To DXA or not to DXA? Simple answers to complex questions about the management of osteoporosis in the elderly Will Bynum, MD, Capt USAF MC NCC Family Medicine Residency

Osteoporosis management: clear as mud Who should be screened? What tools can assist with screening/treatment decisions? How often should screening be repeated? Who should be treated with a bisphosphonate? How should response to treatment be monitored? When, if ever, should a drug holiday be used? What practical advice should be given to patients on BP’s?

Case #1 Mrs. S is a 62 yo female who comes in because one of her friends told her to ask you whether she should be screened for thinning bones. PMHx: HTN, DM2, and obesity Social: current smoker w/ 23 pack year history, drinks 3 drinks/day Family Hx: HTN, CVA, mother fractured hip after a fall Meds: Nexium 40 mg, Metformin 2000 mg, Losartan 50 mg, Aspirin 81 mg, Ca/Vit D 600/400 BID Exam: VS wnl Weight 205 lbs Height 64 inches Remainder of exam unremarkable Mrs. S’s friend wants to know if she should be screened as well. She is 66 years old with no past medical or social history and takes no medications.

Case #1

Should Mrs. S or her friend be screened for osteoporosis? If so, how?

Who should be screened? • Women older than 65 • Postmenopausal women younger than 65 with

risk factors

Two Approaches to Screening 65 yo with no prior hx of osteoporosis UpToDate “Screening for Osteoporosis” NEJM 2012;366(3): 225-233

Case #1 Continued The results of the DXA scan come back as follows: Site

Mrs. S

Total Hip

-2.1

Lumbar Spine

-1.9

Femoral Neck

-2.2

Site

Friend of Mrs. S

T-Score

T-Score

Total Hip

-2.1

Lumbar Spine

-1.9

Femoral Neck

-2.7

What is the diagnosis for each woman?

Z-Score

Z-Score

Diagnosis of osteoporosis DXA Scan • T-score < -2.5 at any site = Osteoporosis • T-score -1.0 to -2.5 at any site = Osteopenia

Clinical History • Fracture of hip or spine* = Osteoporosis *in absence of underlying bone condition

Case #1 Continued The results of the DXA scan come back as follows: Site

Friend of Mrs. S

Total Hip

-2.1

Lumbar Spine

-1.9

Femoral Neck

-2.7

Site

Mrs. S

T-Score

T-Score

Total Hip

-2.1

Lumbar Spine

-1.9

Femoral Neck

-2.2

Z-Score

Z-Score

Both are good candidates for a bisphosphonate. Is a bisphosphonate indicated in either woman?

Who gets a bisphosphonate? • History of spine or hip fracture • Diagnosed osteoporosis on DXA • Osteopenia on DXA and FRAX results of…

> 20% chance of major osteoporotic fracture > 3% chance of hip fracture

FRAX Tool – Mrs. S

How often should repeat DXA be done? • Repeat DXA every 1-2 years until findings are stable • Once stable, repeat DXA every 2 years or less

frequently *All other guidelines suggest a similar approach

AACE Osteoporosis Guidelines 2010

How to define successful treatment? • BMD stable or increasing • No fractures

Mrs. S: six years later 6 years later Mrs. S comes back in to see you. She has been on once weekly alendronate for the past 6 years and has done very well on it with no fractures. She had a follow up DXA done 1 month ago that showed a femoral neck Tscore of -1.8. Other sites were higher than -2.5 as well. She heard something about drug holidays for bisphosphonates and wants to know if she should take one. What do you recommend?

How long should therapy be continued? • Remain in bone for years after therapy stops  No data for exactly how long

• All

bisphosphonates include the following label: The optimal duration of use has not been determined. All patients on bisphosphonate therapy should have the need for continued therapy re-evaluated on a periodic basis.

FLEX & HORIZON Trials • Studied benefits of bisphosphonate use beyond 5 years • No change in the rate of non-vertebral fractures • Increase in vertebral fractures in patients who stopped

bisphosphonate after 5 years • NNT lower if T-score < -2.5 OR history of vertebral fracture and T-

score < -2.0 • NNT higher if no history of vertebral fracture and T-score > -2.0 JAMA 2006;296:292738 J Bone Miner Res 2012;27:243 54 NEJM 2012;366(22):2051-3

In whom should therapy be continued? Consider CONTINUING therapy after 3-5 years if… 1) Femoral neck T-score lower than -2.5 2) Prior vertebral fracture and T-score lower than -2.0 *Continue therapy for 10 years and then consider 1-2 year holiday

Consider STOPPING therapy after 3-5 years if… 1) Femoral neck T-score higher than -2.0 NEJM 2012;366(22):2051-3

In whom should therapy be continued? What about T score -2.0 to -2.5 and no history of vertebral fracture? No guidance on this. Consider risk of adverse effects, fall risk, function, and other osteoporosis risk factors.

What to do after 10 years of therapy?

??? A drug holiday of 1-2 years is reasonable

When should therapy be restarted? • Monitor BMD and bone turnover markers during

drug holiday • DXA every 1-2 years • Restart therapy if… • BMD substantially decreases • Bone turnover markers increase • Fracture occurs

Proper use and adverse effects How do you counsel your patients on the proper use of BPs?

What are the common side effects?

What are the major adverse effects?

What are the major side effects? • Gastritis and reflux • Take on an empty stomach • With 6-8 ounces of water • Remain upright for at least 30 minutes • No other oral intake for 30-45 minutes

• Erosive esophagitis or mucositis • Avoid if impaired swallowing or inability to sit upright • Beware of “pocketing”!!

• Acute phase reaction with IV formulation

What are the major adverse effects? • Osteonecrosis of the jaw • Risk is 1 in 10,000 to 1 in 100,000 patient years • Refer to guidelines if patient needs invasive jaw surgery

• Atypical femur fracture • Presents like a stress fracture • Risk is 3-50 in 100,000 patient years

• Esophageal cancer • Based on case studies, larger trials conflicting • Avoid bisphosphonates in patients with Barrett’s esophagus

**Avoid if GFR 10% • Treatment: Start BP if osteopenic and FRAX > 20% // 3% • Drug holiday after 3-5 years based on T-score and history

of fracture • Strongly consider drug holiday for all patients after 10 years • Strongly consider stopping drug at the end of life

• During holiday monitor with DXA q1-2 years, restart if BMD

worsens significantly

Questions?