71. Osteoporosis Flashcards
In menopausal or peri-menopausal women, provide advice about fracture prevention what ? (5)
- 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).
Describe investigation osteoporosis (3)
- 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
Who to screen osteoporosis ? (3)
- All men and women ≥ 65yo
- ≥ 50yo if risk factor
- <50 yo if disorder associated with rapid bone loss
How to screen osteoporosis in all men and women ≥ 65yo ? (3)
- Consider simplified Osteoporosis Self-Assessment Tool (OST) = Weight (kg) - Age (years)
- > 10, reassess OST in 5y
- <10, do FRAX
Screen osteoporosis in ≥ 50yo when? (8)
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)
Screen osteoporosis in < 50yo when? (8)
<50 yo if disorder associated with rapid bone loss
- Fragility fractures
- High-risk medications
- Malabsorption
- Inflammatory
- Primary hyperparathyroidism
Name labs for secondary causes of osteoporosis (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
Describe prevention : Osteoporosis (5)
- Smoking cessation, alcohol reduction <3 drinks/day
- Vitamin D
- Calcium intake
- Sufficient protein intake (1g/kg/day)
- Exercise Multicomponent program
- Fall awareness and prevention
Describe Vit D intake for osteoporosis prevention (2)
- Vitamin D 1000-2000 IU PO daily
- Consider 10,000 IU PO weekly or 50,000 IU monthly
Describe calcium intake for osteoporosis prevention (2)
- 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
Exercise Multicomponent program includes what ?
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
Describe : Fall awareness and prevention (5)
- Assistive devices
- Medication review (fall risk)
- Environmental hazards
- Hip protectors
- Urinary incontinence
Offer medication for osteoporosis when ? (2)
- if high risk (>20% 10-year fracture risk)
- or moderate but high risk feature
Name 1st-line tx for osteoporosis
Oral bisphosphonate: Alendronate 70mg PO weekly or Risedronate 35mg PO weekly or 150mg PO monthly
Describe method of taking biphosphonate (2)
- Take 1 hour before breakfast with 250mL water, upright 30 mins, avoid any calcium for 2-3h
- Duration of therapy: 3-6 years
Name risks : Biphosphonate (4)
- Ostéonécrose de la mâchoire
- fractures atypiques du fémur
- œsophagite
- ulcères œsophagiens
6 years of therapy is appropriate for who?
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
What’s an inadequate response to biphosphonate ?
> 1 fracture or substantial bone density decline (e.g., ≥ 5%) occurs despite adherence to an adequate course of treatment (typically > 1 yr))
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)
- Extending or switching therapy
- Reassessing for secondary causes
- Consult endocrinology
Name other tx of osteoporosis (5)
- 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)
When to use IV bisphosphonate?
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)
When to use Denosumab? (2)
- Denosumab (Prolia) 60mg sc twice yearly if impaired renal function
- No drug holiday on Denosumab
Name adverse effects : Denosumab (2)
- Joint/muscle pai
- osteonecrosis of jaw
- contraindicated in pregnancy
When to use Teriparatide ?
Teriparatide (Forteo) 20mcg sc daily in severe osteoporosis who cannot tolerate bisphosphonate
