DEXA BONE DENSITOMETRY is now available at the McCain Orthopaedic Center
This test takes approximately 5 minutes in the office and is used to diagnose osteoporosis.
Accudexa is a trademark. The slides are provided courtesy of the Ruth Jackson
Orthopaedic Society. Recommendations are provided by the National Osteoporosis
Foundation on their web site at www.nof.org
Some interventions to maximize and preserve bone mass have multiple health benefits and are sufficiently cost-effective that they can be recommended to the general population. These include an adequate intake of calcium and vitamin D regular weight-bearing exercise, avoidance of tobacco use and alcohol abuse, and treatment of other fracture risk factors such as impaired vision.
ADEQUATE INTAKE OF CALCIUM AND
Advise all patients to obtain an adequate intake of dietary calcium (at least 1200 mg/d including supplements if necessary and vitamin D (400 to 800 IU per day for individuals at risk of deficiency).
A lifelong intake of adequate calcium is necessary for the acquisition of peak bone mass and maintenance of bone health. The skeleton contains 99% of the body's calcium stores; when the exogenous supply is inadequate, calcium is extracted from the skeleton to maintain serum calcium at a constant level.
Controlled clinical trials have demonstrated that the combination of supplemental calcium and vitamin D reduces the risk of fracture of the spine, hip, and other sites. Increasing daily calcium and vitamin D intake is a cost-effective way to help reduce fracture risk. The NOF recommends that all adults receive at least 1200 mg/d of elemental calcium; the typical American diet provides less than 600 mg/d. Table 3 illustrates a simple method for estimating the calcium content of a patient's diet. Increasing dietary calcium is the first-line approach, but calcium supplements should he used when an adequate dietary intake cannot be achieved. Recommend a calcium supplement with the USP designation that supplies the appropriate amount of elemental calcium.
Table 2. Estimating Daily Dietary CALCIUM Intake
STEP 1, Estimate calcium intake from dairy products*
Milk 8 oz) X 300
Yogurt (8 oz) X 400
Cheese (I oz) X 200
STEP 2: Dairy calcium + 250 mg for nondairy sources total dietary calcium
About 75% to 80% of the calcium consumed in American diets is from dairy products.
Vitamin D plays a major role in calcium absorption and bone health. Chief dietary sources of vitamin D include vitamin-D-fortified milk (400 IU per quart) and cereals (50 IU per serving), egg yolks, salt water fish, and liver. Some calcium supplements and most multivitamin tablets also contain vitamin D. An intake of 400 to 800 IU of vitamin D per day is recommended for those at risk of deficiency, such as elderly, chronically ill, housebound, or institutionalized individuals,
REGULAR Weight-bearing EXERCISE
Recommend regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
Among its many health benefits, weight-beating and muscle-strengthening exercise can improve agility, strength, and balance, thus reducing the risk of falls. In addition, exercise may yield a modest Increase in bone density.The NOF strongly endorses physical activity at all ages,both for osteoporosis prevention and overall health. Weight-bearing exercise (in which bones and muscles work against gravity as the feet and legs bear the body's weight) includes walking, jogging, stair climbing, dancing. and tennis. Weight lifting improves muscle mass and bone strength. Before a patient initiates a vigorous exercise program, a physician's evaluation is appropriate.
Advise patients to avoid tobacco smoking and to keep alcohol intake moderate.
'Me use of tobacco products is detrimental to the skeleton as well as to overall health. The NOF strongly encourages a smoking cessation program as an osteoporosis intervention for patients who smoke.
Moderate alcohol intake has no known negative effect on bone an may even be associated with higher bone density in postmenopau women. However, alcoholism is detrimental to bone health and requires treatment when identifi
All patients being considered for drug treatment of osteoporosis should also be counseled on risk factor reduction. Patients should be specifically counseled on the importance of calcium, vitamin D. and exercise as part of any pharmacologic treatment program for osteoporosis The decision to treat osteoporosis with a pharmacologic agent should be based on strong evidence that an intervention effectively prevents fractures and their consequences, that its expected benefits outweigh any potential adverse effects or risks, and that it represents a reasonable use of resources. The cutpoints for intervention identified by the NOF have been developed in part by analysis of treatment cost-effectiveness.
Initiate therapy to reduce fracture risk in women with BMD T-scores below -2 in the absence of risk factors and in women with T-scores Below -1.5 if other risk factors are present.
Women over age 70 with multiple risk factors (especially those with previous nonhip, nonspine fractures) are at high enough risk of fracture to initiate treatment without BMD testing.
Since bone loss accelerates around the time of menopause, should therapy be initiated at this juncture to prevent bone loss, even in women with relatively normal bone density? The approach is reasonable in theory, but there are no data about its effectiveness for fracture prevention and no evidence of its long-term safety (except for epiderniologic data on estrogen replacement therapy and hormone replacement therapy HRT
The clinical utility of biochemical markers of bone turnover is still not clear. A working group was convened by the NOF to fully evaluate this issue and prepare a status report, The use of repeat bone density measurements for monitoring disease progression in response to therapy should follow guidelines developed by the Health Care Financing Administration (HCFA),
US FDA.APPROVED DRUGS FOR OSTEOPOROSIS
FDA-approved pharmacologic options for osteoporosis prevention and/or treatment are hormone replacement therapy (HIRT), alendronate, calcitonin, and raloxifene.
HIRT. Epidemiologic studies of HRT indicate a 50% to 80% decrease in vertebral fractures and a 25% decrease in nonvertebral fractures with 5 years of use and an anticipated 50% to 75% decrease in all fractures with 10 or more years of use. Based on its effectiveness in preventing and treating osteoporosis, along with other potential benefits for postmenopausal health, HRT provides the greatest benefit relative to its cost. Many women will benefit from the effects of HRT on bone and possibly other organ systems, for example. prevention of cardiovascular disease. Since HRT may be associated with a modest increase in risk of breast cancer with long-term use and deep vein thrombosis, women with a history of, or at significant risk for, these conditions may be exceptions. HRT may also reduce the risk of dementia and genitourinary disease, but might have significant side effects in some individuals, including vaginal bleeding, breast tenderness, mood disturbances, and gallbladder disease,
All postmenopausal women should be counseled to consider HRT or estrogen replacement therapy and offered guidance in weighing its risks and benefits. Most women considering HRT for ostcoporosis prevention or treatment will fall into one of three groups:
Those who desire long-term HRTfor its other possible benefits, such as cardioprotection Because HRT is an effective treatment for osteoporosis, these women do not need BMD measurement at least until age 65. Some evidence suggests that women on long-term HRT may be losing bone anyway by this age, but there is no evidence regarding subsequent fracture risk or how it might be affected by other interventions.
Those who do not want to receive HRT under any circumstances.Advise these women to undergo BMD testing to help decide on alternate treatment strategies.
Those who are not sure. Some women will find the risks and benefits of HRT roughly equal and would consider protection against osteoporosis to be a deciding factor. These women should undergo BMD testing to facilitate making a decision.
Alendronate, Well-conducted controlled clinical trials utilizing alendronate sodium indicate that treatment reduces the incidence of fracture at the spine, hip, and wrist by 50% in patients with osteoporosis. The medication is, therefore, a powerful option for those women who meet BMD criteria for treatment but who are unwilling or unable to take HRT. Alendronate may also be used for those who fail HRT treatment.
Alendronate must be taken on an empty stomach, first thing in the morning, with a large glass of water, at least 30 minutes before eating or drinking. Patients should remain upright during this interval, The 5 mg dose has been approved by the FDA for prevention of osteoporosis, and the 10 mg dose has been approved for treatment. Although in clinical trials the incidence of side effects with either dose was no different than placebo, clinical experience suggests that a significant proportion of patients experience upper gastrointestinal disturbance, particularly esophageal symptoms (chest pain, heartburn, painful or difficult swallowing). A rare reported complication of alendronate (probably <1%) is esophageal ulceration.
Calcitonin. Salmon calcitonin, a hormone that inhibits bone resorption, is FDA approved for the treatment of osteoporosis. It is delivered as a single daily intranasal spray that provides 200 units of the drug, (Subcutaneous administration is also available but rarely used.) Efficacy data for calcitonin are weaker than for either HRT or alendronate. (Results from a single controlled clinical trial indicated that calcitonin may decrease osteoporotic vertebral fractures by approximately 40%.) Consequently, calcitonin is generally considered to be a safe but somewhat less effective intervention for osteoporosis. It may be used as an alternative to HRT or alendronate for patients who meet the criteria for other osteoporosis treatments but are unwilling to take them or have found treatment unsuccessful.
Raloxifene. This drug is in a class of compounds called selective estrogen receptor modulators (SERMs), which have been developed to provide the beneficial effects of estrogens without their potential disadvantages. Raloxifene, approved by the FDA for prevention of osteoporosis, is another alternative for postmenopausal patients. Raloxifene has been shown to prevent bone loss, and preliminary data in women with osteoporosis show that it reduces the risk of vertebral fracture by some 40-50%. Raloxifene increases the risk of deep vein thrombosis, to a degree similar to that observed with estrogen. In addition, an increase in hot flashes is observed (-6% over placebo), and raloxifene cannot be used to treat menopausal symptoms,