seminair 28-04-2015 drs. s.p.g. bours
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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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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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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
drine
Bou
rs
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
• 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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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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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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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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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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Preliminary data, FLS MUMC+
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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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Preliminary data, FLS MUMC+
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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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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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