Osteoarthritis and Osteoporosis-website

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Primary care for all ages

Vipul V. Parikh, MDNovember 21, 2008


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OSTEOARTHRITIS &

OSTEOPOROSIS

Sticks and Stones may break my bones

but Arthritis can really hurt me!

Vipul V. Parikh, MD

November 21, 2008


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OSTEOARTHRITIS &

OSTEOPOROSIS Learn about the causes of both

diseases and whether you are at risk

Learn about the signs and symptoms

Learn how the diagnosis can be made

Understand what can be done to

prevent these diseases

Discuss treatments available once you

have the diagnosis


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OSTEOARTHRITIS &

OSTEOPOROSIS

What is the difference? Osteoarthritis is primarily a disease of

the joints

Osteo = bone

Arthritis = joint inflammation

Osteoporosis is a disease of the

bones Osteo = bone

Porosis = a porous condition


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OSTEOARTHRITIS


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OSTEOARTHRITIS

What is It?Also known as Degenerative Joint

Disease (DJD) or Osteoarthrosis

Wear and tear kind of arthritis

Affects 27 million adults in U.S.

Can affect one joint or many joints

Joints most commonly affected are

knees, hips, hands, and spine


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OSTEOARTHRITIS

What is It?

Normal joint

Cartilage

Synovial fluidand membrane

Bursa

Articulation of

various bones

Muscle, tendon,

ligament, fat and

bones


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OSTEOARTHRITIS

What is It? Degeneration

Loss or damage of cartilage

Distorted mechanics, grinding

Bone cyst and scar formation


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OSTEOARTHRITIS

What is It?Abnormal compensatory response

New bone formation bone spurs

Inflammation (occasionally) fluid,

swelling, redness


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OSTEOARTHRITIS

What Causes It? Genetic Factors

Gender - women > men

Trauma (micro or macro)

Co-morbid medical conditions

Age-related processes


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OSTEOARTHRITIS

Am I at Risk?

Genetic Factors

Twin-twin and non-twin studies confirm

that the influence of genetic factors isanywhere from 39-65%

These factors are not well understood and

are still being researched


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OSTEOARTHRITIS

Am I at Risk?

Gender

Before age 45 - men > women

After age 45 - women > men

Fewer women are offered hip

replacement surgery than men


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OSTEOARTHRITIS

Am I at Risk? Trauma

Occupation

Sports

Injury


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OSTEOARTHRITIS

Am I at Risk?

Co-morbid medical conditions

Obesity

Acromegaly Pseudogout


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Felson D. N Engl J Med 2006;354:841-848

OSTEOARTHRITISAm I at Risk?

Age-related processes


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OSTEOARTHRITIS

What might I feel?


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OSTEOARTHRITIS

What might I feel? Pain

Swelling

Stiffness

Grinding

Other signs of inflammation


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OSTEOARTHRITIS

How is it diagnosed? History

Physical Examination


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OSTEOARTHRITIS

How is it diagnosed? Laboratories ANA, ESR, RF

X-rays


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OSTEOARTHRITIS

How is it prevented? Exercise safely

Listen to your body

Weight loss


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OSTEOARTHRITIS

Treatment Options - Exercise Exercise - types

Strengthening

Aerobic fitness

Range of motion


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OSTEOARTHRITIS

Treatment Options - Exercise Exercise - benefits

Improves strength of surrounding muscles

Allows increased flexibility of muscles,

tendons, and ligaments Helps with reduction or maintenance of

weight

Good for cardiovascular fitness

Gives sense of well-being


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OSTEOARTHRITIS

Treatment Options - Exercise Exercise

DOs

Walking

Swimming

Bicycling

Stretching/Strengthening

Yoga/Tai Chi

DONTs

High impact exercises


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OSTEOARTHRITIS

Treatment Options - Exercise Exercise


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OSTEOARTHRITIS

Treatment Options - Medications #1 Acetaminophen

+ safe, effective, inexpensive

- wears off quickly, cannot use in liver

disease


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OSTEOARTHRITIS

Treatment Options - Medications NSAIDs (eg. ibuprofen, naproxen)

+ effective, sometimes longer acting,

inexpensive

- stomach ulcers/irritation, toxic to kidneys

COX-2 inhibitors (eg. celecoxib)

+ effective, less GI side effects

- increase in cardiac risk (high dose), cost,toxic to kidneys


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OSTEOARTHRITIS

Treatment Options - Medications Opiate analog (eg. tramadol)

Opiate medications (eg. codeine)

Glucosamine-chondroitin

NIH study some benefit in moderate to

severe osteoarthritis

Ph l i T t t f O t th iti f th K


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Felson D. N Engl J Med 2006;354:841-848

Pharmacologic Treatment for Osteoarthritis of the Knee


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OSTEOARTHRITIS

Treatment Options - Injections Corticosteroid

Anti-inflammatory

Temporary relief - variable (< 6 weeks)

Optimal frequency is controversialusually not more than every 3 months

Risks damage to tendon, soft tissue

atrophy


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OSTEOARTHRITIS

Treatment Options - Injections Hyaluronic acid derivatives (eg.

Synvisc, Hyalgan, Orthovisc)

A normal component of connective tissues

(synovial fluid) Series of three to five injections

Only approved for use in knees

Some studies question the benefit of thistreatment


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OSTEOARTHRITIS

Treatment Options - SurgeryArthroscopic surgery


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OSTEOARTHRITIS

Treatment Options - SurgeryArthroscopic surgery

2002 study concluded that arthroscopic

debridement or irrigation was no better than

placebo surgery (N Engl J Med 347:81, July

11, 2002)

2008 study concluded arthroscopic

irrigation or debridement was no better than

maximal medical/physical therapy (N Engl J

Med 359:1097, September 11, 2008)

May be appropriate for only select patients

with loose bodies or meniscal tears


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OSTEOARTHRITIS

Treatment Options - Surgery Joint replacement surgery

Hips

Very successful, 90% still functioning well after

10-15 years, some last 25+ years Knees

Also very successful, 80-90% functioning well

after 10 years

Hand Done less frequently, should be managed by a

hand specialist


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OSTEOARTHRITIS

Treatment Options - Surgery Joint replacement surgery Who is a

candidate?

Severe, symptomatic osteoarthritis that

has failed to respond to conservativemanagement

Affecting activities of daily living


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OSTEOARTHRITIS

Treatment Options - Surgery Joint replacement surgery

Maximizing your benefit

If overweight or obese try to lose weight

prior to surgery Strengthen surrounding muscles before

surgery

Choose a high-volume center

Follow through with therapy program

religiously

Be patientand take care of your joint


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OSTEOARTHRITIS

Alternative Therapies Muscle rubs

Heat/cold packs

Vitamins

Green tea

Electrical stimulation (TENS)

Acupuncture


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OSTEOARTHRITIS

Future Directions Understanding genetic factors and

causes for cartilage breakdown

Tissue engineering

Cartilage cell replacement Stem cell transplantation

Gene therapy

Other medications


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OSTEOARTHRITIS

Helpful resources National Institute of Arthritis and

Musculoskeletal and Skin Disease -

www.niams.nih.gov

Arthritis Foundation -www.arthritis.org

American College of Rheumatology -

www.rheumatology.org


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OSTEOPOROSIS


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OSTEOPOROSIS

What is It? Brittle bone disease Natural consequence of aging to some

extent but also preventable

Affects 10 million people in the U.S.and additional 34 million at risk

Not just a disease in women!


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OSTEOPOROSIS

What is it? Bones are a living tissue just like our

skin or muscle

Contains collagen, mineral complexes,

and cells


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OSTEOPOROSIS

What is it? There is constant activity inside the

bone helping to give it strength, but

also keeping it lightweight and flexible


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OSTEOPOROSIS

What is it?

Osteoblasts helpcreate new bone

(bricklayer)

Osteoclasts helpwith resorption of

old bone (chisel)


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OSTEOPOROSIS

What is it? Over time bones can lose strength Balance between bone formation and

bone resorption shifts


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OS O O OS S


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OSTEOPOROSIS

Am I at risk?Age Gender females > males

Menopausal status

Low body weight less than 127 lbs. Ethnicity asian and caucasian >

african-american and hispanic

Family history Medical conditions (rheumatoid

arthritis, celiac sprue, hypogonadism)

OSTEOPOROSIS


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OSTEOPOROSIS

Am I at risk? Poor nutrition

Calcium and vitamin D

Lifestyle habits

Smoking Heavy alcohol

Immobility

Medications chronic steroids (prednisone)

anti-seizure medicine (phenytoin)

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? Evaluation of medical history and risk

factors during doctors visit

Physical exam height measurement,spine evaluation

X-ray may show lack of bone density

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? Evaluating bone mineral density

(BMD) and comparing to norms

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? Gold Standard bone densiometry

(central DEXA) scan

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? cDEXA Scan evaluates BMD in hip

and spine

well-established norms for both men

and women of different ethnicities minimal discomfort

minimal radiation

cost-effective as screening

less accurate with severe arthritis orhardware present

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed?

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? T scoreHow do I compare to young

normal women or men?

Z score How do I compare to

women or men of my age? T score is more important than Z

score in determining fracture risk

OSTEOPOROSIS


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OSTEOPOROSIS

How is it diagnosed? T score -2.5 is osteoporosis T score -1.0 to -2.5 is osteopenia

OSTEOPOROSIS


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OSTEOPOROSIS

Who should be screened? Women age 65 and older Men age 70 and older

Post-menopausal women age


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OSTEOPOROSIS

Prevention Exercise weight-bearing and muscle

strengthening

OSTEOPOROSIS


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OSTEOPOROSIS

Prevention Calcium 1200-1500mg/day Vitamin D 800-1000 IU/day

OSTEOPOROSIS


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OSTEOPOROSIS

PreventionAm I getting enough calcium?

8 oz. glass of milk = 300mg

6 oz. cup yogurt = 300mg

1 oz or 1 cu in. cheese = 200mg 8 oz. fortified orange juice = 300mg

OSTEOPOROSIS


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OSTEOPOROSIS

PreventionAvoidance of tobacco products and

excessive alcohol

Prevention of falls to prevent

fractures Medications - bisphosphonates

OSTEOPOROSIS


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OSTEOPOROSIS

Treatment Options

Bisphosphonates (eg. alendronate,risedronate, ibandronate, zoledronicacid) Binds to bone, inhibits osteoclast activity

Available in tablet or injectable forms Tablets are poorly absorbed but work well if

taken correctly Take on empty stomach

Remain upright and do not eat for -1 hour after

taking Shown to increase BMD and decrease risk of

osteoporotic fractures

OSTEOPOROSIS


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OSTEOPOROSIS

Treatment Options Estrogen/Hormone therapy

Protective anti-resorptive effect

Increases the incidence of breast cancer,

coronary heart disease, stroke, andvenous thromboembolism

May be considered second-line therapy in

perimenopausal women

OSTEOPOROSIS


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OSTEOPOROSIS

Treatment Options Estrogen Agonist/Antagonist (eg.

raloxifene) Selective estrogen receptor modulator

Increases BMD and reduces risk ofvertebral fractures

Less effective than bisphosphonates andestrogen

May lower risk of breast cancer First line agent in those who cannot

tolerate bisphosphonate

OSTEOPOROSIS


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OSTEOPOROSIS

Treatment Options Calcitonin

Binds to osteoclasts, inhibits resorption

Salmon-derived because more potent

(beware if you are allergic to salmon) Nasal spray is most popular preparation

Less effective than other treatments

Helpful in reducing pain from compression

fractures of spine

OSTEOPOROSIS


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OSTEOPOROSIS

Treatment Options Parathyroid Hormone (eg. teriparatide)

Stimulates more bone formation than

resorption

Used for those who cannot toleratebisphosphonates or who continue to have

fractures on bisphosphonates

Provided as a daily injection

Only approved for use up to 24 months

OSTEOPOROSIS


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OSTEOPOROSIS

Do I need treatment?

OSTEOPOROSIS - Bone densityscan with hip or spine T-score -2.5

(YES!)

OSTEOPENIA - Bone density scanwith hip or spine T-score -1.0 to -2.5

(YES! if FRAX score >3% for hip or

>20% for other osteoporosis-related fracture)

Previous vertebral or hip fracture

(YES!)

OSTEOPOROSIS


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OSTEOPOROSIS

What is FRAX?

OSTEOPOROSIS


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OSTEOPOROSIS

Helpful Resources

National Institute of Arthritis andMusculoskeletal and Skin Disease -

www.niams.nih.gov

National Osteoporosis Foundation -www.nof.org

International Osteoporosis Foundation

www.iofbonehealth.org Fracture Risk Assessment Tool

www.shef.ac.uk/FRAX/


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Primary care for all agesHeathcote Health Center

15195 Heathcote Blvd.Suite 330

Haymarket, VA


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Bibliography

Webster's New World College DictionaryCopyright 2005 by Wiley Publishing, Inc., Cleveland,Ohio.

Arthritis Rheum. 1998 Apr;41(4):687-93.

Risk factors for and possible causes of osteoarthritis.

Kenneth C Kalunian, MD Section Editor, Peter Tugwell,MD Deputy Editor, Jerry M Greene, MD. Up to Dateversion 16.2: May 2008 | This Topic Last Updated:September 14, 2007.

Surgical therapy of osteoarthritis. Author Kenneth C

Kalunian, MD, Section Editor Peter Tugwell, MDDeputy Editor, Jerry M Greene, MD. Up to Date version16.2: May 2008 | This Topic Last Updated: May 19,2008


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Bibliography

Overview of the management of osteoporosis inpostmenopausal women. Authors Hillel N Rosen,

MD, Marc K Drezner, MD, Section Editors Clifford J

Rosen, MD, Kenneth E Schmader, MD, Deputy

Editor Jean E Mulder, MD. Up to Date version

16.2: May 2008 | This Topic Last Updated: June 11,

2008

Osteoarthritis, Publication of the

NIH, NIAMS; May 2006.

Osteoporosis, Publication of the NIH, NIAMS;

December 2007.


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Bibliography

Lane N. Osteoarthritis of the Hip. NEJM. Oct 4,2007; 357:14, 1413-1421.

Felson, D. Osteoarthritis of the Knee. NEJM. Feb

23, 2006; 354:8, 841-848.

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