Osteoporosis 2016 | Management of osteoporosis in the young adult: Dr Jennifer Walsh #osteo2016
-
Upload
national-osteoporosis-society -
Category
Healthcare
-
view
26 -
download
0
Transcript of Osteoporosis 2016 | Management of osteoporosis in the young adult: Dr Jennifer Walsh #osteo2016
Management of low bone density in young adults
Jennifer Walsh MBChB PhD FRCP FHEA
Senior Clinical LecturerMellanby Centre for Bone ResearchUniversity of Sheffield
Low bone density in young adults
• Who to measure
• Principles of management
• Specific situationso Idiopathic osteoporosiso Glucocorticoid induced osteoporosiso Premature ovarian failure
Who to measure?
• Hypogonadismo anorexia nervosa, athleteso early menopause, Depo-Provera, GnRH agonistso Turner, Kleinfelter’s
• Malabsorptiono coeliac disease, inflammatory bowel disease
• Inflammatory arthritis• Glucocorticoids• Low trauma fracture
FRAX not valid under 40 years
DXA: Z - score
> - 2.0 within the expected range for age
< - 2.0 below the expected range for age
ISCD 2007 position statement www.iscd.org
Principles of management
• Fracture risk is low in young people
• Identify and treat underlying causes
• Address modifiable risk factors
• Repeat BMD to identify low peak bone mass
• Reserve pharmacological treatment for high current risk of fracture
Fracture risk is low in young adults
Hui JCI 1988
Identify and treat underlying causes
• Common causes include:o Thyrotoxicosiso Coeliac diseaseo Vitamin D deficiencyo Prolactinoma / hypogonadism
• Consider o Osteogenesis imperfectao Cushing’s syndrome
Cohen J Women’s Health 2009
Address modifiable risk factors
• Calcium intake
Halioua Am J Clin Nutr 1989
50 g
400 mg
300 mg
300 mg
Recommended intake 800 to 1000 mg/day
Address modifiable risk factors
1.Kelley Int J Endo 2013 2. Nilsson Osteoporos Int 2013 3. Walsh JCEM 2008 4. Cundy BMJ 1994
• Weight-bearing exercise increases BMD in young women and men1,2
• Smoking cessation, alcohol moderation
• DMPA contraception3
o BMD increases on cessation4
Repeat BMD
• Low BMD may be due to genetically low peak bone masso Probably not associated with increased fracture risk until
menopausal
• Repeat BMD at 18-24 months can confirm stable BMD with low peak bone mass
Idiopathic osteoporosis
• Pre-menopausal women Z <-2.0 with no underlying causeo Poor bone microarchitecture and high marrow fato Reduced bone strength by FEA
Cohen JCEM 2011
Pharmacological treatment
Pharmacological treatment
• Consider treating if low BMD ando Ongoing bone losso Fractureo High dose steroids
• Most treatments not licensed for premenopausal womeno Make clear to patiento Involve patient in decision-making
• Raloxifene contraindicated in premenopausal women• Stop treatment when risk factors resolved
• Bisphosphonateso Case reports of neonatal hypocalcaemia and talipes equinovarus1,2,3
o Case series with normal pregnancy outcomes− N=21, 1 case Apert’s syndrome4
− N=24, high rate spontaneous miscarriage (21%)5
• Discuss family intentions / contraception
• Consider drugs with quicker offset?
Pharmacological treatment- pregnancy
1. Munns JBMR 2004 2. Dunlop Ann Rheum Dis 1990 3. Illidge Clin Oncol (R Coll Radiol) 19964. Levy Bone 2009 5. Ornoy Reprod Tox 2006
Idiopathic osteoporosis - teriparatide
Teriparatiden = 21 (4 non-responders)
Cohen JCEM 2013
Idiopathic osteoporosis - teriparatide• Persistence of effect?
BMD decreases after cessation1
• Fracture prevention?• Sequential therapy?
1. Cohen JCEM 2015
Glucocorticoid-induced osteoporosis
• Reserve treatment for bone loss, fractures or very high doses
Lekamwasam OI 2012
IOF guideline 2012
Premature ovarian failure
• Oestrogen replacemento Not if hormone-sensitive cancer, mantle radiotherapy
• Continue to age 50
• HRT vs COCP
• Transdermal vs oral
Anorexia nervosa
• Complex endocrinopathy and bone pathology• Best treatment is weight gain and return of menses
• Risedronate may increase BMD in adult women1
• Transdermal oestrogen best evidence in adolescents2
1. Miller JCEM 2011 2. Misra JBMR 2012
Summary
• Identify and treat underlying causes• Address modifiable risk factors
o Dairy intake and exercise• Reserve pharmacological treatment for high risk patients
o Very low BMD with fractures or bone losso Discuss off-license use with patiento Contraception
• Evidence base has improved in recent yearso Unlikely to ever have good fracture prevention data
Good reviews: Young adults Ferrari 2012 Osteoporos Int 23:2735–2748Anorexia Misra 2016 Int J Eating Disorders 49:3 276–292