OsteoporosisBy Jody Vulk PA-C Northwest Iowa Bone, Joint & Sports Surgeons

Osteoporosis

“Porous bone“

Bones lose protein & mineral content

Clinical Definitions of OP

Vertebral height loss of > 25% of the vertebral body

2 compression fractures

2 or more fragility fractures

A fracture from forces that would not ordinarily cause fracture in a healthy young adult.

Quantified as forces equivalent to a fall from a standing height or less.

FRAGILITY FRACTURES

Types of Fragility Fractures Compression Fractures of the Vertebra

Proximal Humerus

Distal Radius Fractures

Hip Fractures

True or False

#1 Spine

#2 Wrist

#3 Hip

Most Common Fragility Fractures are:

True Spine 27%

Wrist 19%

Hip 14%

Bone Cells

Osteoclasts

■ Remove or retire old bone.

■ Active throughout lifetime.

Osteoblasts

■ Create new bone

■ Best before age 35 & before menopause

OsteoclastsRemove Old Bone

(Classic)

Osteoblasts Create new bone (having a Blast!)

In Osteoporosis

More of these working… than these.

Osteoclasts

■ Remove or retire old bone.

■ Active throughout lifetime.

Osteoblasts

■ Create new bone

■ Best before age 35 & before menopause

Dual Energy X-ray Absorptiometry

BMD Levels

Normal = 0 to -0.9 T-Score

Osteopenia = -1 to -2.4 T-

Score

Osteoporosis = -2.5 T-

Score

Who needs a BMD? A woman nearing menopause (for baseline)

Men over the age of 70

Women 65 or older (& have never had one)

Those with risk factors for osteoporosis

How often to Test Normal BMD=15 years

Osteopenia=5 years

Severe Osteopenia=1 year

85 or older=3 years

Bone Minerals

True or False

To avoid Osteoporosis--

just is drink more milk.

False

Calcium + Vitamin D + Magnesium+ Phosphorus + Alkaline Phosphatase =

Good Quality Bones

Foods for Healthy Bones

Calculate Need

1000-1500m

gDaily

Calcium supplements

Calcium Citrate

Take with or without food

21% Calcium

More frequently causes gas, bloating, constipation

Calcium Carbonate

Requires stomach acid, take with food

40% Calcium

Fewer side effects

Inexpensive

Calcium Zappers

Osteoporosis & Vitamin D Deficiency

1 Billion worldwide

1/3 of OP patients also Vitamin D deficient

Vitamin D deficiency is not age dependent.

Vitamin D is created through the skin by exposure to sunlight

Vitamin D and Sunlight

You must live near the equator to rely on its benefits.

True or False

Caucasians are more prone to Vitamin D deficiencies than those with darker skin.

False

Darker skin does not absorb

Vitamin D as well.

Vitamin D Rich foodsFatty fish *Cod Liver oil(1360 IU)Swordfish(566 IU) Salmon(sockeye)(447 IU) Tuna(154 IU)

*avoid Cod liver oil

Fortified foods:

Milk (115 IU) Orange juice (137 IU)

Egg yolks (41 IU).

Vitamin D SupplementsErgocalciferol (Vitamin D2)

Fungal derivative

Vegan supplement

Cholecalciferol (Vitamin D3)

Synthesized in the skin

Wool oil

Preferred supplement

New GuidelinesAge DosageAdults < 50 *400 to 800 IU daily

Adults > 50 *800 to 1,000 IU daily

Normal Vitamin D level, do not exceed 4,000IU daily.

*Do not commit these to long term memory, follow-up research pending.

Vitamin D Deficiency Risk Factors

Risk Factors of Vitamin D deficiency

Northern Latitudes

<15 minutes of sun

African American, or dark skinned

Elderly

Obesity

Vitamin D Vitamin D is fat soluble, stored in fat

Testing is on blood Loose weight, boost Vitamin D

Who is at risk?

True or False

Men do not need to be tested for Osteoporosis.

False 2 million men have

OP

Men are more likely to die in the first year

after hip fracture.

Men who fracture are less likely to be

tested.

Early Signs of Osteoporosis

Joan Surber Age 68

Pelvic Fracture 1/28/2012

T-Score of -2.5 in her Lumbar Spine, -1.8 in the Right hip and a -2.2 in the Left hip.

Vitamin D=12ng/mL

Severe Osteoporosis

T-score –2.5 or less

&

a fragility fracture has occurred.

Leg braces as a child

Menopause at age 34

Calcaneus Fracture at age 42

20+ year history of GERD with medication

use

Severe Secondary Osteoporosis with

Vitamin D Deficiency

Risks factors & Prevention Don’t have it in your genes

Hormone replacement (at the guidance of your PCP)

Not recommending to avoid this one.

Avoid long-term use of bone depleting medications

Heredity/Ethnicity

Hormonal Changes (Estrogen & Testosterone)

Aging

Pharmaceuticals

(Cont.) Risk Factors & Prevention

Low BMI

History of Fracture

EAT! -a diet rich in colors and eat real foods!Bubble wrap

(Cont.) Risk Factors & PreventionMalabsorption

Poor Diet

Smoking

Alcohol in excess

Lack of Exercise

Avoid Gastric Bypass, Celiac Sprue, Anorexia… Eat FOODs rich in Vitamins and minerals

Don’t do that!

Limit alcohol to no more than 2 beverages dailyWeight bearing exercises such as walking, tia chi, & weight lifting/resistance exercises

Types of OsteoporosisPrimary

Relatively unknown cause other than advancing age and postmenopausal

Secondary

Has a known cause or reason for having developed (i.e.=oral corticosteroid use, other medications, diseases or conditions)

True or FalseKyphosis of the spine is “normal for aging.”

False

Decreasing height and humped back are not normal. They are indications of compression fractures.

NWIA Bone Approach

But orthopedists fix bones, Right?

Anyone over 50 with a fractured bone from ground height.

We Evaluate

Own The Bone Nutrition Counseling

• Calcium• Vitamin D

Physical Activity Counseling• Weight-bearing and muscle-strengthening exercise• Fall prevention education

Lifestyle Counseling• Smoking Cessation• Limiting excessive alcohol intake

Pharmacology• For the treatment of osteoporosis

Testing• Dual Energy X-Ray Absorptiometry (DXA)

Communication• Physician referral letter• Follow-up note and educational material to patie

Step-wise Approach

Remove Bisphosphonates Fracture immobilization/ fixation Draw Labs/BMD Vitamin D Correction Heal the Fracture

Initially After a Fracture

Step-wise Approach

Check Vitamin D Increase bone mass if warranted Fracture Risk Assessment Educate patients on calcium,

Vitamin D, exercises Resume Bisphosphonates

Through the OP Clinic

Medications

National Osteoporosis Foundation

Recommends treatment:

T-score is less than -2.0Or

Less than -1.5 with a risk factor

(after the fracture has healed )

Medication Route and Frequency Use

Alendronate Oral; Daily or Weekly Prevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction

Calcitonin Intranasal; Daily Management

Ibandronate Oral or IV; Daily/Monthly/q 3 mo.

Prevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction

Raloxifene Oral; Daily Prevent/Manage +Breast CA prevention

Risedronate Oral; Daily or Weekly Prevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction

Teriparatide Injection; Daily Management

Denosumab SubQ; q 6 mo. Management +Breast CA prevention

Zoledronic acid Injection; yearly Management

Exercises

True or FalseSwimming is a great exercise to prevent osteoporosis.

FalseSwimming does not prevent osteoporosis. Only weight bearing exercises prevent osteoporosis.

Balance Training & Good Posture

Resistance Training & Stretching

Weight Bearing Exercise

ReviewCalcium + Vitamin D + Magnesium+ Phosphorus + Alkaline Phosphatase =

Good Quality BonesVitamin D3

Calcium Carbonate

Game Time

What are the top three types of compression fractures?

#1

#1) Spine 27%

#2) Wrist 19%

#3)Hip 14%

What are the top three definitions of clinical osteoporosis?

#2

Clinical Definitions of OP

#1) Vertebral height loss of > 25% of the vertebral body

#2) 2 compression fractures

#3) 2 or more fragility fractures

What are the top objective (laboratory/radiological) definitions of good bone health?

(I have 6 answers)

#3

Good Bone Health BMD with T-score from 0- 0.9. Vitamin D > 30ng/mL Calcium (within local lab normal limits) Magnesium (within local lab normal limits) Alkaline Phosphatase (within local lab normal

limits)

Phosphorus (within local lab normal limits)

List the top sources of Vitamin D.

(7 were listed)

#4

Vitamin D sources1. Sunlight2. Cod liver oil3. Swordfish4. Salmon5. Tuna6. Fortified Milk7. Fortified Orange Juice(Eggs also pictured)

What are some great exercises for preventing bone loss?

(I have listed 6)

#5

Exercises to prevent bone loss Walking Yoga Tai Chi Weight or Strength/Resistance training Balance training Good Posture

What are the top risk factors for developing OP?

( I discussed 11)

#6

OP Risk Factors1. Hereditary/ Ethnic background2. Hormonal changes3. Age4. Medications5. Low BMI6. Previous Fractures7. Malabsorption8. Poor diet9. Smoking10. Alcohol11.Lack of exercise

References

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Watts, Dr. Nelson ,MD Bone Health and OP Center University of Cincinnati, May 18-21, 2011 International Symposium of Osteoporosis, Las Vegas, Nevada (IOF course)