Www.worldosteoporosisday.org WORLD OSTEOPOROSIS DAY 2013 International Osteoporosis Foundation.
Presented by: Nicole Nisly, MD. About Today’s Presentation I will discuss osteoporosis and focus...
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Transcript of Presented by: Nicole Nisly, MD. About Today’s Presentation I will discuss osteoporosis and focus...
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Presented by:Nicole Nisly, MD
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About Today’s Presentation
• I will discuss osteoporosis and focus on causes, treatment options and prevention
• I will discuss medications and life style choices that can be of help
• I will discuss some treatments that are not FDA approved
• I have no conflict of interests to disclose
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About Dr. Nisly
• Hello, my name is Dr Nicole Nisly, thank you for coming today
• I am a Professor of Internal Medicine and work at the University of Iowa Iowa River Landing Clinic (319/467-2000)
• My areas of expertise include Internal Medicine Primary Care, Complementary and Integrative Medicine, LGBTQ Health and Cultural Diversity in Health
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How do we get osteoporosis?
• We reach our maximum bone mass normally by the age of 40
• As we age, we tend to lose bone mass, especially after menopause
• Certain conditions make that loss happen faster
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Risk Factors for Osteoporosishttp://www.shef.ac.UK/FRAX
• Age (most fractures of the hip occur after age of 80)
• Use of corticosteroids• Low Body weight• Smoking• Excessive alcohol use• Parental Hip Fx• Rheumatoid arthritis
• Previous ‘Fragility” fractures• Malabsorption• Early menopause• Hypogonadism• Chronic liver disease• Inflammatory Bowel disease
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How do we know if we have osteoporosis?
• For most women, they should be screened with a DEXA scan at age 65
• Sooner with increased risk factors (FRAX calculated risk of over 20% over 10 years)
• For men: less certain but around age 70, sooner if at risk
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About DEXA Scan Results(dual energy xray absorptiometry)
• This test measures bone mineral density (BMD). • T score compares your BMD to that of a young
women around age 25• Z score compares your BMD to someone of
your age• Osteoporosis: T score of 2.5 or less SD• Osteopenia: T score between 1-2.5 SD• Z score of 2 or lower SD is abnormal
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How often do you test?
• For women at average risk and T score between 2-2.49 SD or any risk factors, repeat every 2 years
• T score between 1.5-1.99 SD, repeat in 3-5 years• T scores at 1-1.49 SD, repeat in 10-15 years• Address risk and benefit, including cost. The
purpose of testing is to help decide when to treat and reduce risks
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Should I test early?
• If you have the risk factors indicated previously or fragility fracture: test women starting at age 50 and men around 70
• Canadian osteoporosis Society recommends earlier testing for women and men between 50-65
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How to test?
• DEXA scan of Hip and Lumbar spine preferred• Peripheral measurements of heel or ultrasound
measurements while more available do not correlate well with fracture risk
• Bone turnover markers are not cost effective in guiding evaluation or treatment
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Other Tests
• Calcium• Biochemistry profile including Albumin and
protein and Alkaline Phosphatase• 25-OH vitamin D• Complete Blood Count• Other tests in certain situations:• Cortisol, parathyroid hormone, celiac disease
screening, 24 hr urinary calcium
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Pre-Menopausal Women & Children
• Bone density testing should only be done in very specific situations of very high risk
• Use Z scores instead of T scores to interpret test• Usual WHO guidelines apply to post
menopausal women
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How about prevention?
• Increase exercise and weight lifting, aim at 3 times per week for 30 minutes
• Balance and fall prevention is important, exercises such as Tai-Chi may help
• Gluten Free Diet and Low or High protein diet are discussed for specific cases
• Vitamin D 3 in gel capsule: 600-4,000 IU daily (most people 600-1,000)
• Calcium: diet is best source. Supplements
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The Issue of Calcium
• Dietary sources: one serving of dairy: 300 mg1 oz hard cheese, 8 oz of milk, 6 oz of yogurt)Greens, non dairy drinks
• Supplements: calcium citrate absorbs better if using certain medications
• Goal: 500-1,000 mg of supplement if needed
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Medications
• Biphosphanates such as Alendronate, Risendronate, Ibandronate and the I.V. form of Zoledronic Acid increase bone mass and reduce fracture
• SERM such as Raloxifene can decrease bone loss and reduce vertebral fracture
• Others: parathyroid hormone shots, Strontium (not available in the US), Denosumab shots, calcitonin
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Natural Therapies
• Tai chi• Soy protein• Ipriflavone (unproven)• Previously discussed life style changes• Environmental modifications such as night lights,
removing rugs, using walkers, exercising regularly• QUIT SMOKING!!• Reduce alcohol
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What is CAM anyway?
• A wide range of practices, new and old, at times safe, other times dangerous, widely used by patients worldwide, however…
• In general, safety and efficacy are not yet well established,
• Not commonly taught in medical schools and• Not commonly utilized in U.S. hospitals
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However…
• Integrative Medicine and various Complementary or Holistic Therapies are making their way into the health care system in various formats
• Education: Core Curriculum, Electives, Resident electives, Fellowships are growing in the U.S.
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Selected Alternative Medicine Systems and Techniques
• Mind-body interventions
• Alternative systems of medical practice
• Biologically based therapies
• Manipulative and body-based methods
• Energy therapies
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Mind-body Interventions
• Art therapy• Biofeedback• Dance/movement
therapy• Hypnosis• Imagery• Meditation
• Music therapy• Prayer and mental
healing• Self-help support
groups• Yoga
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Alternative Systems of Medical Practice
• Acupuncture
• Ayurveda
• Community-based– Latin American community
healthcare
– Native American healthcare
• Homeopathy
• Naturopathic medicine
• Traditional chinese medicine
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Why bother telling your doctor or pharmacist what will they do with
that information?
• Integrated care vs. uncoordinated care• Potential for:
– Side-effects– Drug-dietary supplement interactions– Benefits
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Herbal Medicines
• European Botanical Medicines• Latin American Herbal Remedies• Native American Herbal Agents• Ayurvedic Herbal Agents• Oriental Herbal Agents
– Chinese– Japanese - Kampo
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Medicine Derived From Plants• Aspirin• Atropine• Belladonna• Capsaicin• Cascara• Cocaine• Colchicine• Digoxin• Ephedrine• Ergotamine• Ipecac• Opium
• Physostigmine• Pilocarpine• Podophyllum• Psyllium• Quinidine• Reserpine• Scopolamine• Senna• Taxol• Tubocurarine• Vincristine• Vinblastine
Klepser, 2000
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St. John’s Wort
• Drug Interactions (P450 1A2, 2C9, 3A4) • Activates a receptor, named PXR, in the liver and
intestine, which accelerates drug metabolism. • It may interact with over 80% of drugs available
in the U.S. market.
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I have a cold, allergy or something…
• Mr. Sneezy comes in for refill of his allergy medication.
• Typically he has symptoms during the ragweed season.
• I have frequent colds, can I use Echinacea, he asks?
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Where do I go for reliable information?
• NCCAM (http://nccam.nih.gov/)• ODS (http://ods.od.nih.gov/index.aspx)• NCI/OCCAM (http://www3.cancer.gov/occam/)
– MD Anderson database (http://www.mdanderson.org/departments/CIMER/)
• Natural Medicine Comprehensive Database(www.naturaldatabase.com)• Micromedex• Consumerlab.com
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Talk to your Doctor
• Tell your health care providers about all the complementary and alternative practices you use. This will help ensure coordinated and safe care.
• Be proactive. Don't wait for your health care providers to ask about your CAM use.
• Make the most of the conversation. Bring a list of everything you use, keep a record of the information you receive, and ask questions if something is unclear.
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Using Supplements
• Why I want to take the supplement • How I found out about it • Is it safe for me to take? Will it interact with any of my
medications? • Is it likely to help me? • What else should I know about it? Where can I find more
information? • Should I try this? If not, why not? Might something else be
better?
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Keeping Track of your Intake
Name Name and and companycompany
Dose Dose TakenTaken
Dose Dose RecommRecommendedended
IngredieIngredientsnts
WhyWhy
Gingko Gingko Nature Nature MadeMade
60 60 mg/daymg/day
120 120 mg/daymg/day
Gingko Gingko MemoryMemory
St John’s St John’s wort, wort, walmartwalmart
300 300 mg/daymg/day
900 900 mg/daymg/day
SJW, SJW, Kava, Kava, valerianvalerian
MoodMood
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In conclusion: be an informed and empowered consumer: it is your
health!
The “best patient” is a well informed, interested, responsible and empowered patient, who actively and collaboratively participates in their health care.
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Final Words & Questions