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SMUPASPG19-MED 1 > ENDO-Osteo > Flashcards

ENDO-Osteo Flashcards

1
Q

What is the relationship between bone mass and age?

A

Decreases with age 3r-4th decade.

existing bone cells are reabsorbed by the body faster than new bone is made.

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2
Q

What is the major risk with Osteoporosis? What are the most common type

A

50% vertebral fractures - asymptomatic, Height loss, kyphosis, back pain

25% hip fractures -Falls onto the hip; Risk for DVT, PE; high mortality

25% Colles’ fractures -FOOSH

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3
Q

What are the Nonmodifiable risk factors?

A 
1]  h/o fracture as adult-IDNP
2] H/o fracture in 1st degree relative,
 3] Female sex,
 4] Advanced age, 
5] Caucasian/Asian race,
 6] Family history-IDNP
7] Dementia
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4
Q

What are the modifiable risk factors?

A 
1] Cigarette  smoking- inhib osteoblast, dec ca abosrbtion
2] Low body weight 127 lbs) -IDNP
3] Estrogen deficiency, 
4] Low calcium intake, 
5] Chronic steroid use, 
6] Alcoholism, 7
7] Impaired eyesight, 
8] Recurrent falls, 
9] Inadequate physical activity, 
10] Poor health / frailty
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5
Q

What are the protective factors for osteoporesis?

A

1] Higher BMI,
2] Black race,
3] Estrogen or diuretic therapy (thiazides),
4] Exercise (start as a child!)

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6
Q

Decribe the benefit of (thiazides)

A

decrease calcium excretion by the kidney.
associated with higher bone mineral density
reduce the risk of hip fracture.

uncertain -decrease PTH-stimulated bone resorption reduction bone turn-over rate.

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7
Q

What is the pathogenesis of osteoporesis?

A

Mismatch between bone resorption and bone formation;

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8
Q

What are natural causes of osteoporesis?

A

1] Age-related bone loss: low loss of cortical and trabecular bone

2] Post-menopausal: Rapid loss of trabecular bone

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9
Q

What is the genetic component of osteoporesis?

A

Genes involving Vitamin D synthesis,
estrogen receptors,
bone forming proteins

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10
Q

What are the usual cause of high turnover osteoporesis

A

1] Estrogen deficiency (PMP women)

2] Hyperparathyroidism,

3] Hyperthyroidism,

4] Hypogonadism,

5] Cyclosporine, Heparin

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11
Q

What are the usual cause of low turnover osteoporesis?

A

1] Liver disease,

2] Age 50 years

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12
Q

What medicatins cause Increased bone resorption and decreased bone formation?

A

Glucocorticoids

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13
Q

How is Water a function of bone remodeling?

A

1] Repair microdamage within the skeleton (maintain skeletal strength),

2] Supply calcium from skeleton to body

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14
Q

What regulates bone remodeling?

A

circulating hormones: estrogens, androgens, vitamin D, parathyroid hormone

IGF-1, ILs, prostaglandins, TNF, cytokines

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15
Q

What is end result of bone remodel? what happens to as you age?

A

resorbed bone is replaced by an equal amount of new bone tissue

become imbalanced
→ resorption exceeds formation → osteopenia

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16
Q

What is Rapid bone loss, Loss of horizontal connections is seen in osteoporotic bone?

A

Trabecular bone loss
Osteoclasts penetrate trabeculae leaving no template for new bone formation;

Cortical- inc remodeling l/t porous bones

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17
Q

what does lack of estrogen do to cause the imbalance?

A

1] Activation of new bone remodeling sites,

2] INC imblance between bone formation and resorption

1] INC osteoclast activity ,
2] INC rate of osteoblast apoptosis,
3] Affects trabecular bone earliest

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18
Q

How does Inadequate calcium intake (diet, malabsorption) affect us?

A

Secondary hyperparathyroidism - Increased rate of bone remodeling to maintain adequate serum calcium,

Increased GI absorption of calcium
Decreased renal calcium excretion

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19
Q

What is the most common nutritional deficiency worldwide?

A

Vitamin D Deficiency

asymptomatic, most underdiagnosed medical condition, usually noticed on lab test

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20
Q

Describe what Vitamin D Deficiency causes

A 
secondary hyperparathyroidism-PTH stimulated 
leads to hypocalcemia, 
rickets,
osteomalacia, 
osteoporosis
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21
Q

what are the risk factors for Vitamin D Deficiency?

A 
sun avoidance/use of sunscreen, 
poor nutrition, 
malabsorption,
elderly, 
chronic liver or renal disease, 
people living in northern latitudes
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22
Q

What is the function of vitamin D?

A

1] calcitriol and its effects on calcium and phosphate homeostasis,
2] increase in the serum calcium and phosphate concentrations

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23
Q

Child presents with radiographic evidence of decreased mineralization around the epiphyses and bowing of the LE?

A

Rickets

only occurs before fusion of the epiphyses

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24
Q

How is osteomalacia related to vitamin D?

A

following growth plate closure in adults,
incomplete mineralization of the underlying mature bone matrix (osteoid)

rickets can occur with osteomalacia and continue into adulthood

25
Q

What are the lab values for vitamin D deficency

A

Serum 25-OH Vitamin D, total: major circulating form Represents endogenous production, diet and supplementation

26
Q

What are the ranges of Serum 25-OH Vitamin D, total

A

1] Normal range: 30-100 ng/mL,

2] Deficiency: <20ng/mL,

3] Insufficiency: <30ng/mL

25-OHD3- measure endogenous

25-OHD2- measure of exogenous

D2+D3 = total

27
Q

Describe the 1-25 dihydroxy vitamin D test

A

tests biologically active form of vitamin D (hydroxylated in kidney to this form),
not used for overall vitamin D status.
for establishing inherited or acquired disorders of vit D metabolism, a

OR for sarcoidosis, lymphoma, TB, CKD

28
Q

Describe the initial treatment of vitamin D deficency

A

1] Cholecalciferol (D3) 1000-2000IU for 8 weeks,

2] Ergocalciferol (D2) 50,000IU QW

QOW for 6-8 weeks

29
Q

Describe the mainteance treatment of vitamin D deficency

A

vitamin D level >30

D3 400-1000IU qd to maintain 25-OH

30
Q

When is Parathyroid hormone level testing indicated

A

regulates calcium and phosphate homeostasis

abnormal calcium

31
Q

Describe Primary hyperparathyroidism

A

parathyroid adenoma causes inappropriate release of

results in hypercalcemia l/t osteopenia/osteoporosis
stimulate calcium resorbtion/breakdown, thus extra in blood

32
Q

Describe Secondary hyperparathyroidism

A

commonly due to vitamin D deficiency!!

Kidneys and Gut- unalbe to absorb calcium, thus floating in blood

33
Q

What if PTH is elevated and vitamin D is low?

A

1) replace vitamin D,
2) recheck PTH
3) D- levels should normalize

34
Q

PT c/o Loss of height, kyphosis, mild back pain and had aFalls from standing

A

Osteoporisis
1] asymptomatic until fractures occur,
2] Loss of height, kyphosis, back pain with vertebral fractures
3] Falls from standing that cause hip or wrist fractures – think about osteoporosis

35
Q

What are the radiograph features of spinal osteoporosis

A

wedging of the vertebra anteriorly with vertebral collapse (arrows),
vertebral end-plate irregularity,
demineralization.

36
Q

What are comorbidities that lead to osteoporosis

A

1] Hyperthyroidism
2] Hypogonadism
3] Renal disease
4] Cancer (especially multiple myeloma)***,
5] Diabetes-bone turnover is suppressed, do not have low bone mass (increased BMI),
6] GI or liver disease

37
Q

What is the mnemonic for multiple myeloma

A 
CRAB: 
C = Calcium (elevated),
R = Renal failure, 
A = Anemia, 
B = Bone lesions. Bone pain is also common
Bence jones proteins
38
Q

Why lab values of albumin are important?

A

marker of nutritional status,
necessary for calculating a corrected calcium
ionized calcium so no binding protein interference

39
Q

Pt has Alkaline phosphate, what can this indicate?

A

Paget’s, osteomalacia

40
Q

Pt has Mgphosphate, what can this indicate?

A

found in bone, low levels can indicate osteomalacia.

PTH regulates phos and calcium

41
Q

What is Used to estimate bone mineral density?

A

Bone Densitometry
LOC-for screening and diagnosis of osteoporosis,
based on female Caucasians is used to determine “normal” BMD

42
Q

List the Bone Densitometry scans

A

1] Single-Photon Absorptiometry (SPA) - peripheral (radius, calcaneus),

2] Dual-Photon Absorptiometry (DPA) - axial (spine, hip),

3] MC**Dual-Energy Xray Absorptiometry (DXA or DEXA) - spine, hip; low radiation,

4] Quantitative Computed Tomography - Expensive, lots of radiation,

5] Ultrasonography (heel)

43
Q

What is a comparison of a patient’s BMD to that of a healthy thirty-year-old and same sex?

A 
T score (T-THIRTY)
IF -2.0SD, lower than average by two SDs in females
44
Q

What is used in reference the age-, sex-, and ethnicity-matched population, used in Pre-menopausal women, men <65 yrs, children?

A

Z- score

IF -0.5 SD, your bone density is less than the norm for people your age by one-half of a standard deviation.

45
Q

What is the normal BMD, osteopenia BMD, osteoporosis

A

N-Within T-score -1.0 or higher

Osteopenia-T score between -1.0 and -2.5, osteopenia

OsteoporosisT score -2.5 or lower, osteoporosis

46
Q

Who should be screened for Osteoporosis

A 
1] All women aged ≥65 years, 
2] Post-menopausal women aged ≥60 years if risk factors are present, 
3] Men aged 70 and older., 
4] Prior fracture,
 5] High risk medication use
47
Q

What is used as a screening tool for Osteoporosis

A

Hip with DXA

Every 2-3 yrs

48
Q

Who should be treated for Osteoporosis

A

1] PMP women and men (> 50 years) with h/o hip or vertebral fracture,

2] Any patient with osteoporosis (T-score ≤-2.5),

3] Any patient with osteopenia (T score -1.0 to -2.5) and an estimated 10-year risk of hip or osteoporosis related fracture

49
Q

Describe Nonpharmacologic Therapy of Osteoporosis

A

1] Calcium and Vitamin D intake supp
2] Exercise,
3] Smoking cessation and avoid excessive ETOH intake, 4] Gluten-free diet for celiac disease,
5] Home safety

50
Q

What is DOC 1st line for prevention and treatment of osteoporsis.

A

Bisphosphonates
efficacy, favorable cost, and the availability of long-term safety data. DEC Loss at hip

MOA: Inhibits osteoclast activity, reducing bone resorption, turnover; Increase bone mass, decrease fracture risk

ADRs- erosive esophagitis, empty stomach; remain upright for at least 30 minutes.
5-7 years, consider drug holiday,
consistent f/u with DEXA is the best guide

1] Alendronate (Fosamax) 70mg/week,
2] Risedronate (Actonel) 35mg/week, or 150mg/month,
3] Ibandronate (Boniva) 150mg/month,
4] Zoledronic acid (Reclast) 5mg IV q 12 months

51
Q

WHat Increases bone mineral density, lowers serum LDL levels, decreases risk of vertebral fractures, decreases risk of breast cancer?

A

Selective Estrogen Receptor Modulators (SERMs) as treatment
Raloxifene (Evista) 60mg/day

MOA- Selectively binds to estrogen receptors, inhibiting bone resorption and turnover

ADRs-venous thromboembolism and hot flashes

52
Q

What is Indicated for PMP women with high risk of fracture, or failure of other therapy?

A

Denosumab (Prolia)
Reduces incidence of vertebral, nonvertebral and hip fractures; 60mg SC q 6 months

MOA- RANK-Ligand inhibitor; Reduces bone turnover and resorption by inhibiting osteoclast activity

ADRs-back pain, hypercholesterolemia, hypocalcemia

53
Q

Which is indicated in symptomatic menopausal women with osteoporosis low risk fracture?

A

Estrogen/Progestin
Reduce bone turnover, prevent bone loss, increase bone mineral density, reduce fracture risk; May be

ADR-Increased risk of breast cancer, stroke, thromboembolism, and CAD

54
Q

Which can be used w/ bisphosphonate to maintain bone mass?

A

Parathyroid- Teriparatide (Forteo) 20 or 40 mcg/d SQ for no longer than 24 months;
High risk pt- caution CA

MOA- Stimulates more bone formation/osteoblast than resorption, but osteoclast via PTH

ADRs- nausea, headache, hypercalcemia, BBW of osteosarcoma- malignant bone tumor
Cuts FX healing, but risk cancer

55
Q

Which RX is Best in patients with pain from osteoporotic fractures improves bone pain? Not as effective

A

Calcitonin

Suppresses osteoclast activity;

ADRs- for up to 4 wks, Risk of tachyphylaxis; Recent cancer warning (2012), makes drug less favorable choice

56
Q

Describe Calcium/Vitamin D Supplements as treatment

A

Calcium 1000-1200 mg/day in divided doses with food intake;

Vitamin D 800-1000 IU/day;

Best preparations are calcium carbonate + vitamin D bid–tid with food -ALL

57
Q

How often should BMD be measured after TX?

A

12-24 months after beginning treatment

58
Q

What is the indications for decline

A

1] 4% change in spine or 6% change in hip considered significant,
2] If BMD declines at 2 years, discuss compliance with therapy or consider secondary causes of osteoporosis

SMUPASPG19-MED 1 (27 decks)

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