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Talk for primary care illustrating current hot topics in osteoporosis management
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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