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Osteoporosis Management
Aka: Osteoporosis Management, Osteoporosis Prevention- See also
- Indications: Treatment with Osteoporosis agents
- Hip Fracture or Vertebral Fracture history or
- Other Fracture site AND Osteopenia at femoral neck, hip or spine (T-Score -1.0 to -2.5) or
- Osteoporosis based on femoral neck, hip or spine BMD (T-Score <-2.5)
- Evaluate for Osteoporosis Secondary Causes prior to treatment
- Osteopenia AND high Fracture risk secondary cause (e.g. prolonged glucocorticoid use)
- Osteopenia (T score -1.0 to -2.5) AND abnormal FRAX Score
- See Frax Calculator
- http://www.shef.ac.uk/FRAX/
- Requires hip Bone Mineral Density
- FRAX score (10 year Fracture probability) of Hip Fracture >3% or
- FRAX score for any Osteoporosis related Fracture >20%
- See Frax Calculator
- Efficacy: Number Needed to Treat (NNT) per agent
- Prevention of Hip Fracture over 3 years (NNT)
- Vitamin D 800 IU daily: NNT 45
- Bisphosphonates (Risedronate, Alendronate, Zoledronic acid): NNT 77-91
- Hormone Replacement Therapy: NNT 385
- Prevention of Vertebral Fracture over 3 years (NNT)
- Bisphosphonates (Zoledronic acid, Risedronate, Ibandronate): NNT 13-20
- Note that Alendronate (Fosamax) was less effective with a NNT 37
- Calcitonin (Miacalcin): NNT 10 (5 years)
- Teriparatide (Forteo): NNT 11 (1.5 years)
- Significantly more expensive than Bisphosphonates or Calcitonin ($600/month)
- Bisphosphonates (Zoledronic acid, Risedronate, Ibandronate): NNT 13-20
- Prevention of Hip Fracture over 3 years (NNT)
- Management: General measures and prevention for all patients
- General
- Calcium and Vitamin D supplementation are most cost effective medications
- Even Alendronate (Fosamax), which is generic, runs >$70 per month
- Dietary Supplementation
- Calcium Supplementation 1200 to 1500 mg per day
- Does not increase bone density (but slows loss)
- Overdosage above 1500 mg daily weakens bone
- Vitamin D Supplementation 800 to 1000 IU orally per day
- Increases bone density 1% per year
- If Vitamin D Deficiency, then use Vitamin D Replacement protocol
- Calcium Supplementation 1200 to 1500 mg per day
- Weight bearing Exercise
- Smoking Cessation
- Limit Alcohol to moderate use (2 or less drinks per day)
- Limit Proton Pump Inhibitor use ( Associated with higher risk of Hip Fractures)
- Fall Prevention and Hip Fracture prevention
- See Fall Prevention in the Elderly
- See Hip Protectors (underwear with trochanter pads)
- General
- Management: Osteoporosis Treatments considered effective
- General
- See Indications as above
- See General measures for all patients as above
- Bisphosphonates
- Increases bone density 5-6% per year
- Alendronate (Fosamax)
- Risedronate (Actonel)
- Ibandronate (Boniva)
- Zoledronic Acid (Reclast)
- Estrogen Replacement Therapy (ERT or HRT)
- Standard Dosing
- Minimum preventive plasma estradiol level: 60 pg/ml
- Maximal effect requires Premarin 0.625
- Increases bone density 3-4% per year
- Alternative Estrogen dosing
- Some effect seen at 0.3 mg or Transdermal Estrogen
- 17-beta-estradiol 0.25 mg increases BMD
- Fracture protection lost 5 years after stopping ERT
- Standard Dosing
- Selective Estrogen Receptor Modulator (e.g. Raloxifene)
- Similar benefit to Estrogen Replacement
- Indicated if unable to take Estrogen Replacement
- Calcitonin
- Increases bone density 1-2% per year
- Teriparatide (Forteo)
- Dosing: 20 mcg daily subcutaneously
- Recombinant Parathyroid Hormone
- Limits: Do not use with bisphosphonate and do not use longer than 2 years
- Very expensive
- Efficacy: Reduced risk for osteoporotic Vertebral Fractures
- General
- Management: Osteoporosis treatments of questionable efficacy
- Fluoride Supplementation
- Increases bone density 10% per year
- Unclear whether bone strength is increased
- Fluoride Supplementation
- Management: Agents under investigation for possible benefit in Osteoporosis
- HMG-CoA Reductase Inhibitor (Statin drugs)
- Thiazide Diuretics (e.g. Hydrochlorothiazide)
- Decreases urinary calcium loss
- Reduction in Hip Fracture if used >10 years
- Consider in hypertensive patients
- LaCroix (2000) Ann Intern Med 133:516-26
- Dietary Magnesium 600 mg/day or more
- Dietary Soy Protein 40 grams/day or more
- References