4 - Osteoporosis Flashcards
What are contributors to fragility fractures?
Things that:
1) Reduce bone mass
2) Reduce bone quality
Other associations:
- Drugs (prednisone, steroids, anti-epileptics, aromatase inhibitors, PPIs, and androgen-deprivation therapy)
- Hypogonadism
- Early menopause
- Hyperthyroidism
- Primary hyperparathyroidism
What are your chances of sustaining a fracture if on glucocorticoids?
up to 2X compared with non-glucocorticoid users
How much/how long of glucocorticoids increase your risk of fracture?
risk of fracture at prednisone doses as low as 2.5 to 7.5mg per day x 28 days
What should we do for those on glucocorticoids?
Screen!
BMD test indicated if >5-7.5mg prednisone equivalents for >3 months
What are some risk factors for falls?
- icy roads
- going to the bathroom in the night
- loose carpeting
- stairs
- hypotension
- alzheimer’s medications
- being weak
- parkinson’s
- poor sight
- age
- previous falls
What risk factors for falls are preventable/where can pharmacists and HCPs intervene?
- strengthen muscles
- medication management
What is a fragility fracture?
A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less.
This can be tricky (is falling on ice and breaking your wrist a fragility fracture?)
Does low BMD cause osteoporosis (OP) ?
- Technically .. yes
- But, kind of like cholesterol and CV disease, it is JUST one of several risk factors for fractures
List 4 things we can do to prevent falls/osteoporosis
1) Screen as appropriate for those at risk
2) Minimize fall risk
3) Supplement as appropriate
4) Pharmacotherapy as appropriate
If someone comes into your pharmacy asking about supplements to keep bones healthy, what questions will you ask her?
- Has she had falls before?
- Is she taking calcium, vitamin D, or multivitamin ?
- How old is she?
- Fam Hx of osteoporosis?
- Is she on steroids?
- Is she a smoker?
- What is her BMI?
- How much calcium/dairy is she getting in her diet?
- Alcohol intake?
- Smoker?
What kind of exercise do we recommend for bone health?
Weight-bearing + stability
- aerobics
- strength training
- walking
- tai chi (but only if they’re stable hahah)
*Individualize for adherence and safety
What are 3 considerations we should think about when asking if we should initiate therapy?
1) Risk for fractures
2) Benefits/harms of therapy
3) Patient preference/goals of therapy
What is our primary goal therapy?
Reduce future risk of fractures
What is a clinical vertebral fracture?
-you have enough pain that it brings you into see someone
What is a vertebral fracture?
- doesn’t bring you in to see someone
- a lot are never identified bc they never go to the doctor or they just don’t notice
What is a major osteoporotic fracture?
proximal humerus, wrist, hip, clinical vertebral
What is the benefit of vitamin D and Ca supplementation on fractures?
- Decreases non-vertebral fractures by 5/1000 per year
- No difference in clinical vertebral fractures
- Decrease low risk hip fractures by 1/1000 per year
- Decrease high risk hip fractures by 9/1000 per year
What is the dose of vitamin D supplementation?
800 IU/day
What is the dose of Calcium supplementation?
1200 mg/day (from all sources, includes food)
How much calcium is in 1 serving of daily product?
300 mg
*therefore if you get 4 servings per day (1200mg) there is no need for supplementation
Are there any harms of vitamin D?
negligible up to 4000 IU/day
Are there any harms of calcium ?
GI symptoms (nausea, constipation), hypercalcemia, renal calculi, CV disease ?
Are vitamin D and calcium supplementations costly ?
nah man, minimal cost
What is a T-score?
the number of standard deviations above or below the mean for a healthy 30 year old adult of the same sex and ethnicity ?
What T-score indicates osteoporosis?
T-score < -2.5
To treat or not to treat:
What does it depend on?
1) Patient’s risk of fracture
2) Efficacy
3) Patient’s goals
4) Desire for specific harm avoidance
5) Comorbidities such as autoimmune disorders (on steroids), HTN (at risk of dizziness and increased falls), early menopause
6) Feasibility
What is defined as secondary prevention?
If they’ve already had a fragility fracture OR they have osteoporosis (T score < -2.5)
How well do bisphosphonates work?
Hip fracture RRR = 30-50%
Vertebral fracture RRR = 40%
Major osteoporotic RRR = 40%
What # do we have to know for RRR of bisphosphonates ?
30-50%
40% is also acceptable
Who do we recommend treatment for?
Those with moderate to high risk (10 year risk fracture of >10% to >20%).
What do we need to tell the people who we are offering medication to to prevent fractures?
- inform pt of benefit
- discuss risks of medication and assist the pt in making an informed decision regarding medication use
What are some SE of oral bisphosphonates?
Common: GI (abdominal pain, dyspepsia, diarrhea, nausea, reflux)
Less common: esophageal or gastric ulceration, erosion, perforation
Rare: ONJ (tell people about these even though it is rare because it is in the media)
SE of Zoledronic acid?
injection rxn MSK pain, decreased Ca, rarely A fib, ONJ
SE of Raloxifene?
flushing, leg cramps, flu like symptoms
SE of Denosumab?
rash, MSK pain, decreased Ca, ONJ, infection
SE of Teriparatide?
nausea, dizziness, leg cramps, rarely increased uric acid and Ca
What is ONJ?
- An area of exposed alveolar bone (mandible or maxilla) that does not heal after 8 weeks
- bone-related, not tendon-related
When is the risk of ONJ higher?
- smokers
- TMJ
- dental procedures
- diabetes
- chemotherapy
- glucocorticoid use
- high dose bisphosphonaters
- poor dental hygiene
What are atypical fractures?
- Appear to develop as femur stress fractures
- May present as new thigh pain
- Most commonly associated with increased duration of use, especially > 5 years
Should we monitor therapy? If so, how often?
For patients who are undergoing treatment, repeat measurement of bone mineral density should initially be performed after one to three years; the testing interval can be increased once therapy is shown to be effective
**BMD is similar to LDL testing in the sense that you don’t really need to test it often bc it is just a small part of fracture risk
An alternative: Do not re-assess BMD within the first 5 years of therapy for patients who opt to initiate medication therapy
How long should we treat with bisphosphonates? (i.e. do they need a break?)
Depends on the risk
- Some clinicians say that high risk patients need to be on it for 10 year and no break.
- If they have low risk, break for 5 years is prob a reasonable approach
5 vs 10 year treatment
(FLEX trial):
-there was an increase in vertebral fractures by about 3% NNH = 34
-if you explain this to patients, they may have differing opinions
*some may want to stay on it (really don’t want a fracture), some may not want to
Should women over 80 get bisphosphonates?
**No evidence of protective effects of bisphosphonates on HIP or WRIST fractures in women > 80 years with prior hip or vertebral fractures.
**Bisphosphonates decrease VERTEBRAL fractures in women > 80, most (84%) of whom had previous vertebral fractures with an effect seen over 1-3 years
SO if they’re gonna live longer than 1-3 years, had previous VERTEBRAL fracture, and over 80 yo, can give them bisphophonate and will decrease vertebral fractures by ARR of 2-2.5%.
ALSO think about our #1 goal which is to prevent falls. If we can make other interventions there, medication may not be necessary !!!
List some take home points
1) Continue to monitor for and address fall risk in all patients
2) Encourage an individualized exercise plan
3) Counsel on and document use/intake of calcium + Vitamin D
4) The benefit for pharmacologic therapies is in “secondary prevention” (i.e. T score < -2.5 or previous fracture)
5) When deciding (with the patient) whether to initiate treatment, assess fracture risk and absolute benefit rather than BMD alone
6) Re-testing BMD in patients on therapy provides minimal (if any) benefit in therapeutic management
7) Duration of therapy should be discussed with patients at baseline and at 5 years
