Primary care for all ages

Vipul V. Parikh, MD November 21, 2008

OSTEOARTHRITIS & OSTEOPOROSIS

Sticks and Stones may break my bones but Arthritis can really hurt me!

Vipul V. Parikh, MD November 21, 2008

OSTEOARTHRITIS & OSTEOPOROSIS

Learn about the causes of both diseases and whether you are at risk Learn about the signs and symptoms Learn how the diagnosis can be made Understand what can be done to prevent these diseases Discuss treatments available once you have the diagnosis

OSTEOARTHRITIS & OSTEOPOROSIS What is the difference?

Osteoarthritis is primarily a disease of the joints

Osteo = bone Arthritis = joint inflammation

Osteoporosis is a disease of the bones

Osteo = bone Porosis = a porous condition

OSTEOARTHRITIS

OSTEOARTHRITIS What is It?

Also known as Degenerative Joint Disease (DJD) or Osteoarthrosis Wear and tear kind of arthritis Affects 27 million adults in U.S. Can affect one joint or many joints Joints most commonly affected are knees, hips, hands, and spine

OSTEOARTHRITIS What is It?

Normal joint
Cartilage Synovial fluid and membrane Bursa Articulation of various bones Muscle, tendon, ligament, fat and bones

OSTEOARTHRITIS What is It?

Degeneration
Loss or damage of cartilage Distorted mechanics, grinding Bone cyst and scar formation

OSTEOARTHRITIS What is It?

Abnormal compensatory response

New bone formation bone spurs Inflammation (occasionally) fluid, swelling, redness

OSTEOARTHRITIS What Causes It?

Genetic Factors Gender - women > men Trauma (micro or macro) Co-morbid medical conditions Age-related processes

OSTEOARTHRITIS Am I at Risk?

Genetic Factors
Twin-twin and non-twin studies confirm that the influence of genetic factors is anywhere from 39-65% These factors are not well understood and are still being researched

OSTEOARTHRITIS Am I at Risk?

Gender
Before age 45 - men > women After age 45 - women > men Fewer women are offered hip replacement surgery than men

OSTEOARTHRITIS Am I at Risk?

Trauma
Occupation

Sports

Injury

OSTEOARTHRITIS Am I at Risk?

Co-morbid medical conditions

Obesity Acromegaly Pseudogout

OSTEOARTHRITIS Am I at Risk?

Age-related processes

Felson D. N Engl J Med 2006;354:841-848

OSTEOARTHRITIS What might I feel?

OSTEOARTHRITIS What might I feel?

Pain Swelling Stiffness Grinding Other signs of inflammation

OSTEOARTHRITIS How is it diagnosed?

History Physical Examination

OSTEOARTHRITIS How is it diagnosed?

Laboratories ANA, ESR, RF X-rays

OSTEOARTHRITIS How is it prevented?

Exercise safely Listen to your body Weight loss

OSTEOARTHRITIS Treatment Options - Exercise

Exercise - types
Strengthening Aerobic fitness Range of motion

OSTEOARTHRITIS Treatment Options - Exercise

Exercise - benefits
Improves strength of surrounding muscles Allows increased flexibility of muscles, tendons, and ligaments Helps with reduction or maintenance of weight Good for cardiovascular fitness Gives sense of well-being

OSTEOARTHRITIS Treatment Options - Exercise

Exercise
DOs
Walking Swimming Bicycling Stretching/Strengthening Yoga/Tai Chi

DONTs
High impact exercises

OSTEOARTHRITIS Treatment Options - Exercise

Exercise

OSTEOARTHRITIS Treatment Options - Medications

#1 Acetaminophen
+ safe, effective, inexpensive - wears off quickly, cannot use in liver disease

OSTEOARTHRITIS Treatment Options - Medications

NSAIDs (eg. ibuprofen, naproxen)

+ effective, sometimes longer acting, inexpensive - stomach ulcers/irritation, toxic to kidneys

COX-2 inhibitors (eg. celecoxib)

+ effective, less GI side effects - increase in cardiac risk (high dose), cost, toxic to kidneys

OSTEOARTHRITIS Treatment Options - Medications

Opiate analog (eg. tramadol) Opiate medications (eg. codeine) Glucosamine-chondroitin

NIH study some benefit in moderate to severe osteoarthritis

Pharmacologic Treatment for Osteoarthritis of the Knee

Felson D. N Engl J Med 2006;354:841-848

OSTEOARTHRITIS Treatment Options - Injections

Corticosteroid
Anti-inflammatory Temporary relief - variable (< 6 weeks) Optimal frequency is controversial usually not more than every 3 months Risks damage to tendon, soft tissue atrophy

OSTEOARTHRITIS Treatment Options - Injections

Hyaluronic acid derivatives (eg. Synvisc, Hyalgan, Orthovisc)

A normal component of connective tissues (synovial fluid) Series of three to five injections Only approved for use in knees Some studies question the benefit of this treatment

OSTEOARTHRITIS Treatment Options - Surgery

Arthroscopic surgery

OSTEOARTHRITIS Treatment Options - Surgery

Arthroscopic surgery
2002 study concluded that arthroscopic debridement or irrigation was no better than placebo surgery (N Engl J Med 347:81, July 11, 2002) 2008 study concluded arthroscopic irrigation or debridement was no better than maximal medical/physical therapy (N Engl J Med 359:1097, September 11, 2008) May be appropriate for only select patients with loose bodies or meniscal tears

OSTEOARTHRITIS Treatment Options - Surgery

Joint replacement surgery

Hips
Very successful, 90% still functioning well after 10-15 years, some last 25+ years

Knees
Also very successful, 80-90% functioning well after 10 years

Hand
Done less frequently, should be managed by a hand specialist

OSTEOARTHRITIS Treatment Options - Surgery

Joint replacement surgery Who is a candidate?

Severe, symptomatic osteoarthritis that has failed to respond to conservative management Affecting activities of daily living

OSTEOARTHRITIS Treatment Options - Surgery

Joint replacement surgery Maximizing your benefit

If overweight or obese try to lose weight prior to surgery Strengthen surrounding muscles before surgery Choose a high-volume center Follow through with therapy program religiously Be patientand take care of your joint

OSTEOARTHRITIS Alternative Therapies

Muscle rubs Heat/cold packs Vitamins Green tea Electrical stimulation (TENS) Acupuncture

OSTEOARTHRITIS Future Directions

Understanding genetic factors and causes for cartilage breakdown Tissue engineering

Cartilage cell replacement Stem cell transplantation

Gene therapy Other medications

OSTEOARTHRITIS Helpful resources

National Institute of Arthritis and Musculoskeletal and Skin Disease www.niams.nih.gov Arthritis Foundation www.arthritis.org American College of Rheumatology www.rheumatology.org

OSTEOPOROSIS

OSTEOPOROSIS What is It?

Brittle bone disease Natural consequence of aging to some extent but also preventable Affects 10 million people in the U.S. and additional 34 million at risk Not just a disease in women!

OSTEOPOROSIS What is it?

Bones are a living tissue just like our skin or muscle Contains collagen, mineral complexes, and cells

OSTEOPOROSIS What is it?

There is constant activity inside the bone helping to give it strength, but also keeping it lightweight and flexible

OSTEOPOROSIS What is it?

Osteoblasts help create new bone (bricklayer)

Osteoclasts help with resorption of old bone (chisel)

OSTEOPOROSIS What is it?

Over time bones can lose strength Balance between bone formation and bone resorption shifts

OSTEOPOROSIS What is it?

Age birth 25 years osteoblasts > osteoclasts Age 25-50 years

osteoblasts = osteoclasts

Age 50 years and older osteoblasts < osteoclasts Taking care of bones is a lifelong process

OSTEOPOROSIS Am I at risk?
Age Gender females > males Menopausal status Low body weight less than 127 lbs. Ethnicity asian and caucasian > african-american and hispanic Family history Medical conditions (rheumatoid arthritis, celiac sprue, hypogonadism)

OSTEOPOROSIS Am I at risk?

Poor nutrition
Calcium and vitamin D

Lifestyle habits
Smoking Heavy alcohol

Immobility Medications

chronic steroids (prednisone) anti-seizure medicine (phenytoin)

OSTEOPOROSIS How is it diagnosed?

Evaluation of medical history and risk factors during doctors visit Physical exam height measurement, spine evaluation

X-ray may show lack of bone density

OSTEOPOROSIS How is it diagnosed?

Evaluating bone mineral density (BMD) and comparing to norms

OSTEOPOROSIS How is it diagnosed?

Gold Standard bone densiometry (central DEXA) scan

OSTEOPOROSIS How is it diagnosed?

cDEXA Scan evaluates BMD in hip and spine well-established norms for both men and women of different ethnicities minimal discomfort minimal radiation cost-effective as screening less accurate with severe arthritis or hardware present

OSTEOPOROSIS How is it diagnosed?

OSTEOPOROSIS How is it diagnosed?

T score How do I compare to young normal women or men? Z score How do I compare to women or men of my age? T score is more important than Z score in determining fracture risk

OSTEOPOROSIS How is it diagnosed?

T score -2.5 is osteoporosis T score -1.0 to -2.5 is osteopenia

OSTEOPOROSIS Who should be screened?

Women age 65 and older Men age 70 and older Post-menopausal women age <65 with a single additional risk factor Women going through menopause with significant risk factors Men age 50-70 with risk factors Previous low-impact fracture Long-term use of high-risk medication

OSTEOPOROSIS Prevention

Exercise weight-bearing and muscle strengthening

OSTEOPOROSIS Prevention
Calcium 1200-1500mg/day Vitamin D 800-1000 IU/day

OSTEOPOROSIS Prevention

Am I getting enough calcium?

8 oz. glass of milk = 300mg 6 oz. cup yogurt = 300mg 1 oz or 1 cu in. cheese = 200mg 8 oz. fortified orange juice = 300mg

OSTEOPOROSIS Prevention

Avoidance of tobacco products and excessive alcohol

Prevention of falls to prevent fractures Medications - bisphosphonates

OSTEOPOROSIS Treatment Options

Bisphosphonates (eg. alendronate, risedronate, ibandronate, zoledronic acid)

Binds to bone, inhibits osteoclast activity Available in tablet or injectable forms Tablets are poorly absorbed but work well if taken correctly
Take on empty stomach Remain upright and do not eat for -1 hour after taking

Shown to increase BMD and decrease risk of osteoporotic fractures

OSTEOPOROSIS Treatment Options

Estrogen/Hormone therapy
Protective anti-resorptive effect Increases the incidence of breast cancer, coronary heart disease, stroke, and venous thromboembolism May be considered second-line therapy in perimenopausal women

OSTEOPOROSIS Treatment Options

Estrogen Agonist/Antagonist (eg. raloxifene)

Selective estrogen receptor modulator Increases BMD and reduces risk of vertebral fractures Less effective than bisphosphonates and estrogen May lower risk of breast cancer First line agent in those who cannot tolerate bisphosphonate

OSTEOPOROSIS Treatment Options

Calcitonin
Binds to osteoclasts, inhibits resorption Salmon-derived because more potent (beware if you are allergic to salmon) Nasal spray is most popular preparation Less effective than other treatments Helpful in reducing pain from compression fractures of spine

OSTEOPOROSIS Treatment Options

Parathyroid Hormone (eg. teriparatide)

Stimulates more bone formation than resorption Used for those who cannot tolerate bisphosphonates or who continue to have fractures on bisphosphonates Provided as a daily injection Only approved for use up to 24 months

OSTEOPOROSIS Do I need treatment?

OSTEOPOROSIS - Bone density scan with hip or spine T-score -2.5 (YES!) OSTEOPENIA - Bone density scan with hip or spine T-score -1.0 to -2.5 (YES! if FRAX score >3% for hip or >20% for other osteoporosisrelated fracture) Previous vertebral or hip fracture (YES!)

OSTEOPOROSIS What is FRAX?

OSTEOPOROSIS Helpful Resources

National Institute of Arthritis and Musculoskeletal and Skin Disease www.niams.nih.gov National Osteoporosis Foundation www.nof.org International Osteoporosis Foundation www.iofbonehealth.org Fracture Risk Assessment Tool www.shef.ac.uk/FRAX/

Primary care for all ages

Heathcote Health Center 15195 Heathcote Blvd. Suite 330 Haymarket, VA

Bibliography
Webster's New World College Dictionary Copyright 2005 by Wiley Publishing, Inc., Cleveland, Ohio. Arthritis Rheum. 1998 Apr;41(4):687-93. Risk factors for and possible causes of osteoarthritis. Kenneth C Kalunian, MD Section Editor, Peter Tugwell, MD Deputy Editor, Jerry M Greene, MD. Up to Date version 16.2: May 2008 | This Topic Last Updated: September 14, 2007. Surgical therapy of osteoarthritis. Author Kenneth C Kalunian, MD, Section Editor Peter Tugwell, MD Deputy Editor, Jerry M Greene, MD. Up to Date version 16.2: May 2008 | This Topic Last Updated: May 19, 2008

Bibliography
Overview of the management of osteoporosis in postmenopausal women. Authors Hillel N Rosen, MD, Marc K Drezner, MD, Section Editors Clifford J Rosen, MD, Kenneth E Schmader, MD, Deputy Editor Jean E Mulder, MD. Up to Date version 16.2: May 2008 | This Topic Last Updated: June 11, 2008 Osteoarthritis, Publication of the NIH, NIAMS; May 2006. Osteoporosis, Publication of the NIH, NIAMS; December 2007.

Bibliography

Lane N. Osteoarthritis of the Hip. NEJM. Oct 4, 2007; 357:14, 1413-1421. Felson, D. Osteoarthritis of the Knee. NEJM. Feb 23, 2006; 354:8, 841-848.