Osteoporosis Management

Aka: Osteoporosis Management, Osteoporosis Prevention

1. See also
   1. Osteoporosis
   2. Osteoporosis Evaluation
   3. Osteoporosis Secondary Causes
   4. Medication Causes of Osteoporosis
2. Indications: Treatment with Osteoporosis agents
   1. Hip Fracture or Vertebral Fracture history or
   2. Other Fracture site AND Osteopenia at femoral neck, hip or spine (T-Score -1.0 to -2.5) or
   3. Osteoporosis based on femoral neck, hip or spine BMD (T-Score <-2.5)
      1. Evaluate for Osteoporosis Secondary Causes prior to treatment
   4. Osteopenia AND high Fracture risk secondary cause (e.g. prolonged glucocorticoid use)
   5. Osteopenia (T score -1.0 to -2.5) AND abnormal FRAX Score
      1. See Frax Calculator
         1. http://www.shef.ac.uk/FRAX/
         2. Requires hip Bone Mineral Density
      2. FRAX score (10 year Fracture probability) of Hip Fracture >3% or
      3. FRAX score for any Osteoporosis related Fracture >20%
3. Efficacy: Number Needed to Treat (NNT) per agent
   1. Prevention of Hip Fracture over 3 years (NNT)
      1. Vitamin D 800 IU daily: NNT 45
      2. Bisphosphonates (Risedronate, Alendronate, Zoledronic acid): NNT 77-91
      3. Hormone Replacement Therapy: NNT 385
   2. Prevention of Vertebral Fracture over 3 years (NNT)
      1. Bisphosphonates (Zoledronic acid, Risedronate, Ibandronate): NNT 13-20
         1. Note that Alendronate (Fosamax) was less effective with a NNT 37
      2. Calcitonin (Miacalcin): NNT 10 (5 years)
      3. Teriparatide (Forteo): NNT 11 (1.5 years)
         1. Significantly more expensive than Bisphosphonates or Calcitonin ($600/month)
4. Management: General measures and prevention for all patients
   1. General
      1. Calcium and Vitamin D supplementation are most cost effective medications
      2. Even Alendronate (Fosamax), which is generic, runs >$70 per month
   2. Dietary Supplementation
      1. Calcium Supplementation 1200 to 1500 mg per day
         1. Does not increase bone density (but slows loss)
         2. Overdosage above 1500 mg daily weakens bone
      2. Vitamin D Supplementation 800 to 1000 IU orally per day
         1. Increases bone density 1% per year
         2. If Vitamin D Deficiency, then use Vitamin D Replacement protocol
   3. Weight bearing Exercise
      1. See Exercise in Osteoporosis
   4. Smoking Cessation
   5. Limit Alcohol to moderate use (2 or less drinks per day)
   6. Limit Proton Pump Inhibitor use ( Associated with higher risk of Hip Fractures)
      1. Yang (2006) JAMA 296:2947-53
   7. Fall Prevention and Hip Fracture prevention
      1. See Fall Prevention in the Elderly
      2. See Hip Protectors (underwear with trochanter pads)
5. Management: Osteoporosis Treatments considered effective
   1. General
      1. See Indications as above
      2. See General measures for all patients as above
   2. Bisphosphonates
      1. Increases bone density 5-6% per year
      2. Alendronate (Fosamax)
      3. Risedronate (Actonel)
      4. Ibandronate (Boniva)
      5. Zoledronic Acid (Reclast)
   3. Estrogen Replacement Therapy (ERT or HRT)
      1. Standard Dosing
         1. Minimum preventive plasma estradiol level: 60 pg/ml
         2. Maximal effect requires Premarin 0.625
         3. Increases bone density 3-4% per year
      2. Alternative Estrogen dosing
         1. Some effect seen at 0.3 mg or Transdermal Estrogen
         2. 17-beta-estradiol 0.25 mg increases BMD
            1. Prestwood (2003) JAMA 290:1042-8
      3. Fracture protection lost 5 years after stopping ERT
         1. Yates (2004) Obstet Gynecol 103:440-6
   4. Selective Estrogen Receptor Modulator (e.g. Raloxifene)
      1. Similar benefit to Estrogen Replacement
      2. Indicated if unable to take Estrogen Replacement
   5. Calcitonin
      1. Increases bone density 1-2% per year
   6. Teriparatide (Forteo)
      1. Dosing: 20 mcg daily subcutaneously
      2. Recombinant Parathyroid Hormone
      3. Limits: Do not use with bisphosphonate and do not use longer than 2 years
      4. Very expensive
      5. Efficacy: Reduced risk for osteoporotic Vertebral Fractures
         1. Neer (2001) N Engl J Med 344:1434-41
6. Management: Osteoporosis treatments of questionable efficacy
   1. Fluoride Supplementation
      1. Increases bone density 10% per year
      2. Unclear whether bone strength is increased
7. Management: Agents under investigation for possible benefit in Osteoporosis
   1. HMG-CoA Reductase Inhibitor (Statin drugs)
   2. Thiazide Diuretics (e.g. Hydrochlorothiazide)
      1. Decreases urinary calcium loss
      2. Reduction in Hip Fracture if used >10 years
      3. Consider in hypertensive patients
      4. LaCroix (2000) Ann Intern Med 133:516-26
   3. Dietary Magnesium 600 mg/day or more
   4. Dietary Soy Protein 40 grams/day or more
      1. Scheiber (1999) Menopause 6:233-41
8. References
   1. Andrews (1998) Postgrad Med 104(4): 89-97
   2. Campion (2003) Am Fam Physician 67(7):1521-6
   3. Lindsay (1984) Obstet Gynecol 63:759-63
   4. South-Paul (2001) Am Fam Physician 63(6):1121-8
   5. Taxel (1998) Geriatrics 53(8): 22-3