II. Indications: Treatment with Osteoporosis agents
- Hip Fracture or Vertebral Fracture history or
- Other Fracture site AND Osteopenia at femoral neck, hip or spine (T-Score -1.0 to -2.5) or
-
Osteoporosis based on femoral neck, hip or spine BMD (T-Score <-2.5)
- Evaluate for Osteoporosis Secondary Causes prior to treatment
- Osteopenia AND high Fracture risk secondary cause (e.g. prolonged Glucocorticoid use)
-
Osteopenia (T score -1.0 to -2.5) AND abnormal FRAX Score
- See Frax Calculator
- http://www.shef.ac.uk/FRAX/
- Requires hip Bone Mineral Density
- FRAX score (10 year Fracture probability) of Hip Fracture >3% or
- FRAX score for any Osteoporosis related Fracture >20%
- See Frax Calculator
III. Efficacy: Number Needed to Treat (NNT) per agent
- Prevention of Hip Fracture over 3 years (NNT)
- Vitamin D 800 IU daily: NNT 45
- Bisphosphonates (Risedronate, Alendronate, Zoledronic acid): NNT 77-91
- Hormone Replacement Therapy: NNT 385
- Prevention of Vertebral Fracture over 3 years (NNT)
- Bisphosphonates (Zoledronic acid, Risedronate, Ibandronate): NNT 13-20
- Note that Alendronate (Fosamax) was less effective with a NNT 37
- Calcitonin (Miacalcin): NNT 10 (5 years)
- Possible increased risk of cancer
- Teriparatide (Forteo): NNT 11 (1.5 years)
- Significantly more expensive than Bisphosphonates or Calcitonin ($600/month)
- Bisphosphonates (Zoledronic acid, Risedronate, Ibandronate): NNT 13-20
IV. Management: General measures and prevention for all patients
-
General
- Calcium and Vitamin D supplementation are most cost effective medications
- Even Alendronate (Fosamax), which is generic, costs >$50 per month
-
Dietary Supplementation
-
Calcium Supplementation 1200 to 1500 mg per day
- Does not increase bone density (but slows loss)
- Overdosage above 1500 mg daily weakens bone
-
Vitamin D Supplementation 800 to 2000 IU (20-50 mcg) orally per day
- Increases bone density 1% per year
- Goal Serum 25-Hydroxy Vitamin D level: 30-100 ng/ml
- If Vitamin D Deficiency, then use Vitamin D Replacement protocol
- Postmenopausal women in community, age <75 do not appear to benefit from Vitamin D supplement
- Does not effect Bone Mineral Density, Muscle Strength, fall risk or function
- Hansen (2015) JAMA Intern Med 175(10): 1612-21 [PubMed]
-
Calcium Supplementation 1200 to 1500 mg per day
- Weight bearing Exercise
- See Exercise in Osteoporosis
- Include balance training for Fall Prevention
- Lifestyle changes
- Tobacco Cessation
- Limit Alcohol to moderate use (2 or less drinks per day)
- Limit Caffeine to <250 mg per day
- Sunlight exposure for 30 minutes daily on at least 5 days per week
- Limit Proton Pump Inhibitor use (associated with higher risk of Hip Fractures)
-
Fall Prevention and Hip Fracture prevention
- See Fall Prevention in the Elderly
- See Hip Protectors (underwear with trochanter pads)
V. Management: Osteoporosis Treatments considered effective
-
General
- See Indications as above
- See general measures for all patients (as above)
-
Bisphosphonates
- Increases bone density 5-6% per year
- Consider stopping oral Bisphosphonates after 5 years (and reclast after 3 years)
- See Bisphosphonates for protocol
- Preparations
- Alendronate (Fosamax)
- Indicated for the prevention and treatment of Osteoporosis (hip, Vertebral, non-Vertebral)
- Oral: 10 mg daily or 70 mg weekly (half dose for prevention)
- Available with Cholecalciferol 2800-5600 IU (Fosamax plus D weekly)
- Most cost effective agent ($60/year in 2020)
- Risedronate (Actonel)
- Indicated for the prevention and treatment of Osteoporosis (hip, Vertebral, non-Vertebral)
- Oral: 5 mg daily or 35 mg weekly or 150 mg monthly
- Available as delayed release (Atelvia) 35 mg weekly
- Costs $1700 per year in 2020
- Ibandronate (Boniva)
- Indicated for the prevention and treatment of Osteoporosis (Vertebral only)
- Oral: 2.5 mg daily or 150 mg monthly
- IV: 3 mg every 3 months (treatment only)
- Zoledronic Acid (Reclast)
- Indicated for the prevention and treatment of Osteoporosis (hip, Vertebral, non-Vertebral)
- IV: 5 mg yearly (every 2 years for prevention)
- Costs $270 per year (in addition to infusion cost)
- Contraindicated in Hypocalcemia or GFR <35 ml/min
- Alendronate (Fosamax)
-
Estrogen Replacement Therapy (ERT or HRT) in women
- Benefits may not outweigh risks of CVA, VTE, CAD, Breast Cancer
- Standard Dosing
- Minimum preventive plasma estradiol level: 60 pg/ml
- Maximal effect requires Premarin 0.625
- Increases bone density 3-4% per year
- Alternative Estrogen dosing
- Some effect seen at 0.3 mg or Transdermal Estrogen
- 17-beta-estradiol 0.25 mg increases BMD
- Fracture protection lost 5 years after stopping ERT
-
Selective Estrogen Receptor Modulator (e.g. Raloxifene) in women
- Similar benefit to Estrogen Replacement with the risks of VTE, but not Breast Cancer, CVA, CAD
- Indicated if unable to take Estrogen Replacement, and only for Vertebral Fracture prevention and treatment
- Raloxifene (Evista) 60 mg orally daily
-
Testosterone Replacement in men
- Increases bone density
- Unclear if prevents osteoporotic Fractures
- Consider in men with symptomatic Hypogonadism
- Example: Low testosterone and low libido
VI. Management: Osteoporosis Treatments for high risk patients
- Indications: High risk Osteoporosis patients
- Recombinant Parathyroid Hormone Analog: Teriparatide (Forteo), Abaloparatide (Tymlos)
- Indicated for Osteoporosis treatment (Vertebral, non-Vertebral, hip) and Vertebral spine Fractures
- Daily Subcutaneous Injection (20 mcg SQ daily for Forteo, 80 mcg SQ daily for Tymlos)
- Precautions: Do not use with bisphosphonate and do not use longer than 2 years (Osteosarcoma risk)
- Very expensive ($20,000 to 46,000 per year in 2020)
- Efficacy: Reduced risk for osteoporotic Vertebral Fractures
- Romosozumab (Evenity) Injection
- SQ Injectable Monoclonal Antibody, sclerositin inhibitor
- Increases bone growth and decreases bone breakdown
- Indicated for high risk women with Fractures despite bisphosphonate or multiple Vertebral Fractures
- Contraindicated if MI or CVA in last year (associated with increased cardiovascular risk)
- Limit to one year of use (effects wane after this) and then switch to bisphosphonate
- Costs $22,000 per year in 2019 (covered under Medicare Part B)
- (2019) Presc Lett 26(6)
- Denosumab (Prolia) Injection
- Indicated for Osteoporosis treatment (Vertebral, non-Vertebral) and Vertebral spine Fractures
- Monoclonal Antibody blocks Osteoclasts (nuclear factor kappa B Ligand activator receptor)
- Dose: 60 mg SQ every 6 months
- Increased risk of infection
- Risk of rebound Vertebral Fractures when stopped or dose delayed
- Switch to bisphosphonate when course completed
- Consider in men with high Fracture risk secondary to androgen deprivation therapy (for Prostate Cancer)
- Cost $2600 per year in 2020
VII. Management: Vertebral spine Fracture medical management
VIII. Management: Agents under investigation for possible benefit in Osteoporosis
- HMG-CoA Reductase Inhibitor (Statin drugs)
-
Thiazide Diuretics (e.g. Hydrochlorothiazide)
- Decreases urinary Calcium loss
- Reduction in Hip Fracture if used >10 years
- Consider in hypertensive patients
- LaCroix (2000) Ann Intern Med 133:516-26 [PubMed]
- Dietary Magnesium 600 mg/day or more
- Dietary Soy Protein 40 grams/day or more
IX. Management: Agents no longer recommended for Osteoporosis treatment
-
Fluoride Supplementation
- Initial studies showed increased bone density 10% per year
- However, unclear whether bone strength was increased
X. References
- (2020) presc lett 27(10): 58-9
- Andrews (1998) Postgrad Med 104(4): 89-97 [PubMed]
- Campion (2003) Am Fam Physician 67(7):1521-6 [PubMed]
- Jeremiah (2015) Am Fam Physician 92(4): 261-8 [PubMed]
- Lindsay (1984) Obstet Gynecol 63:759-63 [PubMed]
- South-Paul (2001) Am Fam Physician 63(6):1121-8 [PubMed]
- Taxel (1998) Geriatrics 53(8): 22-3 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Definition (MEDLINEPLUS) |
Osteoporosis makes your bones weak and more likely to break. Anyone can develop osteoporosis, but it is common in older women. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis. Risk factors include
Osteoporosis is a silent disease. You might not know you have it until you break a bone. A bone mineral density test is the best way to check your bone health. To keep bones strong, eat a diet rich in calcium and vitamin D, exercise and do not smoke. If needed, medicines can also help. NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases |
Definition (MSHCZE) | Časté onemocnění charakterizované úbytkem kostní hmoty, „řídnutí kostí“. Typ I je tzv. o. postmenopauzální (výrazně častější u žen, časté jsou fraktury obratlů a distálního předloktí, postižena je zejm. trabekulární kost), typ II je o. senilní (poměr žen k mužům je asi 2:1, frakturami je postižen skelet axiální i apendikulární, bývají zlomeniny krčku stehenní kosti, postižena je kost trabekulární i kortikální). Příčina není zcela jasná, vyskytuje se ve vyšším věku častěji u žen po přechodu nebo po odstranění vaječníků ještě v plodném období, bývá následkem dlouhodobé nehybnosti, delší léčby kortikoidy nebo důsledkem některých vzácnějších chorob. Vliv má kouření, nadměrná konzumace kávy aj. Projevuje se bolestmi (např. zad) a představuje vyšší riziko zlomeniny (krček stehenní kosti, kompresivní fraktura obratle). K diagnostice lze využít rentgenové vyšetření, osteodenzitometrii, biochemická vyšetření sledující kostní metabolismus. Léčba je dlouhodobá a může spíše jen zastavit další vývoj onemocnění. Uplatňují se kalcium, vitamin D, fluoridy, bisfosfonáty zejm. alendronát, kalcitonin, HRT, SERM, anabolika, symptomatická a fyzikální terapie; velký význam má rehabilitace (a přiměřené zatěžování kostí). Důležitá je prevence (dostatek vápníku, pohyb, u žen podávání pohlavních hormonů po – zejm. předčasném – přechodu, srov. HRT). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
Definition (NCI) | A condition of reduced bone mass, with decreased cortical thickness and a decrease in the number and size of the trabeculae of cancellous bone (but normal chemical composition), resulting in increased fracture incidence. Osteoporosis is classified as primary (Type 1, postmenopausal osteoporosis; Type 2, age-associated osteoporosis; and idiopathic, which can affect juveniles, premenopausal women, and middle-aged men) and secondary osteoporosis (which results from an identifiable cause of bone mass loss). |
Definition (NCI_NCI-GLOSS) | A condition that is marked by a decrease in bone mass and density, causing bones to become fragile. |
Definition (NCI_CTCAE) | A disorder characterized by reduced bone mass, with a decrease in cortical thickness and in the number and size of the trabeculae of cancellous bone (but normal chemical composition), resulting in increased fracture incidence. |
Definition (MSH) | Reduction of bone mass without alteration in the composition of bone, leading to fractures. Primary osteoporosis can be of two major types: postmenopausal osteoporosis (OSTEOPOROSIS, POSTMENOPAUSAL) and age-related or senile osteoporosis. |
Definition (CSP) | loss of bone mass and strength due to nutritional, metabolic, or other factors, usually resulting in deformity or fracture; a major public health problem of the elderly, especially women. |
Concepts | Disease or Syndrome (T047) |
MSH | D010024 |
ICD9 | 733.00, 733.0 |
ICD10 | M81.9 , M81.0, M81.99 |
SnomedCT | 203428004, 156825006, 203440004, 64859006 |
LNC | MTHU020796, LA10527-2 |
English | Osteoporoses, Osteoporosis NOS, Osteoporosis, unspecified, osteoporosis, osteoporosis (diagnosis), OSTEOPOROSIS, Osteoporosis [Disease/Finding], Unspecified osteoporosis, site unspecified, Unspecified osteoporosis, Osteoporosis, unspecified (disorder), Osteoporosis NOS (disorder), Bone rarefaction, OP - Osteoporosis, Osteoporosis (disorder), rarefaction; bone, Osteoporosis, NOS, Osteoporosis |
French | OSTEOPOROSE, Ostéoporose, non précisée, Ostéoporose SAI, Ostéoporose |
Portuguese | OSTEOPOROSE, Osteoporose NE, Osteoporose |
Spanish | OSTEOPOROSIS, Osteoporosis NEOM, Osteoporosis no especificada, osteoporosis, no especificada, osteoporosis, SAI (trastorno), osteoporosis, SAI, osteoporosis, no especificada (trastorno), osteoporosis (trastorno), osteoporosis, Osteoporosis |
German | OSTEOPOROSE, Osteoporose, unspezifisch, Osteoporose NNB, Osteoporose, nicht naeher bezeichnet, Osteoporose |
Dutch | osteoporose NAO, niet-gespecificeerde osteoporose, rarefactio; bot, Osteoporose, niet gespecificeerd, osteoporose, Osteoporose, Porose, osteo- |
Italian | Osteoporosi non specificata, Osteoporosi NAS, Osteoporosi |
Japanese | 骨粗鬆症NOS, 骨粗鬆症、詳細不明, コツソショウショウNOS, コツソショウショウ, コツソショウショウショウサイフメイ, 骨多孔症-老人性, 年齢関連骨消失, 年令関連骨消失, 老人性骨粗鬆症, 老年性骨粗鬆症, 外傷後骨粗鬆症, 骨消失-年齢関連, 骨多孔症-年齢関連, 骨多孔症, オステオポロシス, 骨粗しょう症, 年齢関連骨減少, 年齢関連骨多孔症, 老年性骨多孔症, 骨粗鬆症-外傷後, 年齢関連骨粗鬆症, 年令関連骨多孔症, 老人性骨粗しょう症, 年令関連骨粗しょう症, 骨減少-年齢関連, 老人性骨多孔症, 老年性骨粗しょう症, 骨粗鬆症, オステオポローシス |
Swedish | Benskörhet |
Czech | osteoporóza, Osteoporóza NOS, Osteoporóza, Osteoporóza, blíže neurčená, řídnutí kostí |
Finnish | Osteoporoosi |
Russian | OSTEOPOROZ, KLIMAKTERICHESKII OSTEOPOROZ, RAREFIKATSIIA KOSTI, OSTEOPOROZ KLIMAKTERICHESKII, OSTEOPOROZ STARCHESKII, КЛИМАКТЕРИЧЕСКИЙ ОСТЕОПОРОЗ, ОСТЕОПОРОЗ, ОСТЕОПОРОЗ КЛИМАКТЕРИЧЕСКИЙ, ОСТЕОПОРОЗ СТАРЧЕСКИЙ, РАРЕФИКАЦИЯ КОСТИ |
Korean | 상세불명의 골다공증 |
Croatian | OSTEOPOROZA |
Polish | Osteoporoza pourazowa, Osteoporoza starcza, Osteoporoza, Osteoporoza związana z wiekiem, Zrzeszotnienie kości |
Hungarian | Osteoporosis k.m.n., Osteoporosis, nem meghatározott, Osteoporosis |
Norwegian | Osteoporose, Benskjørhet, Beinskjørhet |