Practical Medicine: Osteoporosis

Who to screen?

We screen the following patients:

Men with

  1. Steroid use
  2. Hypogonadism
  3. Androgen deprivation
  4. Past fracture
  5. Frequent falls
  6. Smoking
  7. Loss of height
  8. Malabsorption
  9. Alcohol abuse
  10. Fracture with minimal injury
  11. Osteopenia on routine x-rays
  12. Hyperparathyroidism

Women over the age of 65

Women under the age of 65 with these risk factors:

  1. Steroid use
  2. Hypogonadism
  3. Early Menopause
  4. Past fracture
  5. Parent with hip fracture
  6. Smoking
  7. Inflammatory bowel disease
  8. Malabsorption
  9. Alcohol abuse
  10. Fracture with minimal injury
  11. Osteopenia on routine x-rays
  12. Liver Disease
  13. Rheumatoid Arthritis

What tests to order?

We order the following tests:

  1. DXA
  2. 25-OH Vitamin D
  3. Calcium
  4. Phosphorus
  5. Alkaline Phosphatase
  6. Testosterone in men

Bone Turnover markers are not always reliable

FRAX Score: We use the FRAX Score to decide on who to treat.

How often DXA should be obtained?

We obtain DXA depends on T scores and risk factors:

Every year if

  1. Monitoring treatment of osteoporosis with medication
  2. Fracture despite medical therapy

Every 2 years if 

  1. T score of -2.00 to -2.5
  2. Risk Factors for ongoing bone loss such as steroid therapy

Every 3-5 years if 

  1. T score of -1.50 to -2.00
  2. No risk factors for ongoing bone loss such as steroid therapy

Every 7 -10 years if 

  1. T score of -1.00 to -1.50
  2. No risk factors for ongoing bone loss such as steroid therapy

Who to treat?

We treat the following men and women, 50 years of age or older, if they have a:

  1. Frax Score of 3% or higher for hip fracture with T score of  -1.0 to -2.5
  2. Frax Score of 20% or higher of osteoporosis related fracture with T score of  -1.0 to -2.5
  3. Previous hip fracture
  4. Previous vertebral body fracture
  5. Spine T score of -2.5 or less
  6. Femoral Neck T score of -2.5 or less

Risk modification

We recommend the following for our osteoporosis patients:

  1. Weight bearing exercises
  2. Calcium 1200 mg daily preferably from diet
  3. Vitamin D 600-800 units daily if Vitamin D level is normal
  4. Vitamin D 50,000 units weekly for 8-12 weeks if Vitamin D level is less than 10 followed by Vitamin D 600-800 units daily.
  5. Vitamin D 50,000 units weekly for 8 weeks if level is less than 30 followed by Vitamin D 600-800 units daily.
  6. Fall prevention
  7. Risk factor modification such as smoking, and alcohol abuse
  8. Drug modification and avoidance of medications causing bone loss

Biphosphonates

Biphosphonates:

  1. Alendronate. We find this to be most effective oral therapy.
  2. Risedronate. This can be as effective.
  3. Ibandronate. The oral form is convenient with monthly dosing. The Intravenous form of ibandronate lacks fracture data.
  4. Intravenous Zoledronic acid. This is for those that can not tolerate oral biphosphonates.

We avoid bisphosphonates in patients with:

  1. Esophageal problems such as Barrett’s esophagus
  2. Chronic kidney disease or eGFR of <30
  3. Inability to sit upright
  4. Bone pain with any of the biphosphonates
  5. Osteonecrosis of the jaw
  6. Major dental work; Treatment can be started after released by the surgeon.
  7. Who have taken five years of any of the biphosphonates

Oral biphosphonates have two other issues:

  1. Remembering to take it
  2. Taking it as directed. We print these direction and give it to patients to make sure they take it properly.

Denosumab (Prolia) Injection

Denosumab (Prolia) Injection

We use this medication along with Vitamin D and Calcium for the following patients who have:

  1. Esophageal problems such as Barrett’s esophagus and can not take oral biphosphonates
  2. Chronic kidney disease. We would check with nephrologist before trying in Stage 4 CKD patients.
  3. Inability to sit upright
  4. Bone pain with any of the biphosphonates
  5. Who have taken five years of any of the biphosphonates

We avoid Denosumab in patients:

  1. With low vitamin D. Need vitamin D corrected before starting
  2. With low calcium level. Need this corrected before treatment
  3. For osteoporosis prevention
  4. With osteonecrosis of the jaw

We Monitor Calcium level one month after taking Denosumab injection in patients who may not be compliant with taking Calcium or those with conditions such as kidney failure who are prone develop hypocalcemia.

Teriparatide (Forteo)

Teriparatide (Forteo)

We use Teriparatide in patients with:

  1. T Score of -3.5 or less
  2. T Score of -2.5 or Less plus a fragility fracture (a fracture that occurs after falling from standing height or less that often includes back, hips, and wrists)
  3. T score getting worse despite biphosphonates or Denosumab especially in patients on steroids
  4. Unable to take biphosphonates or Denosumab

We avoid using Teriparatide (Forteo) in patients with:

  1. History of radiation therapy
  2. History of Paget disease of bone
  3. Hypercalcemia as in hyperparathyroidism or conditions such as malignancy that cause hypercalcemia
  4. History of malignancy unless ok with oncology and if benefits outweigh the risks
  5. History of Chronic kidney failure unless ok with nephrology and if benefits outweigh the risks
  6. History of kidney stones unless ok with nephrology and if benefits outweigh the risks
  7. Elevated Alkaline phosphatase of unknown cause
  8. Low vitamin D. Needs corrected before starting

We obtain these tests before and after start of treatment with Teriparatide. We usually give the first dose in office and monitor blood pressure and pulse afterwards:

Before Treatment:

  1. Calcium
  2. 25-OH Vitamin D
  3. Phosphorus
  4. Alkaline Phosphatase
  5. Creatinine
  6. Albumin
  7. 24 urine for Calcium

After treatment:

  1. Calcium level after 2-3 months. If elevated, may need to decrease calcium intake and if still elevated need to look for another cause of the hypercalcemia.
  2. DXA after two years unless there is a fracture after 6 months of therapy. We usually do not see further fractures on teriparatide after 4-6 months of treatment.