4 - Osteoporosis Flashcards
1
Q
Describe osteoporosis. Define bone strength and fragility fracture
A
- Generalized skeletal disease characterized by compromised bone strength predisposing a person to increased risk of fracture
- Bone strength = bone mineral content (often measured by BMD) + bone quality (reflecting microarchitectural structure)
- Fragility fracture – occurs spontaneously or from minor trauma (falling from a standing height or less)
2
Q
Goals of therapy for osteoporosis
A
- Reduce future risk of fractures
- - Major = hip and vertebral fractures
- - Hairline fractures don’t really affect people enough to go to the Dr. but could be seen on an X-ray
- - Clinical vertebral = causes pain and seen on an X-ray
- - Major osteoporotic = spine, forearm, shoulder, hip - Prevent negative outcomes as a result of fractures (disability, loss of independence, chronic pain, hospitalizations, death)
3
Q
Describe the clinical assessment for osteoporosis
A
- Identify risk factors prompting assessment for osteoporosis (BMD testing)
- Physical exam – measure height annually (> 6 cm loss since peak height or > 2 cm w/in past year)
- Fall risk assessment
4
Q
What are some risk factors for older adults (50 years and older) prompting assessment for osteoporosis?
A
- Fragility fracture after age 40
- Prolonged use of glucocorticoids
- Parental hip fracture
- Vertebral fracture or osteopenia identified on radiography
5
Q
What are some risk factors for younger adults (< 50 y/o) prompting assessment for osteoporosis?
A
- Fragility fracture
- Prolonged use of glucocorticoids (prednisone 7.5 mg/day or more for 3 months or more in past year)
- Hypogonadism or premature menopause (age < 45 y/o)
- Malabsorption syndrome
- Primary hyperparathyroidism
6
Q
Drugs associated w/ osteoporosis
A
- Immunosuppressants
- PPIs
- EtOH
- Antacid (aluminum)
- Canagliflozin
- Heparin > 30 d
- Lithium
- SSRIs
- Thiazolidinediones
- Vitamin A
7
Q
Fall risk factors
A
- Muscle weakness
- Previous falls
- Impaired visual acuity
- Poor balance/ gait
- Disability
- Advanced age
- Postural hypotension
- Fear of falling
- Medications (diuretics, CNS depressants)
- Environmental factors
- Chronic conditions (arthritis, stroke, incontinence, DM, PD, dementia)
8
Q
When to treat osteoporosis
A
Depends on:
- Px risk of fracture (low < 10% = pharmacotherapy no likely benefit; moderate 10-20% = pharmacotherapy considered; high > 20% or hx of fragility fracture = pharmacotherapy recommended)
- Efficacy, safety, cost considerations of therapy
- Px goals
9
Q
Pharmacotherapy options for osteoporosis
A
- Bisphosphonates (alendronate, risedronate) – 1st line for established osteoporosis & corticosteroid-induced osteoporosis
- Denosumab SQ q6months – 1st line for established osteoporosis
- Raloxifene – decreases vertebral #s in menopausal women
- Estrogen +/- progesterone – consider for osteoporosis prevention in early post-menopause if sx of estrogen deficiency
- Teriparatide – consider for high-risk osteoporosis & corticosteroid-induced osteoporosis w/ prior fragility & low BMD
- Calcitonin – not recommended; useful for pain from acute vertebral compression
- Efficacy similar for bisphosphonates, denosumab, & estrogen (effective for vertebral, hip, & non-vertebral fractures)
10
Q
Adverse effects of bisphosphonates
A
- “Common” = GI (abdominal pain, dyspepsia, reflux, diarrhea)
- “Rare” = ONJ
- Pt should be able to swallow the capsule & stay upright for at least 30 min; should be taken 30 min before breakfast
11
Q
Adverse effects of denosumab
A
Rash, MSK pain, decreased calcium
12
Q
Adverse effects of raloxifene
A
- 5-15% flushing
- Leg cramps
- Flu-like sx
13
Q
Adverse effects of teriparatide
A
Nausea, dizziness, leg cramps
14
Q
Describe ONJ
A
- Area of exposed alveolar bone (mandible or maxilla) that doesn’t heal after 8 weeks
- Risk is higher in high-dose bisphosphonates for bone metastases, glucocorticoid use, diabetes, poor dental hygiene
15
Q
Describe atypical fractures
A
- Appear to develop as femur stress fractures
- May present as new thigh pain
- Most commonly associated w/ increased duration of use, especially > 5 years
16
Q
Monitoring for osteoporosis
A
- Recommendation was every 1-3 years, but no evidence for that claim
- Goal is to prevent fractures; studying BMD frequently is costly & yearly is unnecessary
- BMD not correlated to response of therapy/ risk, so don’t reassess BMD for at least 5 years
17
Q
Duration of therapy for osteoporosis
A
- For alendronate & zoledronic acid, continuing therapy for 5 years vs. 10 years increases risk of vertebral fractures; no difference in non-vertebral (5.3% at 5 years vs. 2.4% at 10 years for alendronate)
- Should discuss duration of therapy w/ px at baseline & at 5 years
- Drug holidays allowed as bisphosphonates stay in the bone for extended periods of time; reassess risk in 1 year
18
Q
Tips for good bone care/ hygiene
A
- Lifestyle (regular exercise, weight-bearing)
- Vitamin D
- Calcium
- Fall prevention (minimize hazards for falling in the home; assess drugs; improve strength & balance)
- Smoking cessation
- Dietary measures (encourage adequate protein, calcium & vit D intake, avoid excess alcohol & caffeine)
19
Q
Supplementation for osteoporosis. What are the harms?
A
- Calcium 1200 mg/day and vitamin D 800 IU/day
- Decreases risk of non-vertebral (5/1000 decrease/year) & high-risk hip fractures (9/1000 decrease/year)
- Harm:
- Vitamin D –> negligible up to ~4000 IU/day
- Calcium –> GI sx (nausea, constipation, bloating), hypercalcemia
- Dietary Ca preferred (300 mg each = 1 cup milk, ¾ cup yogurt)
20
Q
Is exercise recommended for osteoporosis? If so, what kind?
A
- Weight-bearing and stability
- Reduced rate/risk of falls (RRR ~ 30%)
- Small increase in BMD (up to 1%) over ~ 12 months
- Individualize for adherence and safety
