Osteoporosis: An Overview
Guest: Dr. Kathie Hermayer - Medicine/Endocrinology, Diabetes & Medical Genetics
Host: Dr. Marcy Bolster – Rheumatology & Immunology, Division of
My name is Marcy Bolster. I’m a professor of Medicine at the Medical University of South Carolina. I specialize in rheumatology, and I’m Medical Director for the MUSC Center for Osteoporosis and Bone Health. I’ll be talking today with Dr. Kathie Hermayer. She is a professor of Medicine at the Medical University of South Carolina. Her specialty is endocrinology. Today we will be talking about an overview of osteoporosis. Good morning, Dr. Hermayer. Welcome.
Dr. Kathie Hermayer: Thank you, Dr. Bolster.
Dr. Marcy Bolster: Why don’t we get started with some background information, maybe a definition, what is osteoporosis?
Dr. Kathie Hermayer: Osteoporosis is a thinning of the bones which results from an alteration in the bone formation markers and resorption markers of the body. It ultimately can lead to fractures. Some of the most fearful fractures could be back, pelvis and hip fractures. And, particularly, women are at risk, postmenopausal women over the age of 50. Usually by the age of 70, about 50 percent of women will have an osteoporotic-related fracture.
Dr. Marcy Bolster: How does somebody know that they have osteoporosis? Is it something that they can feel, or is it a symptom that they might have?
Dr. Kathie Hermayer: Osteoporosis is essentially a silent disease. People really do not get pain from osteoporosis. What contributes to pain is when they fracture. So, we call it a silent killer because they don’t know they have it. Sometimes, on a blood test, there may be a suspicion for osteoporosis if somebody has an elevated calcium level, which could be leading to osteoporosis. But, normally, we recommend getting a bone mineral density study to make the diagnosis of osteoporosis.
Dr. Marcy Bolster: What’s the biggest risk to a patient once they find out that they have osteoporosis? What should be their biggest concern?
Dr. Kathie Hermayer: If somebody has osteoporosis, they need to be careful about fractures. The whole goal of therapy is prevention. So, what we like to do is prevent the first fracture, because once you have one fracture, your risk for another fracture goes up two to threefold. So, we like to prevent that first fracture, if at all possible. Unfortunately, we may see patients after they’ve already had a fracture, and then the, so to speak, horse is already out of the barn, and we have to prevent future fractures which is actually a harder task to do because, then, they’re more at risk for a fracture.
Dr. Marcy Bolster: So, we’ve talked about the incidents of hip fractures and the risk that provides to patients who are found to have osteoporosis, or who may not even know that they have osteoporosis, and then suffer from a hip fracture. What’s the course for a patient after a hip fracture? What can the patient expect?
Dr. Kathie Hermayer: We would recommend, after a hip fracture, that a patient go on osteoporosis-related therapy. The mortality associated with a hip fracture is about 30 percent. So, it’s rather high. And, obviously, one of the things you want to do is prevent a refracture, or a fracture to the other hip, or to the back. So, we would recommend starting therapy within a certain window of time from the initial hip fracture. Hip fractures are associated with a loss of quality of life. They’re obviously debilitating. They’re painful. It’s very hard for the patient and the family as well. So, again, we like to prevent them at all costs. However, if a hip fracture does occur, have a discussion with you primary care provider, as well as your orthopedic surgeon, and any specialists involved, as to what would be the proper therapy for you to embark upon to prevent further fractures and subsequent disability.
Dr. Marcy Bolster: And what about with fractures that occur in the spine? We know when a patient has a hip fracture, it’s a very painful fracture, are the fractures in the spine always painful?
Dr. Kathie Hermayer: Generally speaking, spinal fractures can be painful, but they can also not be painful, so it can be either/or. Sometimes patients will know they’ve had a fracture. They could be in the shower, taking a shower, and all of a sudden they take a wrong turn, and fracture. However, people can also have the silent compression fractures that could be picked up either on a PA and lateral spinal x-ray, or on a DXA scan. A good tip-off for the possibility of a compression fracture is height loss. That’s why we recommend, when you’re being screened for osteoporosis, we take your height by something called a stadiometer. We also ask you what your previous height readings have been so we can see if you’ve had a significant, say greater than one and half inches, loss of height, which may also be a tip-off that you’ve suffered a silent compression fracture to your spine.
Dr. Marcy Bolster: And do people that have these silent compression fractures need to be treated for osteoporosis?
Dr. Kathie Hermayer: Absolutely. Silent compression fractures are just as serious as a known fracture where you may have pain involved. They could also be leading toward future fractures and disability down the road.
Dr. Marcy Bolster: And what does it mean if a patient is told that they have osteopenia?
Dr. Kathie Hermayer: The World Health Organization diagnosis of osteoporosis is using something called the T-score. A T-score is where they compare you to a 30-year-old healthy bone. For a female, if you have a T-score of -2.5 or less, that’s considered osteoporosis. If you have a T-score of -1 to -2.5, that’s considered osteopenia. However, if you’ve already fractured with either a normal bone density or an osteopenic T-score, that’s still considered osteoporosis because that patient has had a fracture to a major area, such as their spine, hip or pelvis.
Dr. Marcy Bolster: So, is it true that you’re saying that even if a patient has osteopenia, they could be at risk of fracture?
Dr. Kathie Hermayer: Absolutely. As a matter of fact, if a patient has already fractured with osteopenia or normal bone mass, they’re considered osteoporotic.
Dr. Marcy Bolster: And how is it that the diagnosis of osteoporosis is made?
Dr. Kathie Hermayer: Generally, when I see somebody, as an endocrinologist, and usually it’s on referral for this purpose, I will do a set of screening labs and an intake evaluation history. The most common cause of osteoporosis in women is postmenopausal, and usually related to their estrogen levels. However, there’s another term called secondary osteoporosis, where osteoporosis can come from other causes besides menopause and postmenopausal changes in the bone architecture. And there could be other disease entities such as hyperthyroidism, type 1 diabetes, steroid use, cigarette smoking. Family history can be a predisposing factor. So, there are other etiologies to look for besides postmenopausal.
Dr. Marcy Bolster: And what test is done to be able to detect osteoporosis?
Dr. Kathie Hermayer: Probably the gold standard for detecting osteoporosis is the bone mineral density study.
Dr. Marcy Bolster: And that’s also called a DXA scan?
Dr. Kathie Hermayer: Correct.
Dr. Marcy Bolster: Tell me about the DXA scan, what does that entail for a patient?
Dr. Kathie Hermayer: I usually tell my patients it’s like having an x-ray. And probably the hardest thing for a patient to do, when they’re being screened for osteoporosis, is to lie on the table, which can be cold. It’s essentially like having an x-ray taken. They basically take an x-ray of your back and hip. Sometimes they’ll also x-ray your distal forearm, but the standard x-ray techniques are for the back and the hip.
Dr. Marcy Bolster: And why is it that the DXA scan looks at the spine and the hip?
Dr. Kathie Hermayer: Those are the areas that we consider major areas for fracture, so they’ll try to look at the bone density for both the back and the hip to see if there are areas at risk for a fracture.
Dr. Marcy Bolster: Once a patient is diagnosed with osteoporosis, what are some of the considerations for medical therapy?
Dr. Kathie Hermayer: When somebody is diagnosed with osteoporosis, we do have a discussion about medical therapy. There are pros and cons to different therapies. However, what I like to explain to people is that there are different categories of drugs we use to treat osteoporosis. Probably the biggest ones out there are the antiresorptive agents, and that will be the bisphosphonates, such as Fosamax, Actonel, Boniva, the IV form, now, Reclast. And then we have other antiresorptive agents such as the selective estrogen receptor modulators, such as Evista, otherwise known as raloxifene. And, also, estrogen replacement therapy is a good thing for bone. The Women’s Health Initiative actually showed a 34 percent decrease hip fracture rate due to estrogen therapy. So, even though estrogens are used with caution, in terms of breast cancer, stroke risk, MI risk, they are a good thing when it comes to hip fracture reduction, and also lumbar spinal density protection. Another drug that we recommend for osteoporosis therapy is Miacalcin, otherwise known as Calcitonin. That primarily works on the back, not so much on the hip. That’s available in either a nasal form or an injectable form. Those are your major antiresorptive agents. Then you move into the anabolic bone builder agents of which there is only one known in our country that’s approved by the FDA, and that’s known as Forteo. It’s an injection that is permitted by the FDA for up to two years of therapy.
Dr. Marcy Bolster: Dr. Hermayer, this has been a very informative discussion. I appreciate your time very much.
Dr. Kathie Hermayer: Thank you for inviting me, Dr. Bolster.