Osteoporosis Case Studies
March 2012
Ronald C. Hamdy, MD, FRCP, FACP
Professor of Medicine
Director, Osteoporosis Center
Professor/Chair, Geriatric Medicine
East Tennessee State University
Editor-in-Chief, Journal of Clinical Densitometry
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis









Asymptomatic
Natural menopause 2 years ago
Exercises regularly – strenuous routine
Good dietary calcium and vitamin D intake
Family history: negative for osteoporosis
No prescribed medications
OsCal 500 mg + Vitamin D twice daily
Multivitamins once a day
Weight 121 pounds; height 64”
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis









Asymptomatic
Natural menopause 2 years ago
Exercises regularly – strenuous routine
Good dietary calcium and vitamin D intake
Family history: negative for osteoporosis
No prescribed medications
OsCal 500 mg + Vitamin D twice daily
Multivitamins once a day
Weight 121 pounds; height 64”
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis
L1
L2
L3
L4
Area
9.9
11.4
13.9
14.1
BMD
1.419
1.445
1.483
1.494
T-score
+ 2.4
+ 2.9
+ 2.4
+ 1.7
L1-4
48.8
1.463
+ 2.6
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis
L1
L2
L3
L4
Area
9.9
11.4
13.9
14.1
BMD
1.419
1.445
1.483
1.494
T-score
+ 2.4
+ 2.9
+ 2.4
+ 1.7
L1-4
48.8
1.463
+ 2.6
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
1.081
0.773
1.047
T-score
+ 0.8
- 0.2
+ 0.4
1.016
0.818
1.047
+ 0.3
+ 0.3
+ 0.4
Lunar, Prodigy
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis
 Diagnosis: Normal bone density (WHO criteria)
Mrs. MB, 51 years old WW,
Concerned about Osteoporosis
 Diagnosis: Normal bone density (WHO criteria)
 Management recommendations:
Maintain Bone Mass – Healthy lifestyle
Repeat DXA scan 2 years
Mrs. MB, 53 years old WW, Second visit
Concerned about Osteoporosis
Baseline
BMD T-score
2-years
BMD T-score
BMD change
%
Abs
LSC
1.081 + 0.8
0.773 - 0.2
1.047 + 0.4
0.985
0.732
0.969
+ 0.0
- 0.5
- 0.3
- 8.9
- 5.3
- 7.4
0.096
0.041
0.078
0.034
0.053
0.050
LEFT
Fem Neck
Trochanter
Total Hip
1.016 + 0.3
0.818 + 0.3
1.047 + 0.4
0.945
0.750
0.966
- 0.3
+ 0.1
- 0.3
- 7.0
- 8.3
- 7.7
0.071
0.068
0.081
0.031
0.042
0.022
L1-L4
1.463
1.394
+ 1.8
- 5.0
0.069
0.028
Region
RIGHT
Fem Neck
Trochanter
Total Hip
+ 2.6
Mrs. MB, 53 years old WW, Second visit
Concerned about Osteoporosis
Baseline
BMD T-score
2-years
BMD T-score
BMD change
%
Abs
LSC
1.081 + 0.8
0.773 - 0.2
1.047 + 0.4
0.985
0.732
0.969
+ 0.0
- 0.5
- 0.3
- 8.9
- 5.3
- 7.4
0.096
0.041
0.078
0.034
0.053
0.050
LEFT
Fem Neck
Trochanter
Total Hip
1.016 + 0.3
0.818 + 0.3
1.047 + 0.4
0.945
0.750
0.966
- 0.3
+ 0.1
- 0.3
- 7.0
- 8.3
- 7.7
0.071
0.068
0.081
0.031
0.042
0.022
L1-L4
1.463
1.394
+ 1.8
- 5.0
0.069
0.028
Region
RIGHT
Fem Neck
Trochanter
Total Hip
+ 2.6
Laboratory investigations:
Blood Chemistry profile, Vit. D, PTH: Within normal limits.
Mrs. MB, 53 years old WW, Second visit
Concerned about Osteoporosis
Normal BMD
Mrs. MB, 53 years old WW, Second visit
Concerned about Osteoporosis
Normal BMD
Bone loss sustained:
Expected Post-menopausal loss
Management recommendation:
Maintain Bone mass
Repeat DXA scan 1 year
Mrs. MB, 54 years old WW, Third visit
VERY concerned about Osteoporosis
Mrs. MB, 54 years old WW, Third visit
VERY concerned about Osteoporosis
VERY
VERY
Mrs. MB, 54 years old WW, Third visit
VERY concerned about Osteoporosis
Base
BMD
2-yrs
BMD
%
Diff.
1-yr
BMD T-score
BMD change 04-05
%
Abs
LSC
1.081
0.773
1.047
0.985
0.732
0.969
- 8.9
- 5.3
- 7.4
0.977
0.713
0.958
- 0.1
- 0.5
- 0.3
- 0.8
- 0.3
- 0.8
0.008
0.019
0.011
0.034
0.053
0.050
LEFT
Fem Neck
Trochanter
Total Hip
1.016
0.818
1.047
0.945
0.750
0.966
- 7.0
- 8.3
- 7.7
0.938
0.739
0.948
- 0.3
- 0.1
- 0.3
- 0.7
- 1.5
- 1.8
0.007
0.011
0.018
0.031
0.042
0.022
L1-L4
1.463
1.394
- 5.0
1.374
+ 1.7
- 1.4
0.020
0.028
Region
RIGHT
Fem Neck
Trochanter
Total Hip
Age-associated
Changes in Bone Mass
Peak Bone Mass
Bone Mass
MENOPAUSE
1- 5% annually
Active
Growth
10
20
Slow
Loss
30
40
1- 2% annually
Rapid
Loss
50
Continuing
Loss
60
Age in Years
70
80
90
Mrs. MRW, 76 years WW
 Low back pain , gradually worsening
 Episode of very severe pain, incapacitating, 3 weeks ago
 Positive family history;
Sister 85 yrs, died after hip fracture
 Daily calcium intake: about 1500 mg
 CBC, CMP, TSH; within normal limits
 Meds: NSAID, calcium supplements
 Weight 130 pounds, height 64”
 X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
 Low back pain , gradually worsening
 Episode of very severe pain, incapacitating, 3 weeks ago
 Positive family history;
Sister 85 yrs, died after hip fracture
 Daily calcium intake: about 1500 mg
 CBC, CMP, TSH; within normal limits
 Meds: NSAID, calcium supplements
 Weight 130 pounds, height 64”
 X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
 Low back pain , gradually worsening
 Episode of very severe pain, incapacitating, 3 weeks ago
 Positive family history;
Sister 85 yrs, died after hip fracture
 Daily calcium intake: about 1500 mg
 CBC, CMP, TSH; within normal limits
 Meds: NSAID, calcium supplements
 Weight 130 pounds, height 64”
 X-ray evidence of vertebral compression fracture
Mrs. MRW, 76 years WW
L1
L2
L3
L4
Area
12.65
11.80
15.55
11.61
BMD
0.849
1.012
0.920
1.123
T-score
- 0.69
- 0.15
- 1.49
+ 0.06
L1-4
51.61
0.969
- 0.71
Mrs. MRW, 76 years WW
L1
L2
L3
L4
Area
12.65
11.80
15.55
11.61
BMD
0.849
1.012
0.920
1.123
T-score
- 0.69
- 0.15
- 1.49
+ 0.06
L1-4
51.61
0.969
- 0.71
Vertebral compression fractures
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
Mrs. MRW, 76 years WW
L1
L2
L3
L4
Area
12.65
11.80
15.55
11.61
BMD
0.849
1.012
0.920
1.123
T-score
- 0.69
- 0.15
- 1.49
+ 0.06
L1-4
51.61
0.969
- 0.71
Vertebral compression fractures
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
Diagnosis: Osteoporosis
10-years % # probability:
Hip #
33
Other #
50
Mrs. MRW, 76 years WW
L1
L2
L3
L4
Area
12.65
11.80
15.55
11.61
BMD
0.849
1.012
0.920
1.123
T-score
- 0.69
- 0.15
- 1.49
+ 0.06
L1-4
51.61
0.969
- 0.71
Diagnosis: Osteoporosis
Vertebral compression fractures
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
Goal: Reduce Fracture Risk
especially hip
Mrs. MRW, 76 years WW
Vertebral compression fractures  Bisphosphonates:
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
Alendronate, Fosamax, generics
Risedronate, Actonel, Atelvia
Ibandronate, Boniva
Zoledronate, Reclast
 Raloxifene, Evista
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
 Calcitonin, Miacalcin
 Teriparatide, Forteo
 Denosumab, Prolia
Goal: Reduce Fracture Risk
especially hip
Risk for hip fractures relative to placebo for participants who are at
high risk for fracture, by agent
MacLean, C. et. al. Ann Intern Med 2008;148:197-213
FDA Approved Medication –Hip Fractures
Study
Numbers
Duration
years
risk
reduction
Alendronate
FIT
2,027
3
Yes
Risedronate
HIP
5,445
3
Yes
Ibandronate
BONE
2,946
3
No
Zoledronate
HORIZON
7,736
3
Yes
Raloxifene
MORE
7,705
3
No
Calcitonin
PROOF
1,255
5
No
FREEDOM
7,736
3
Yes
1,637
1.5
*
Denosumab
Teriparatide
* Study aborted 18 months
Mrs. MRW, 76 years WW
Vertebral compression fractures
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
 Bisphosphonates:
Alendronate, Fosamax, generics
Risedronate, Actonel, Atelvia
Ibandronate, Boniva
Zoledronate, Reclast
 Raloxifene, Evista
 Calcitonin, Miacalcin
 Teriparatide, Forteo
 Denosumab, Prolia
Diagnosis: Osteoporosis
Goal: Reduce Fracture Risk
especially hip
Mrs. MRW, 76 years WW
Vertebral compression fractures  Bisphosphonates:
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.557
0.535
0.736
T-score
- 2.6
- 1.7
- 1.7
0.554
0.516
0.724
- 2.7
- 1.8
- 1.8
Alendronate, Fosamax, generics
Risedronate, Actonel, Atelvia
Ibandronate, Boniva
Zoledronate, Reclast
 Raloxifene, Evista
 Calcitonin, Miacalcin
 Teriparatide, Forteo
Diagnosis: Osteoporosis
 Denosumab, Prolia
Goal: Reduce Fracture Risk
especially hip
Mrs. MRW, 76 years WW
CONCERNED ABOUT:
• OSTEONECROSIS OF THE JAW
• ATYPICAL FEMORAL SHAFT FRACTURES
Mrs. MRW, 76 years WW
CONCERNED ABOUT:
• OSTEONECROSIS OF THE JAW
• ATYPICAL FEMORAL SHAFT FRACTURES
Probability:
1:10,000 to 1:100,000
Mrs. MRW, 76 years WW
CONCERNED ABOUT:
• OSTEONECROSIS OF THE JAW (ONJ)
• ATYPICAL FEMORAL SHAFT FRACTURES (AFSF)
Probability:
1:10,000 to 1:100,000
Probability #:
Hip #
33 %
1:3
Other #
50 %
1:2
Atypical femoral shaft fractures
Prodromal symptoms/signs
 Clinical:
Pain, localised tenderness
 Imaging:
X-rays, technetium scan, MRI, CT-scans, MRI
 Laboratory:
Bone turnover markers: N-TX, C-TX
Prevention of Hip fracture with Hip
Protectors
1801 elderly men and women in long stay or supported home care
0.12
Cumulative
Hazard of
Hip
Fractures
Control Group
67 hip fractures
0.10
0.08
Hip Protectors
13 hip fractures
0.06
54%*
0.04
0.02
0.00
0
*P=0.008
6
12
18
24
Months
Kannus P, et al. N Engl J Med 2000; 343:1506-1513
Mrs. MRW, 76 years WW
 Bisphosphonates:
? Kyphoplasty
?? Vertebroplasty
alendronate,
risedronate,
ibandronate
zoledronate
 Raloxifene
 Calcitonin
 Teriparatide
 Denosumab
Mrs. MRW, 76 years WW
 Bisphosphonates:
? Kyphoplasty
?? Vertebroplasty
alendronate,
risedronate,
ibandronate
zoledronate
 Raloxifene
 Calcitonin
 Teriparatide
Calcium/vitamin D
 Denosumab
DAILY CALCIUM INTAKE
Elemental Calcium (mg)
 Postmenopausal:
 Premenopausal:
1,500
1,000
 Pregnant/nursing:
 Men < 65 years:
 Men > 65 years:
1,200 - 1,500
1,000
1,500
Mrs. IB, WW, 56 years









Asymptomatic
Surgical menopause when 41 years
Exercises regularly
Good dietary calcium and vitamin D intake
Family history: positive for osteoporosis
No prescribed medications
CitraCal 500 mg + Vitamin D twice daily
Multivitamins once a day
Weight 175 pounds; height 64” – No height loss
Mrs. IB, WW, 56 years









Asymptomatic
Surgical menopause when 41 years
Exercises regularly
Good dietary calcium and vitamin D intake
Family history: positive for osteoporosis
No prescribed medications
CitraCal 500 mg + Vitamin D twice daily
Multivitamins once a day
Weight 175 pounds; height 64” – No height loss
Mrs. IB, WW, 56 years
L1
L2
L3
L4
L1-4
Area
11.1
11.3
11.5
12.3
46.2
BMD
0.910
0.914
0.922
0.927
0.925
T-score
- 1.8
- 1.8
- 2.3
- 2.6
- 2.1
RIGHT HIP
Femoral Neck
Trochanter
Total Hip
LEFT HIP
Femoral Neck
Trochanter
Total Hip
BMD
0.887
0.713
0.925
T-score
- 1.2
- 0.9
- 0.9
0.910
0.755
0.961
- 1.1
- 0.7
- 0.8
Diagnosis: Osteopenia
WHO – Fracture Risk Assessment Tool – FRAX –
• Age
• Weight
• Height
WHO – Fracture Risk Assessment Tool – FRAX –
• Age
• Weight
• Height
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
WHO – Fracture Risk Assessment Tool – FRAX –
• Age
• Weight
• Height
Femoral neck
T-score
or
Z-score
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
WHO – Fracture Risk Assessment Tool – FRAX –
• Age
• Weight
• Height
Femoral neck
T-score
or
Z-score
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
10-year
probability
of fracture
(%)
 Hip
 Others
WHO – Fracture Risk Assessment Tool – FRAX –
• Age
• Weight
• Height
Femoral neck
T-score
or
Z-score
• Previous fracture
• Parent fractured hip
• Current smoking
• Glucocorticoids
• Rheumatoid arthritis
• Secondary osteoporosis
• Alcohol > 3/day
10-year
probability
of fracture
(%)
 Hip
 Others
NOF Guidelines
Hip > 3%
Others > 20%
Mrs. IB, WW, 56 years
• Diagnosis: Osteopenia (WHO criteria)
• 10-year % fracture probability
• Hip
• Others
1
26
NOF Guidelines
Hip > 3%
Others > 20%
Mrs. IB, WW, 56 years
 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)
 Zoledronate (Reclast)
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
 Teriparatide (Forteo)
 Denosumab (Prolia)
 ? ? HRT ? ?
What is the goal of treatment ?
Mrs. IB, WW, 56 years
 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)
 Zoledronate (Reclast)
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
 Teriparatide (Forteo)
 Denosumab (Prolia)
 ? ? HRT ? ?
What is the goal of treatment ?
Fracture Risk Reduction
Mrs. IB, WW, 56 years
 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)
 Zoledronate (Reclast)
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
 Teriparatide (Forteo)
 Denosumab (Prolia)
 ? ? HRT ? ?
What is the goal of treatment ?
Fracture Risk Reduction
10-year probability
Hip # 1
Other # 26
Mrs. IB, WW, 56 years
 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)
 Zoledronate (Reclast)
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
 Teriparatide (Forteo)
 Denosumab (Prolia)
 ? ? HRT ? ?
What is the goal of treatment ?
Fracture Risk Reduction
10-year probability
Hip # 1
Other # 26
FDA Approved Medication – Vertebral Fractures
Study
Numbers
Duration
years
risk
reduction
Alendronate
FIT
2,027
3
Yes
Risedronate
VERT
3
Yes
Ibandronate
BONE
2,458
1,116
2,946
3
Yes
Zoledronate
HORIZON
7,736
3
Yes
Raloxifene
MORE
7,705
3
Yes
Calcitonin
PROOF
1,255
5
Yes
FREEDOM
7,736
3
Yes
1,637
1.5
Yes
Denosumab
Teriparatide
Hormonal Replacement Therapy - WHI
Mrs. IB, WW, 56 years
 Alendronate (Fosamax)
 Risedronate (Actonel, Atelvia)
 Ibandronate (Boniva)
Calcium
 Zoledronate (Reclast)
Vitamin D
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
 Teriparatide (Forteo)
 Denosumab (Prolia)
 ? ? Hormonal Replacement Therapy ? ?
Mrs. PRP, WW, 82 years
 Diagnosed with osteoporosis about 9 years ago
Based on fragility fracture T10: moderate wedge
 Secondary causes excluded.
 Started risedronate (Actonel) 35 mg weekly, then
converted to 150 mg once a month
 No adverse effects, taking it as directed, own routine
 Good compliance
 Good daily calcium/vitamin D intake
Mrs. PRP, WW, 82 years
Right Total Hip
Scan
Date
Age
BMD
T-scores % BMD Change
2001
2003
2004
73
75
76
0.700
0.721
0.724
- 2.0
- 1.8
-1.8
+ 3.0
+ 1.8
+ 3.0
+ 1.3
2006
2007
78
79
0.757
0.747
- 1.5
-1.6
+ 6.1
+ 6.3
+ 4.3
- 0.2
2010
82
0.771
- 1.4
+ 9.2
+ 2.9
Baseline Previous
Mrs. PRP, WW, 82 years
Right Total Hip
Scan
Date
Age
BMD
T-scores % BMD Change
2001
2003
2004
73
75
76
0.700
0.721
0.724
- 2.0
- 1.8
-1.8
+ 3.0
+ 1.8
+ 3.0
+ 1.3
2006
2007
78
79
0.757
0.747
- 1.5
-1.6
+ 6.1
+ 6.3
+ 4.3
- 0.2
2010
82
0.771
- 1.4
+ 9.2
+ 2.9
Baseline Previous
Should risedronate (Actonel) be continued ?
Bisphosphonate
therapy
Fracture Risk
Reduction
Oversuppressed bone
turnover
Delayed # healing
Atypical femoral shaft
#
Osteo-necrosis Jaw
Bisphosphonate therapy
& Bone Turnover
Suppress,
but not
Over-suppress !
COLLAGEN CROSS LINKS
N-TELOPEPTIDE
REGION
HELICAL REGION
C-TELOPEPTIDE
REGION
CTx
NTx
Pyr
Dpd
C-Telopeptide or C-Tx
1000 pg/mL
 C-Telopeptide or  C-Tx
200 pg/mL
100 pg/mL
Mrs. PRP, WW, 82 years
Right Total Hip
Scan
Date
Age
BMD
T-scores % BMD Change
2001
2003
2004
73
75
76
0.700
0.721
0.724
- 2.0
- 1.8
-1.8
+ 3.0
+ 1.8
+ 3.0
+ 1.3
2006
2007
78
79
0.757
0.747
- 1.5
-1.6
+ 6.1
+ 6.4
+ 4.5
- 0.3
2010
82
0.771
- 1.4
+ 9.2
+ 3.0
Baseline Previous
C-Tx 320 pg/mL
Continue risedronate (Actonel)
Mrs. RV, 60 years, WW, Second visit
RIGHT HIP
Fem Neck
Total Hip
2008
2010
BMD T-score BMD T-score
0.676 - 1.6
0.655 - 1.7
0.750 - 1.6
0.688 - 2.1
% Change
BMD
- 3.3
- 8.3
LEFT HIP
Fem Neck
Total Hip
0.609
0.735
- 2.0
- 12.2
L1-L4
Cannot be interpreted: scoliosis and artifacts
- 2.2
- 1.7
0.597
0.646
- 2.3
- 2.4
Prescribed alendronate in 2008
Mrs. RV, 60 years, WW, Second visit
RIGHT HIP
Fem Neck
Total Hip
2008
2010
BMD T-score BMD T-score
0.676 - 1.6
0.655 - 1.7
0.750 - 1.6
0.688 - 2.1
% Change
BMD
- 3.3
- 8.3
LEFT HIP
Fem Neck
Total Hip
0.609
0.735
- 2.0
- 12.2
L1-L4
Cannot be interpreted: scoliosis and artifacts
- 2.2
- 1.7
0.597
0.646
- 2.3
- 2.4
Did not refill her
second prescription
of Alendronate
Mrs. WF, 68 yrs,
Wt: 140 lbs Ht: 62 in
 Known to have osteoporosis
 CBC, Blood Chem. Profile, TSH:
within normal limits.
 Prescribed a bisphosphonate.
Mrs. WF, 68 yrs,
Wt: 140 lbs Ht: 62 in
DXA Scan
Results
Baseline
BMD T-score
2 yrs later % Change
BMD T-score
BMD
Right Total Hip
0.721 -2.5
0.689 - 2.9
- 4.5
2.2
Left Total Hip
0.688 -2.7
0.657 - 2.9
- 5.1
2.8
Lumbar Vertebrae
Multiple vertebral compression fractures
Bisphosphonates, good compliance
Complete blood picture
Blood chemistry profile
Thyroid stimulating hormone
Normal
LSC
Mrs. WF, 68 yrs,
Wt: 140 lbs Ht: 62 in
DXA Scan
Results
Baseline
BMD T-score
2 yrs later % Change
BMD T-score
BMD
LSC
Right Total Hip
0.721 -2.5
0.689 - 2.9
- 4.5
2.2
Left Total Hip
0.688 -2.7
0.657 - 2.9
- 5.1
2.8
Lumbar Vertebrae
Multiple vertebral compression fractures
Bisphosphonates, good compliance
Complete blood picture
Blood chemistry profile
Thyroid stimulating hormone
Normal
25(OH) Vitamin D
12 ng/mL
Non-response to oral bisphosphonates
• Compliance
• Inadequate Calcium/vitamin D
• Secondary osteoporosis
Osteoporosis
Diagnosis:
Fragility fractures
DXA - WHO Guidelines:
 < -2.5 Osteoporosis
 < - 1.0 to – 2.5: Osteopenia
 > - 1.0: Normal
Osteoporosis
Diagnosis:
Fragility fractures
DXA - WHO Guidelines:
 < -2.5 Osteoporosis
 < - 1.0 to – 2.5: Osteopenia
 > - 1.0: Normal
Management strategy:
WHO FRAX 10 year # probability %
NOF guidelines:
Hip # > 3.0
Other # >20
Osteoporosis
Medications:
Diagnosis:
 Alendronate (Fosamax, generics)
Fragility fractures
DXA - WHO Guidelines:  Risedronate (Actonel, Atelvia)
 < -2.5 Osteoporosis
 Osteopenia
 > - 1.0: Normal
Management strategy:
 Ibandronate (Boniva)
 Zoledronate (Reclast)
 Raloxifene (Evista)
 Calcitonin (Miacalcin)
WHO FRAX 10 year # probability %  Teriparatide (Forteo)
NOF guidelines:
Hip # > 3.0  Denosumab (Prolia)
Other # >20  HRT ??
FDA Approved Medication for Osteoporosis
# Risk Reduction
Vertebrae
Hips
 Calcium
Alendronate
Yes
Yes
 Vitamin D
Risedronate
Yes
Yes
 Diet
Ibandronate
Yes
No
 Exercise
Zoledronate
Yes
Yes
 No smoking
Raloxifene
Yes
No
Calcitonin
Teriparatide
Denosumab
Yes
No
Yes
Yes
WHO – FRAX
NOF – Guidelines
Hip > 3%
Yes
Others > 20%
Medications
Lifestyle changes
Calcium &
Vitamin D
Medications
causing bone
loss
Diseases
Management
Of
Osteoporosis
Fall
Prevention
Reduce impact
of falls
Early diagnosis
Prevention
Osteoporosis
It is never
too early or too late
to prevent or treat
osteoporosis !