Osteoporosis talk july 2012 4 slideshare

70 year old Woman

I only smoke when I drinkI only smoke when I drinkI only smoke when I drinkI only smoke when I drinkI like a glass of I like a glass of wine with my wine with my dinner Doctordinner Doctor

I like a glass of I like a glass of wine with my wine with my dinner Doctordinner Doctor

But Calcium But Calcium supplements cause supplements cause

Heart attacks!Heart attacks!

But Calcium But Calcium supplements cause supplements cause

Heart attacks!Heart attacks!

•Suggests 20-30% increased risk of myocardial infarction in patients taking Calcium supplements

•No significant increase in CVA’s

•Meta-analysis

•Excludes patients taking Ca and Vit D supplements

•At odds with results of WHI study

•Could there be something there?

Possible reduction of risk of MI with higher dietary Ca

Small increased risk of MI with supplements only

My nephew is a My nephew is a dentist.....dentist.....

My nephew is a My nephew is a dentist.....dentist.....

Osteonecrosis of the Osteonecrosis of the jawjaw

Rare in bisphosphonate doses used in OP1:100,000

More common with IV bisphosphonates (but still rare)

Rare in bisphosphonate doses used in OP1:100,000

More common with IV bisphosphonates (but still rare)

•Discuss potential risks and symptoms with patient

•Encourage good dental hygiene

•Pretreatment dental visit not necessary

•< 3yrs treatment with BP• Dental extractions and implants as normal

•> 3 yrs treatment• Stop BP for 3 months before treatment

• Restart when bone healed

Has the treatment Has the treatment worked Doctor?worked Doctor?

Has the treatment Has the treatment worked Doctor?worked Doctor?

Least Significant Change

3.5% Lumbar Spine2.2% Hip

What do the changes mean?What do the changes mean?Fr

actu

re ri

sk %

Adapted from Chapurlat RD et al Osteoporosis Int 2005:16. pp 842848

How much change is significant??

Ideal is increase in BMD

Patients with static BMD still have reduced risk of fracture

Only worry about Decrease

Alternatives to bisphosphonates

(Protelos)Strontium

Yes Yes/No*

(Forsteo)Teriparetide

Yes No

(Evista)Raloxifene

Yes No

Denosumab(Prolia)

Yes Yes

Vertebral Hip

* >75yrs osteoporosis femoral neck

Do we need to treat everybody?

I’m 51 and healthy

T ScoresLS- -2.6Hip -2.6

Google ‘FRAX’

How long do I need to be on treatment?

Do Bisphosphonates work in long term?

After 5 years little to support continued

benefit on fracture risk

Possibility of drug holiday in some (low risk

pts)

Change to alternative agent

Drug holiday?

•Patients with lower risk

•May stop for up to 2 years

•Possible small drop in BMD

•No increased risk of fracture

•Avoid in high risk patients

I’m 51 and healthy

T ScoresLS- -2.6Hip -2.6

Summary

•Encourage Dietary Ca

•For most Single dose Ca supplement plenty

•Not essential to treat everybody!

•Use FRAX to help aid decision

•Monitor for Bone loss (2 yrs)

•Consider revise Bisphosphonates at 5-7yrs

•Consider Drug holiday