National Osteoporosis Foundation recommendations for calcium and vitamin D intake
Men age 50-70: 1000 mg/day calcium
Women >50 and men >70: 1,200 mg/day calcium
Men and women >50: 800-1000 IU
Dietary sources of calcium
Milk, yogurt, cheese,spinach, kale, soy beans, fish, calcium fortified foods (orange juice, oatmeal, breakfast cereal)
Dietary sources of Vitamin D
Fatty fish, fortified foods, cheese, egg yolks
Treatment options for osteoporosis
- Adequate calcium and vitamin D, primarily from dietary intake
- Regular weight-bearing/muscle strengthening activities
- Fall prevention
- Lifestyle modification
When to treat Osteoporosis
- Hip or vertebral fractures
- Osteoporosis (as defined by T-scores)
- Osteopenia + FRAX 10-year risk score ≥3 % for hip fracture ≥20% for any major osteoporotic fracture
T-score classifications
≥-1 = normal BMD
-1 to -2.5 = osteopenia
≤-2.5 = osteoporosis
Calcium supplements
***Calcium carbonate Least expensive Take with food- requires stomach acid to be absorbed GI upset ***Calcium citrate Doesn’t require stomach acid to get absorbed Better absorption in older patients Can take on empty stomach More expensive \+++Adverse effects for both: Constipation, gas upset stomach
Osteoporosis Pharmacologic Treatment (Drug classes)
Bisphosphonates RANK-L inhibitor Parathyroid hormone analogs Estrogens/testosterone Raloxifene Calcitonin
Bisphosphonates: Drug names
Alendronate (Fosamax®)
Risendronate (Actonel®)
Ibandronate
Zoledronic acid (Reclast®)
Bisphosphonates: Mechanism of action
Inhibits bone resorption via action on osteoclasts
Bisphosphonates: Place in treatment
First-line therapy
Bisphosphonates: Administration keys
-Administer in the morning prior to food, beverage, or other medications
30 minutes prior for alendronate and risendronate
60 minutes prior for ibandronate
-Give with glass of water
-Remain standing/sitting straight up for 30-60 minutes
-Important to have adequate calcium/vitamin D intake
Bisphosphonates: Adverse effects
- Decreased serum calcium
- Abdominal pain
- Acid regurgitation
- Dysphagia
Bisphosphonates: Contraindications
- Abnormalities of the esophagus
- Hypocalcemia
- Inability to stand or sit upright for at least 30 minutes
Bisphosphonates: Precautions
- Atypical femur fractures
- Bone/join/muscle pain
- Gastrointestinal mucosa irritation
- Hypocalcemia
- Osteonecrosis of the jaw
- Drug interactions (absorption issues with vitamins and food)
- Renal dose adjustment: not recommended if CrCl < 30 mL/min (risendronate, ibandronate) or < 35 mL/min (alendronate, zoledronic acid)
Bisphosphonate Drug Holiday
- Consider after 3-5 years of continuous, compliant, effective bisphosphonate therapy
- Duration of 2-3 years
-Benefits:
Minimal BMD reduction
Persisting reduction of bone turnover markers
No unequivocal increase in fracture risk
RANK-L Inhibitor: Drug names
Denosumab (Prolia®)
RANK-L Inhibitor: Mechanism of action
monoclonal antibody which binds to RANKL and prevents osteoclast formation, leading to decreased bone resorption
RANK-L Inhibitor: Place in treatment
2nd line (Not for prevention of osteoporosis)
RANK-L Inhibitor: Administration keys
Very important to have adequate calcium intake
RANK-L Inhibitor: Adverse effects
Common side effects:
- Hypertension (11%)
- Dermatitis/Rash (3-11%)
- Hypercholesterolemia (7.2%)
- Arthralgia (7-14%)
Serious side effects:
- Malignant neoplasm (3-5%)
- Pancreatitis (< 1%)
RANK-L Inhibitor: Contraindications
Hypocalcemia, Pregnancy
RANK-L Inhibitor: Precautions
- Atypical femur fractures
- Osteonecrosis of the jaw
- Hypocalcemia
- Increased risk of infections
Parathyroid Hormone Analogs (PTH Analogs): Drug names
Teriparatide
Abaloparatide
