#129 Osteoporosis

Question 1

Of women older than 80 who get a hip fracture, what % can walk independently after 1 year?

Answer 1

56%

Question 2

What is osteoporosis?

Answer 2

skeletal disorder characterized by loss of bone mass, deterioration of microarchitecture, and a decline in bone quality, all of which lead to an increased vulnerability to fracture.

Question 3

Does a 50 and 80 year old woman with the same bone mineral density have the same fracture risk?

Answer 3

No. Uncertain why, but older age is an independent risk factor

Question 4

Which ethnic group in the US has the highest rate of hip fractures

Answer 4

Caucasian

Question 5

When does most bone growth and mineral density accrue?

Answer 5

2-4 years before peak height velocity. (Mean age 11.8 years in girls)

Question 6

When does peak bone mass occur in Caucasian females?

Answer 6

19 years old

Question 7

When is bone loss most rapid in females? What % is typically lost?

Answer 7

1 year prior to final menses and lasts about 3 years. 6% and 7% loss at femoral neck and lumbar spine, respectively

Question 8

Is estrogen important for bone health in women, men, or both?

Answer 8

Both.

Question 9

What conditions (resulting in low estrogen) lead to lowering of bone mineral density?

Answer 9

Anorexia nervous, lactation, menopause, hypogonadism, prolonged use of depoprovera, gnrh agonists, or aromatase inhibitors

Question 10

What two nutritional contents are important for bone health?

Answer 10

Vitamin D and calcium

Question 11

What does vitamin D deficiency lead to?

Answer 11

softer, poorly mineralized bone manifested as rickets in children and osteomalacia in adults.

Question 12

What does prolonged calcium deficiency lead to?

Answer 12

Osteoporosis

Question 13

In regards to DEXA scan results; what is a t score and how do you interpret it?

Answer 13

Comparison to young, healthy female counterparts. Less than or equal to -2.5 is diagnostic of osteoporosis (at any of the three sites: total hip, femoral neck, lumbar spine). -1.5 to -2.5 is low bone mass (prev osteopenia)

Question 14

In regards to DEXA scan, what is a Z score?

Answer 14

Compares patients BMD to BMD of women of same age

Question 15

How can you clinically diagnose osteoporosis (w/o imaging)?

Answer 15

medical history of a low-trauma fracture in an at-risk woman. Low-trauma fractures are fractures that occur in a situation that would not be expected to cause fractures in most individuals (eg, a vertebral fracture from opening a window or a simple fall from a standing position)

Question 16

What does the FRAX score tell you?

Answer 16

predict the risk of osteoporotic fracture for a person in the next 10 years

Question 17

In regards to starting treatment, what is the FRAX score used for and what is the cut off(s)?

Answer 17

Used to determine whether to start treatment for patients in the osteopenia range. Treatment should be considered when there is a 3% risk of hip fracture or a 20% risk of a major osteoporotic fracture (defined as a fracture of the forearm, hip, shoulder, or clinical spine) or both in the next 10 years.

Question 18

What variables are included in calculating a FRAX score?

Answer 18

age, sex, body mass index, previous fragility fracture, parental hip fracture, current smoking status, corticosteroid use (greater than or equal to 5 mg prednisolone per day for 3 months), alcohol intake greater than or equal to 3 units per day (approximately three drinks), rheumatoid arthritis, and other secondary causes of osteoporosis. Femoral neck BMD can also be included, but not required

Question 19

What are the tests done to look for causes of secondary osteoporosis?

Answer 19

First tier: CBC, metabolic panel, 24hr Ur Ca, 25-OH D vitamin, TSH
Second tier: celiac panel, serum protein electrophoresis

Question 20

Which are the 4 FDA approved bisphosphonates?

Answer 20

Alendronate, risedronate, ibandronate, and zoledronate

Question 21

By how much do bisphosphonates reduce vertebral fractures?

Answer 21

By 35-65%

Question 22

What is mechanism of action of bisphosphonates?

Answer 22

antiresorptive agents because the mechanism of action is inhibition of osteoclast resorption of bone.

Question 23

What are adverse effects of bisphosphonates/what should you check in patient prior to initiation?

Answer 23

Check renal function, correct hypocalcemia. MSK aches and pains, GI irritation, esophageal ulceration. Osteonecrosis of Jaw, seizures, atypical fractures of femoral shaft, esophageal cancer

Question 24

What rheumatologic or autoimmune disorders cause or contribute to osteoporosis/fractures?

Answer 24

Lupus, rheumatoid arthritis, ankylosing spondylitis

Question 25

What endocrine disorders cause or contribute to osteoporosis/fractures?

Answer 25

Adrenal insufficiency, Cushing syndrome, diabetes, hyperparathyroid, thyrotoxicosis

Question 26

What GI disorders cause or contribute to osteoporosis/fractures?

Answer 26

Celiac disease, gastric bypass surgery, GI surgery, inflammatory bowel disease, malabsorption, pancreatic disease, primary biliary cirrhosis

Question 27

What medications cause or contribute to osteoporosis/fractures?

Answer 27

Anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates, Cancer chemotherapy, cyclosporine A and tacrolimus, depo medroxyprogesterone, glucocorticoids (prednisone 5mg/d >= 3 months), GnRH agonist, lithium

Question 28

Mechanism of action of Raloxifene? Pros and cons?

Answer 28

Selective estrogen receptor modulator.
Decreases risk of vertebral fracture, decreases risk of invasive breast cancer
Increases risk of VTE,
Increases leg cramps. Increased risk of death from stroke.
No documented improvement in hip fracture risk

Question 29

Denosumab mechanism of action?

Answer 29

antiresorptive treatment, is a human monoclonal antibody to the receptor activator of nuclear factor-κB ligand, blocking proliferation and differentiation of osteoclasts.

Question 30

What is teriparatide and how does it work?

Answer 30

Recombinant human Parathyroid hormone. It increases trabecular size and connectivity, thereby improving bone microarchitecture and geometry.

Question 31

How long can you use teriparatide? What’s the reason for limitation?

Answer 31

2 years. Believed to be increased risk for osteosarcoma

Question 32

Which women are not candidates for teriparatide?

Answer 32

Women with bones metastases, Paget’s disease of the bone, or women with hx of skeletal irradiation.

Question 33

What should be done after discontinuing teriparatide?

Answer 33

Add antiresorptive agent. Quick loss of bone mineral content with discontinuation of PTH

Question 34

What are criteria for early DEXA screening?

Answer 34

Postmenopausal with a risk factor:
Medical hx of fragility fracture 
Body weight <127
Medical causes of bone loss
Parental hx of hip fracture
Current smoker
Alcoholism
Rheumatoid arthritis

Question 35

Which women with osteopenia are recommended for treatment?

Answer 35

FRAX score >20% for any fracture. >3% risk for hip fracture. Hx low trauma fracture regardless of FRAX score