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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.