete blood count, chemistry group, work-up for hypogonadism<\/a>, cushing\u2019s syndrome<\/a>, myeloma, vitamin D deficiency, celiac disease, thyroid dysfunction<\/a>, hypophosphatasia<\/a>, renal and liver dysfunction, osteomalacia, hyperparathyroidism, hypercalciuria, malabsorption, inflammation.\u00a0 If these are found, treating the underlying condition may significantly improve bone health.\u00a0 Certain medications such as steroid medications (including injections, oral, inhaled, and potentially nasal), anticonvulsants, Depo-provera,\u00a0 SSRI, thiazolidinediones, and proton pump inhibitors, can lead to bone loss.<\/p>\n

If there are any questions about which medication to choose, or how to proceed with the secondary cause evaluation, or to obtain more patient-specific recommendations, an endocrinology<\/a> consultation is welcome.\u00a0 The use of an expensive medication, such as teriparatide, is often worth evaluation for secondary causes to be sure the medication can be efficacious.\u00a0 There are many medications available to decrease fracture risk.\u00a0 The effects on bone density and fracture risk reduction are as below.<\/p>\n\n\n\n\n\t\n\t\n\t\n\t\n\t\n\t\n\t
<\/td>Bone Density Effects (spine)<\/td>Bone density Effects (hip)<\/td>Spine fracture risk reduction<\/td>Hip fracture risk reduction<\/td>Nonvertebral fracture risk reduction<\/td>\n<\/tr>\n
Calcitonin (Miacalcin)<\/td>None<\/td>None<\/td><\/td><\/td><\/td>\n<\/tr>\n
Raloxifene (Evista)<\/td>++<\/td>+<\/td>-<\/td>No data<\/td>No data<\/td>\n<\/tr>\n
Oral bisphosphonates (Alendronate, Risedronate, Ibandronate)<\/td>+++<\/td>++<\/td>-<\/td>-<\/td>-<\/td>\n<\/tr>\n
IV bisphosphonates (Ibandronate, Zoledronic acid)<\/td>+++<\/td>++<\/td>-<\/td>-<\/td>-<\/td>\n<\/tr>\n
Denosumab (Prolia)<\/td>+<\/td>+<\/td>-<\/td>-<\/td>-<\/td>\n<\/tr>\n
Teriperitide (Forteo)<\/td>++++<\/td>+<\/td>-<\/td>No data<\/td>-<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n

Calcitonin (Miacalcin)<\/h2>\n

Mechanism of Action:<\/strong> directly inhibit osteoclast bone resorption<\/p>\n

FDA approved Indications:<\/strong> Postmenopausal osteoporosis, hypercalcemia, Paget\u2019s disease<\/p>\n

Contraindication:<\/strong> Hypersensitivity to calcitonin<\/p>\n

Precaution:<\/strong> Could cause hypocalcemic tetany<\/p>\n

Side Effects:<\/strong> Flushing, nausea, dizziness (orthostasis), allergic reaction, injection site reaction, rash, nasal irritation, peripheral edema, eye pain, visual changes, increased urination<\/p>\n

Monitoring:<\/strong> Bone density, nasal examination, monitor for allergy, bone turnover markers, evidence for fracture, urine sediment<\/p>\n

Raloxifene (Evista)<\/h2>\n

Mechanism of Action:<\/strong> Selective Estrogen Receptor Modulator, reducing bone resorption and increases BMD (bone mineral density)<\/p>\n

FDA approved Indications:\u00a0\u00a0 <\/strong>Post-menopausal osteoporosis\u2014treatment and\u00a0 prophylaxis; Invasive breast cancer with postmenopausal osteoporosis, prophylaxis; Invasive breast cancer with postmenopausal women at high risk, prophylaxis<\/p>\n

Contraindication:<\/strong> VTE history, nursing mothers, pregnant women or women who may become pregnant<\/p>\n

Black box warning:<\/strong> Increased risk for DVT and PE.\u00a0 Women with active clotting or history of VTE should not use raloxifene.\u00a0 Increased risk of death due to stroke in post-menopausal women with history of CAD or at risk for cardiac event who took raloxifene was seen.\u00a0 Consider risk\/benefit ratio in women at risk for stroke<\/p>\n

Precaution:<\/strong> immobilization period, thromboembolic disease or risk of, CAD or high cardiac risk, hypertriglyceridemia, premenopausal women, use with estrogen, stroke risk.<\/p>\n

Side Effects:<\/strong> Hot flashes, peripheral edema, clotting, hypertriglyceridemia<\/a>, retinal vein thrombosis<\/p>\n

Monitoring:<\/strong> breast exams, mammograms, bone density, monitor for adverse effects especially in patients with hepatic or renal dysfunction, eye exams, INR in patients on Coumadin starting or stopping therapy triglycerides<\/p>\n

Oral bisphosphonates<\/h2>\n

Mechanism of Action:<\/strong> binds to bone hydroxyapatite, decreases osteoclast activity, affects bone metabolism<\/p>\n

FDA approved Indications:\u00a0 Alendronate (Fosamax):<\/strong> male osteoporosis, corticosteroid-induced osteoporosis, Paget\u2019s disease, postmenopausal osteoporosis, prophylaxis for post-menopausal osteoporosis.\u00a0 Risedronate (Actonel): <\/strong>male osteoporosis, corticosteroid-induced osteoporosis, prophylaxis for corticosteroid-induced osteoporosis, Paget\u2019s disease, postmenopausal osteoporosis, prophylaxis for post-menopausal osteoporosis.\u00a0 Ibandronate (Boniva):<\/strong> postmenopausal osteoporosis, prophylaxis for post-menopausal osteoporosis<\/p>\n

Contraindications:<\/strong> esophageal dysmotility, uncorrected hypocalcemia, inability to sit\/stand for 60minutes, hypersensitivity to the medication<\/p>\n

Precaution:<\/strong> renal dysfunction, hypocalcemia, hypovitaminosis D, atypical fractures of the thigh, Barret\u2019s esophagus, esophagitis, ulcers, upper GI irritation, bone pain, renal impairment (CrCl <30), concurrent use with proton pump inhibitors.\u00a0 Osteonecrosis of the jaw<\/strong>\u2014increased risk with anemia, coagulopathy, cancer patients, steroid use, chemotherapy, radiation, dental disease, infection, dental procedures<\/p>\n

Side Effects:<\/strong> Ulceration of esophagus, duodenum,\u00a0 gastric; arthralgia, osteonecrosis of the jaw, bone pain, myalgia, GI symptoms, flu-like symptoms, fever, vomiting, rash, asthenia<\/p>\n

Monitoring:<\/strong> Paget\u2019s disease \u2013improvement in signs\/symptoms, normalization of alkaline phosphatase .\u00a0 Osteoporosis\u2014BMD, decreased fracture incidence.\u00a0 Glucocorticoid-induced\u2014monitor BMD. BMD, Dental exams for signs of osteonecrosis of the jaw,\u00a0 biochemical markers of bone formation\/resorption, evidence of fractures, calcium, electrolytes, phosphate levels, renal function, joint\/bone\/muscle pain, signs of esophageal reaction\/dysphagia, disorders affecting bone metabolism (calcium levels)<\/p>\n

IV bisphosphonates<\/h2>\n

Mechanism of action:<\/strong> (Zoledronic Acid)\u00a0 inhibits bone resorption, inhibits osteoclast activity, induces osteoclast apoptosis, blocks resorption of mineralized bone and cartilage through bone binding.<\/p>\n

FDA approved indications: \u00a0\u00a0Zoledronic acid (Reclast)<\/strong> : postmenopausal osteoporosis, male osteoporosis, prophylaxis for post-menopausal osteoporosis, secondary osteoporosis prophylaxis in patients with low trauma hip fracture, corticosteroid-induced osteoporosis prophylaxis or treatment, Paget\u2019s disease, hypercalcemia, multiple myeloma, bone metastasis.\u00a0 Ibandronate (Boniva):<\/strong> postmenopausal osteoporosis, postmenopausal osteoporosis prophylaxis<\/p>\n

Contraindications:<\/strong> CrCl <35, hypocalcemia, renal failure, hypersensitivity to the medication<\/p>\n

Precaution:<\/strong> renal dysfunction, hypocalcemia, hypovitaminosis D, atypical fractures of the thigh, aspirin-sensitive asthma, bone pain, renal impairment (CrCl <30), pregnancy (should not use).\u00a0 Osteonecrosis of the jaw<\/strong>\u2014increased risk with anemia, coagulopathy, cancer patients, steroid use, chemotherapy, radiation, dental disease, infection, dental procedures<\/p>\n

Side Effects:<\/strong> Flu-like\u00a0 symptoms; arthralgia, osteonecrosis of the jaw, bone pain, myalgia, fever, vomiting, renal failure, atrial fibrillation, CVA, dyspnea<\/p>\n

Monitoring:<\/strong> \u00a0<\/strong>calcium, alkaline phosphatase in Paget\u2019s disease, skeletal events, BMD, creatinine, calcium, phosphorus, magnesium (especially in those at risk for hypocalcemia<\/a>), fluid status (should be hydrated prior to use)<\/p>\n

Denosumab (Prolia)<\/h2>\n

Mechanism of Action:<\/strong> receptor activator of NF Kappa B Ligand (RANKL) inhibitor resulting in decreased osteoclast activity and decreased bone resorption<\/p>\n

FDA approved indications:<\/strong> postmenopausal osteoporosis, osteopenia in men at high risk receiving androgen-deprivation therapy for non-metastatic prostate cancer, breast cancer in women with osteopenia receiving aromatase therapy, bone metastasis with solid tumors<\/p>\n

Contraindications:<\/strong> hypocalcemia<\/p>\n

Precautions:<\/strong> hypocalcemia, especially in renal failure patients (monitoring necessary per nephrology recommendations\/protocol), at risk for osteonecrosis of the jaw (as above)<\/p>\n

Side Effects:<\/strong> infections, hypocalcemia, hypophosphatemia, rash, diarrhea, arthralgia, fatigue<\/p>\n

Monitoring:<\/strong> skeletal events\/fractures, calcium, phosphorus, magnesium, dental exams for osteonecrosis of the jaw, signs and symptoms of bone turnover suppression such as atypical fractures and delayed fracture healing.<\/p>\n

Teriparatide (Forteo)<\/h2>\n

Mechanism of Action:<\/strong>\u00a0 works like PTH to activate osteoblasts when given in a pulsatile fashion<\/p>\n

FDA approved indications<\/strong>: osteoporosis (primary or hypogonadal), osteoporosis due to corticosteroids, postmenopausal osteoporosis<\/p>\n

BLACK BOX WARNING:<\/strong> \u00a0osteosarcoma has been reported in laboratory animals, so it should not be used in patients with unexplained elevation in alkaline phosphatase, history of implanted or external beam radiotherapy, Paget\u2019s disease, open epiphyses<\/p>\n

Contraindications:<\/strong> hypersensitivity to the medication<\/p>\n

Precautions:<\/strong> active or recurrent kidney stones, bone metastasis\/skeletal malignancies, metabolic bone disease, Paget\u2019s disease, open epiphyses, patients at risk for osteosarcoma, pediatric populations, history of radiation, preexisting hypercalcemia, unexplained elevation of alkaline phosphatase, use for more than 2 years not recommended, orthostasis has been reported<\/p>\n

Side effects:<\/strong> angina, hypotension, syncope, nausea\/vomiting, arthralgia<\/p>\n

Monitoring:<\/strong> biochemical markers of bone formation\/resorption, fracture, calcium, urine calcium in patients with history of nephrolithiasis\/hypercalciuria, uric acid, orthostatic hypotension, signs\/symptoms of osteosarcoma<\/p>\n

References<\/h2>\n