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DISCLOSURES
SPEAKER ON OCCASION FOR 1. P&G 2. Pfizer 3. Merck 4. Novartis
GOAL
Review advances in the diagnosis and treatment of osteoporosis
OBJECTIVES
1. Show the impact of osteoporosis on the
osteoporosis
3. Outline evidence-based treatment
Osteoporosis
Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.
NIH Consensus Development Conference, March 2000
Normal Bone
Osteoporotic Bone
Osteoporosis
8 million Osteoporotic Women and 2.5 million Osteoporotic Men in USA
Expected to increase by about 40% by 2020 1 Estimated Direct costs in 2001 = $ 11.6 - 17.1 billion annually 1
1 Surgeon-Generals
Prevalence of VCFs
Lifetime prevalence in Caucasians:
15% in women 5-9% in men
Osteoporotic fractures, Cardiovascular events & Breast cancer in osteoporotic postmenopausal women
120
100 80 60 40 20 0
Prior spine fracture (1627) No prior spine fracture (938) from Silverman et al, 2004 J Am Geriatr Soc 52:1543-8
Each year, one in three Ontarians over the age of 65 will take a serious tumble that may land them in hospital with a broken hip. One in three of those who do break their hip will die within a year. Two thirds will experience dementia-like symptoms. Most will never see home again.
Osteoporosis-associated Mortality
Age-standardised mortality risk increased 2-3 fold after all types of osteoporotic fracture Women 2.2 1.7 1.9 Men 3.2 2.4 2.2
Proximal femur
Vertebral Other major
Despite the introduction of methods to identify those with osteoporosis and despite effective treatment, a large care gap continues to exist for these patients.
ASSESSMENT
MANAGEMENT
1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141. 2. WHO, Geneva 1994.
ABOUT T-SCORES?
Advantages Unitless Basis for the majority of osteoporosis guidelines Simplicity Disadvantages Depends on site measured Depends on technology Depends on reference databasepopulation mean and standard deviation
Risk of Fractures Over 10 Years in Women AGE T-Score = -1.0 T-Score = -2.5
50 60
70
6% 8%
12 %
11 % 16 %
23 %
80
13 %
26 %
Proposed Change
Previous OSC guidelines advised intervention based on WHO category as a marker of relative fracture risk.
Now propose that an individuals 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization
Absolute fracture risk in 10 years: low: <10% moderate: 10-20% high: >20%
WOMEN
0.0 -0.5
Low Risk
LOWEST T-Score
Moderate Risk
High Risk
AGE (years)
High Risk
55 60 65 70 75 80 85
AGE (years)
When both factors are present the patient should be considered at high risk regardless of the BMD result.
CASE EXAMPLE
Woman age 52 - t is -2.6 Fracture Risk Category?
CASE EXAMPLE
WOMEN
0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0 -4.5 50 55 60 65 70 75 80 85
Low Risk
LOWEST T-Score
Low Risk
Moderate Risk
Moderate Risk
High Risk
High Risk
AGE (years)
CASE EXAMPLE
WOMEN
AGE
50 55 60 65 70 75 80 85
LOW <10%
>-2.3 >-1.9 >-1.4 >-1.0 >-0.8 >-0.7 >-0.6 >-0.7
HIGH >20%
<-3.9 <-3.4 <-3.0 <-2.6 <-2.2 <-2.1 <-2.0 <-2.2
CASE EXAMPLE
Fracture Risk Category Moderate Risk
CASE EXAMPLE
Fracture Risk Category Moderate Risk If Fragility Fracture History High Risk
CASE EXAMPLE
70 year-old man BMD done because of strong family history of osteoporosis (mother fractured hip, sister has OP) Lowest T-score 2.7 in total hip
Low Risk
X
Moderate Risk
High Risk
55 60 65 70 75 80 85
AGE (years)
CASE EXAMPLE
Fracture Risk Category
Moderate Risk
CASE EXAMPLE
Fracture Risk Category Moderate Risk If Fragility Fracture History, Corticosteroid use High Risk
Endorsements
Canadian Association of Nuclear Medicine Canadian Association of Radiologists Canadian Rheumatology Association International Society of Clinical Densitometry Society of Obstetricians and Gynecologists of Canada Canadian Society of Endocrinology and Metabolism
PTH
Vitamin D Life Style
20
40
60
80
Age
RR 95% CI
RLX 60, 120 (MORE)*** ALN 5/10 (FIT1)*
CT 200 (PROOF)* Teriparatide 20g* Strontium ranelate (SOTI)* Strontium ranelate (SOTI +TROPOS)** 0.2 0.6 1.0
CT 200 (PROOF)* Teriparatide 20g* Strontium ranelate (SOTI)* Strontium ranelate (TROPOS)*** 0.2 0.6 1.0
30
20 10 0 18
Placebo (n = 20)
Etidronate (n = 20)
3-year RCT, 66 subjects High risk subgroup: reduction in fracture rate with etidronate, p = 0.023 No statistically significant effect at nonvertebral sites
p=NS
alendronate
% of cohort with a hip fracture
0.50
80 fractures n= 21,615
0.40
29 fractures n = 12,215
0.30
risedronate
46%*
Adjusted Relative Rate Reduction at Month 6 p = 0.02 95% CI: 9% - 68%
Month 6
0.20
43%*
Adjusted Relative Rate Reduction at Month 12 p = 0.01 95% CI: 13% - 63%
Month 12
0.10
0.00 Baseline
Silverman SL. Osteoporos Int 2007 Jan;18(1):25-34. Epub 2006 Nov 15.
Osteoporosis in Men
Has Its Time Come?
HEADLINES 7.8.07
Back injuries. If you think that golf is for wimps, consider this: A golf swing puts a higher compressive load on the low back (8 times body weight) than running (3 times) or even rowing (7 times). Thats why a single swing can produce a herniated disc or even a compression fracture of one of the vertebral bodies. Although these injuries are extremely painful and can be quite serious, they are rare. Muscle strains, however, are quite common because of the twisting that is required for a good swing. The modern swing, with its inverted-C follow-through, may make for longer drives than the classic swing but it also produces more torque and more injuries (see Golf injuries above).