seminair 28-04-2015 drs. s.p.g. bours

Secondary Osteoporosis

Sandrine Bours Rheumatologist and Endocrinologist

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Outline

•  Introduction •  Secondary osteoporosis at FLS in VieCuri Venlo •  Literature about secondary osteoporosis after fractures •  New data: secondary osteoporosis at FLS in Maastricht •  Patients with diseases leading to secondary osteoporosis •  Conclusions

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Introduction

•  Osteoporosis à fracture risk •  Primary osteoporosis

-  Post menopausal -  Age related

•  Secondary osteoporosis -  Medication -  Diseases

•  If secondary causes not recognized, treatment to prevent fractures suboptimal

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Dit is de titel van deze presentatie | Naam Auteur | 20 juni 2009 5

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Outline


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Subjects and methods

•  Cross-sectional chart review study

•  All consecutive patients > 50 years with a non-vertebral fracture or clinical vertebral fracture

•  Exclusion: metastatic cancer to bone, high-impact multi-

trauma, osteomyelitis or failure of a prosthesis

Bours, Geusens, van den Bergh. JCEM 2011

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Subjects and methods - data collection - •  Medical & pharmacological history, dietary calcium intake

•  BMD by DXA

•  Laboratory investigations: serum calcium, inorganic phosphate, 25(OH) vitamin D (25(OH)D), creatinine, iPTH, TSH, free T4, serum and urine protein electrophoresis, ESR (Erytrocyte Sedimentation Rate), alkaline phosphatasis, and in men serum testosterone, and on indication 24h urine excretion of calcium

•  626 patients included (out of 893 patients) San

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Known contributors to secondary osteoporosis

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Newly diagnosed contributors to secondary osteoporosis

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100% of patients

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Calcium and vitamin D intake

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Vitamin D deficiency?

•  SECOB = SECondary Osteoporosis and metabolic Bone disease

•  26.5% new contributors to SECOB

•  42.5% known and new contributors to SECOB

•  70.3% contributors to SECOB + 25(OH)D < 50 nmol/l

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Outline


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Known secondary osteoporosis 15

Bours, van den Bergh, Geusens. Curr. Opin Rheumatol 2014

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Prevalence of contributors to secondary osteoporosis, in patients with a recent clinical fracture AND • Osteoporosis: 10–30.5% (57%) • Any BMD: 26–51% (32-70%)

(% if vitamin D deficiency alone would also be included)

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New secondary osteoporosis

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Secondary osteoporosis in patients with a recent fracture AND osteoporosis •  1013 patients with fractures

-  590 patients at FLS - 100 patients with osteoporosis included

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Dumitrescu, BMC Musculoskeletal Disorders 2008, 9:109

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Dumitrescu, BMC Musculoskeletal Disorders 2008, 9:109

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Secondary osteoporosis in patients with a minimal trauma fracture •  327 patients 50-80 years old

-  187 excluded -  77 did not want to participate -  63 patients included

•  DXA + lab (calcium, phosphate, liver function, urea, electrolytes, blood count, 25(OH)D, TSH. In men also testosterone, LH, FSH prolactin)

•  12.7 ± 5.4 months post-fracture

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Wong et al, Intern Med J 2003; 33; 505-510

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Women N=47

Men N=16

Total N=63

Calcium intake <1000mg/day 32 (68%) 13 (81%) 45 (71%)

Vit D < 45 nmol/l 28 (44%)

Low testosterone 5 (31%)

Hyperprolactinaemia 1 (6%)

TSH < 0.01 Hyperthyroidism Oversuppletion

4 (6%) 2 2

Osteoporosis 34 (72%)

Osteopenia 7 (14%)

T-score <-1 12 (75%)

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Wong et al, Intern Med J 2003; 33; 505-510

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Secondary osteoporosis in patients with hip fractures •  Patients ≥ 50 years with hip fracture •  Controls: patients with low BMD, no hip fracture •  304 patients

-  72 excluded -  232 eligible -  157 included

•  75 controls

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Edwards et al, Osteoporos Int 2008; 19:991–999

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Which tests are useful to perform at the FLS?

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Which tests are useful to perform at the FLS?

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Outline


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The FLS at Maastricht

•  New start 1 May 2012 •  All patients with fractures ≥ 50 years with recent clinical

vertebral or non-vertebral fractures •  Questionnaire •  Lab (serum calcium, inorganic phosphate, 25(OH)D,

creatinine, iPTH, TSH, serum electrophoresis, alkaline phosphatasis, in men < 75 years serum testosterone, and on indication 24h urine excretion of calcium)

•  DXA + VFA

•  45% of patients with recent fracture attended the FLS

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Results

•  1 May 2012 – 1 November 2013 •  1017 patients •  727 women (71.5%), 290 men (28.5%) •  Mean age 65.9 years (± 9.8) •  DXA results:

-  Normal BMD : 184 patients (18.1%) -  Osteopenia : 507 patients (49.9%) -  Osteoporosis: 326 patients (32.1%)

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Preliminary data, FLS MUMC+

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New secondary osteoporosis Men N=290

Women N=727

Total N=1017

MGUS/myeloma 21 (7.2%) 45 (6.3%) 66 (6.5%) CKD stage 3-4 34 (11.7%) 36 (5%) 70 (6.9%) Hyperparathyroidism 1o 7 (2.4%) 8 (1.1%) 15 (1.5%) 2o vit. D deficiency 11 (3.8%) 11 (1.5%) 22 (2.2%) 2o CKD 4 (1.4%) 6 (0.8%) 10 (1.0%) 2o combined 17 (5.9%) 7 (1.0%) 24 (2.4%) Hyperthyroidism 11 (3.8%) 37 (5.1%) 29 (2.9%) Hypogonadism 55 (19.0%)

Total contributors 160 150 Total patients 99 (34.1%) 123 (16.9%) 222 (21.8%)

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•  Vitamin D < 50 nmol/l in 32.4% •  Vitamin D < 75 nmol/l in 55.4% •  New contributors to secondary osteoporosis

–  in both sexes –  at all ages –  after all fractures –  at any level of BMD

•  New contributor to SECOB AND vitamin D < 50 nmol/l in 44.3%

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Outline


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Rheumatoid arthritis: BEST trial

•  Patients with RA randomized to (1) sequential monotherapy, (2) step-up therapy, (3) initial combination therapy with tapered high-dose prednisone or (4) initial combination therapy including infliximab.

•  Disease activity score (DAS) ≤ 2.4 •  275 patients, average 54 years, 67% women (18%

postmenopausal) •  Active disease at baseline (DAS 4.4) •  Prevalence of VF after 5 years: 15%

-  Lower than previously reported (19-36%) -  Higher than general population (5%)

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Dirven et al. BMC Musculoskeletal Disorders 2012, 13:125

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•  VF vs no VF: -  Baseline: lower DAS (p = 0.069) -  After 5 years: higher DAS with mean difference of 0.20

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Dirven et al. BMC Musculoskeletal Disorders 2012, 13:125

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Patients with diseases leading to secondary osteoporosis •  Risk of osteoporosis increased in inflammatory diseases

such as reumatoid arthritis (RA), inflammatory bowel diseases (IBD), chronic obstructive pulmonary disease (COPD)

•  Risk of vertebral fractures increased in RA, ankylosing spondylarthritis, SLE, IBD, COPD

•  Hyperparathyroidism: DXA is part of workup to surgery •  Hypogonadism: risk factor for low BMD •  Other endocrinological diseases associated with lower BMD:

hypercortisolism, hyperthyroidism

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Conclusions (1)

•  Secondary osteoporosis is common in patients with recent fractures

•  Known secondary osteoporosis in 3-55% of patients •  Newly detected secondary osteoporosis in 25% of all

patients –  At all ages –  At any BMD –  Both men and women –  At any baseline fractures

•  If vitamin D deficiency included: higher %

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•  Secondary osteoporosis or SECOB •  Main problem (presenting problem) is the fracture •  What about screening in populations at risk? DXA or only

vertebral assessment?

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Conclusions (2)

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Work in progress…

•  Work data FLS in Maastricht •  Control population without fractures •  Screening for osteoporosis in diseases known to be a

possible contributor?

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Thanks!

•  FLS Viecuri MC and Maastricht UMC+ •  Joop van den Bergh and Piet Geusens •  Departments of Rheumatology and Endocrinology Maastricht

UMC+

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seminair 28-04-2015 drs. s.p.g. bours

Health & Medicine