71. Osteoporosis

Question 1

In menopausal or peri-menopausal women, provide advice about fracture prevention what ? (5)

Answer 1

• improving their physical fitness
• reducing alcohol
• smoking cessation
• risks of physical abuse
• and environmental factors that may contribute to falls (e.g., don’t stop at suggesting calcium and vitamin D).

Question 2

Describe investigation osteoporosis (3)

Answer 2

• Screen with FRAX +/- BMD T-score to determine 10-year risk of fracture
• Consider lateral T4-L4 spine X-ray if vertebral fracture suspected
• Consider labs for secondary causes of osteoporosis

Question 3

Who to screen osteoporosis ? (3)

Answer 3

• All men and women ≥ 65yo
• ≥ 50yo if risk factor
• <50 yo if disorder associated with rapid bone loss

Question 4

How to screen osteoporosis in all men and women ≥ 65yo ? (3)

Answer 4

• Consider simplified Osteoporosis Self-Assessment Tool (OST) = Weight (kg) - Age (years)
• > 10, reassess OST in 5y
• <10, do FRAX

Question 5

Screen osteoporosis in ≥ 50yo when? (8)

Answer 5

if risk factor:

• Fragility fracture after age 40 (low trauma fractures) and risk of future fractures
• Vertebral compression fracture or osteopenia on X-ray
• Parental hip fracture
• Prolonged use of glucocorticoids (3mo of >7.5 mg prednisone daily in past year)
• Rheumatoid arthritis, malabsorption syndrome
• Current smoker
• High alcohol intake (>3 units/day)
• Major weight loss (10% below body weight at age 25)

Question 6

Screen osteoporosis in < 50yo when? (8)

Answer 6

<50 yo if disorder associated with rapid bone loss

• Fragility fractures
• High-risk medications
• Malabsorption
• Inflammatory
• Primary hyperparathyroidism

Question 7

Name labs for secondary causes of osteoporosis (7)

Answer 7

• Calcium, Albumin
• CBC
• Creatinine
• Alk phos
• TSH
• SPEP (if vertebral fractures on X-ray)
• 25-OH Vitamin D checked once after 3 month of supplementation in impaired instesinal absorption, or osteoporosis requiring pharmacotherapy

Question 8

Describe prevention : Osteoporosis (5)

Answer 8

• Smoking cessation, alcohol reduction <3 drinks/day
• Vitamin D
• Calcium intake
• Sufficient protein intake (1g/kg/day)
• Exercise Multicomponent program
• Fall awareness and prevention

Question 9

Describe Vit D intake for osteoporosis prevention (2)

Answer 9

• Vitamin D 1000-2000 IU PO daily
• Consider 10,000 IU PO weekly or 50,000 IU monthly

Question 10

Describe calcium intake for osteoporosis prevention (2)

Answer 10

• intake 1200mg/day from diet (three servings of low fat milk products)
• Can consider Calcium supplement ≤500mg PO daily in those who cannot meet recommended dietary allowance at high risk of fractures

Question 11

Exercise Multicomponent program includes what ?

Answer 11

Resistance training ≥ twice weekly, including exercises targeting abdominal and back extensor muscles.
* Back extensor muscles daily

Balance and functional training ≥ twice weekly to reduce the risk of falls.

• Shifting body weight to the limits of stability
• Reacting to things that upset one’s balance (e.g., catching and throwing a ball)
• Maintaining balance while moving (e.g., Tai chi, heel raises, agility training)
• Reducing base of support (e.g., standing on one foot)

Aerobic physical activity 150 mins/week of moderate intensity

Question 12

Describe : Fall awareness and prevention (5)

Answer 12

• Assistive devices
• Medication review (fall risk)
• Environmental hazards
• Hip protectors
• Urinary incontinence

Question 13

Offer medication for osteoporosis when ? (2)

Answer 13

• if high risk (>20% 10-year fracture risk)
• or moderate but high risk feature

Question 14

Name 1st-line tx for osteoporosis

Answer 14

Oral bisphosphonate: Alendronate 70mg PO weekly or Risedronate 35mg PO weekly or 150mg PO monthly

Question 15

Describe method of taking biphosphonate (2)

Answer 15

• Take 1 hour before breakfast with 250mL water, upright 30 mins, avoid any calcium for 2-3h
• Duration of therapy: 3-6 years

Question 16

Name risks : Biphosphonate (4)

Answer 16

• Ostéonécrose de la mâchoire
• fractures atypiques du fémur
• œsophagite
• ulcères œsophagiens

Question 17

6 years of therapy is appropriate for who?

Answer 17

for individuals with a history of
* hip, vertebral or multiple nonvertebral fractures,
* or new or ongoing risk factor(s) for accelerated bone loss or fracture

Question 18

What’s an inadequate response to biphosphonate ?

Answer 18

> 1 fracture or substantial bone density decline (e.g., ≥ 5%) occurs despite adherence to an adequate course of treatment (typically > 1 yr))

Question 19

If inadequate response occurs despite adherence to an adequate course of treatment (typically > 1 yr)) or ongoing concern for fracture after 3-6 years, consider what? (3)

Answer 19

• Extending or switching therapy
• Reassessing for secondary causes
• Consult endocrinology

Question 20

Name other tx of osteoporosis (5)

Answer 20

• IV bisphosphonate: Zoledronic acid 5mg IV once yearly
• Monoclonal Ab (RANKL inhibitor): Denosumab (Prolia) 60mg sc twice yearly
• PTH Analog: Teriparatide (Forteo) 20mcg sc daily
• SERM: Raloxifene
• Other: Calcitonin intranasal, Hormone therapy (in menopausal symptoms)

Question 21

When to use IV bisphosphonate?

Answer 21

Zoledronic acid 5mg IV once yearly
* if GI/esophageal disorders,
* or inability to tolerate (eg. sit upright for 30-60 mins)

Consider Drug Holiday after 3y (6y in high risk)

Question 22

When to use Denosumab? (2)

Answer 22

• Denosumab (Prolia) 60mg sc twice yearly if impaired renal function
• No drug holiday on Denosumab

Question 23

Name adverse effects : Denosumab (2)

Answer 23

• Joint/muscle pai
• osteonecrosis of jaw
• contraindicated in pregnancy

Question 24

When to use Teriparatide ?

Answer 24

Teriparatide (Forteo) 20mcg sc daily in severe osteoporosis who cannot tolerate bisphosphonate

Question 25

Name adverse effect : Teriparatide

Answer 25

• Hypercalciuria/emia
• angioedema

Question 26

Name risk : Raloxifene

Answer 26

Risk of thromboembolism