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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

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Osteoporosis

Todd T. Brown, M.D., PhD
04-12-2008

  • Osteoporosis believed to be uncommon in Africa perhaps due to a generally younger population, although there is little evidence to confirm this impression.
  • No information available on osteoporosis concerns specifically in HIV+ populations in sub-Sarahan Africa.
  • Unclear whether recommendations developed for North American or European populations should be applied to Zambian patients, but there are no alternative suggestions available at this time.

REFERENCES

Zambia Information Author: Paul Auwaerter, M.D.

CLINICAL

  • Osteoporosis in HIV+ pts 3-4x more common than in general population.
  • Increased prevalence may be due in part to high prevalence of risk factors, including low body weight, hypogonadism, smoking, alcohol use, steroid use. 
  • Role of ART unclear. ART initiation associated with 2-3% loss in bone mineral density (BMD) in first 6 mos in multiple studies. Unclear if due to medication effect or by-product of viral suppression and/or immune reconstitution. Longitudinal studies of treated HIV+ pts generally show stable BMD over time.
  • Specific ARVs not clearly implicated in pathognesis, although bone loss with TDF slightly more pronounced than with d4T.
  • BMD explains approximately 50% of fracture risk in general population, perhaps less in HIV+ pts. Bone quality also important but difficult to assess.
  • Fracture risk in HIV+ pts not adequately assessed to date

DIAGNOSIS

  • Dual x-ray absortiometry (DXA) of hip and spine used to assess BMD.
  • Osteoporosis defined as T-score < -2.5 (i.e., BMD > 2.5 standard deviations lower than a young, gender-matched control population).
  • Osteopenia defined as T-score between -1 and -2.5.
  • Definitions using T-scores created for post-menopausal women. Utility in other populations (pre-menopausal women and men) controversial. Some advocate for use of Z-score (number of SD lower than age, and gender-matched population) in these populations.
  • In general population, fracture risk increases ~2x for each SD decrease in BMD.
  • Universal screening of HIV+ pts not recommended, except for post-menopausal women > 65 yrs as recommended in general population. Screening also reasonable in men and pre-menopausal women with gonadal dysfunction, wasting, or steroid use.

TREATMENT

Secondary Cause Evaluation

  • Laboratory evaluation for significant osteopenia or osteoporosis: PTH, calcium, phosphate, TSH, testosterone (men) and 25-OH vitamin D.
  • In selected cases, consider celiac disease, multiple myeloma, idiopathic hypercalciuria and Cushing's syndrome.
Non-pharmacologic Therapy

  • Calcium 1200 to 1500 mg/d plus vitamin D 400 to 800 IU/d
  • Weight-bearing exercise (30 minutes at least 3 days/wk)
  • Cessation of heavy alcohol use and smoking
Pharmacologic Therapy Do we want to give specific dosing regimen for these therapies? Author emailed these to Nicole who in turn got the okay from Paul P and Joel to incorporate the dosing info. and publish. Nicole

  • Consider drug treatment for those with T-score < -2.5 or fragility fracture. For osteopenia, consider therapy based on other risk factors and the degree of bone loss. If no treatment, repeat DXA in 1-2 years
  • Bisphosphonates (risedronate [35 mg q wk], alendronate [70 mg q week], ibandronate [150 mg q month]) considered first-line and have been shown to safe and efficacious in HIV+ pts. Annual IV zoledronate [5 mg q year] useful if PO therapy not tolerated. Duration of therapy unclear.
  • Raloxifene (60 mg q day) is reasonable alternative or adjunctive treatment to bisphosphonates in postmenopausal women.
  • Teriparatide (parathyroid hormone analog) stimulates new bone formation and should be considered in those not responsive to bisphosphonates (20 mcg per day subcutaneously). A course of 18-24 mos without concomitant bisphosphonates is recommended. Has not been specifically evaluated in HIV+ pts

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DrugRecommendations/Comments

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