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Clinical Medicine > Metabolic Bone Disease > Flashcards

Metabolic Bone Disease Flashcards

1
Q

If there are increased calcium levels the x gland releases x?

A

the thyroid gland releases calcitonin

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2
Q

When calcitonin is released what happens?

A

osteoclast activity is inhibited and calcium reabsorption in the kidneys decreases, so calcium level in the blood decreases

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3
Q

If there is decreased calcium levels the x gland releases x?

A

parathyroid glands release PTH

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4
Q

When PTH is released what happens?

A

osteoclasts release calcium from bone, calcium is reabsorbed from urine by the kidneys, calcium absorption in the small intestine via vitamin D synthesis; so calcium level in the blood increases

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5
Q

What is bone remodeling?

A

orderly process of bone resorption and subsequent bone formation AKA “coupling”

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6
Q

90-95% of bone cells are?

A

osteocytes

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7
Q

What do osteocytes do?

A

actively secrete and calcifies bone matrix material; regulate bone resorption and formation

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8
Q

Osteocyte activity produces

A

active release of cytokines needed for osteoclast development

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9
Q

What receptors and inhibitors regulate and control osteoclast production?

A

RANKL and OPG

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10
Q

What is bone mineral density?

A

amount of bone acquired during adolescence and young adulthood

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11
Q

Factors impacting the remodeling process

A

hormones, physical activity, nutrition, genetic influence

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12
Q

When is peak bone mass of the proximal femur?

A

18-20

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13
Q

When is peak bone mass of the spine?

A

25-30

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14
Q

What is osteoporosis?

A

skeletal disorder defined by decreased bone strength and increased fracture risk

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15
Q

What’s the most common metabolic bone disease?

A

osteoporosis

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16
Q

What fractures are associated with osteoporosis?

A

fragility fractures

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17
Q

Primary causes of bone loss

A

aging, estrogen status (age of menopause), nutrition (Ca/vitamin D), peak bone mass, genetics, level of physical activity

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18
Q

Who is more affected by osteoporosis?

A

women

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19
Q

What’s considered juvenile osteoporosis?

A

8-14 y/o

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20
Q

Stage I osteoporosis impacts?

A

post-menopausal women (ages 51-75)

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21
Q

Stage I osteoporosis is?

A

accelerated trabecular bone loss

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22
Q

Common fractures with stage I osteoporosis?

A

vertebral body and distal forearm fractures

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23
Q

Stage II osteoporosis impacts?

A

men and women aged >70

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24
Q

Stage II osteoporosis is?

A

both trabecular and cortical bone loss

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25
Q

Common fractures with stage II osteoporosis?

A

wrist, vertebra, hip

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26
Q

Secondary osteoporosis impacts who more?

A

men

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27
Q

What’s secondary osteoporosis?

A

underlying factor has been identified like environmental factor or disease state

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28
Q

Environmental factors of osteoporosis?

A

poor nutrition, calcium/vitamin D deficiency, physical inactivity, decreased sun exposure, medications, tobacco use, alcohol use (>3 drinks/day), traumatic injury (NWB/bed ridden), high caffeine intake

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29
Q

Medications associated with osteporosis

A

PPI, chronic corticosteroid use >3 months, aromatase inhibitors, anticonvulsants, anticoagulants, SSRI, excessive thyroxine, chemotherapy

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30
Q

Secondary causes of bone loss

A

hypogonadism, Cushing’s, hyperparathyroidism, hyperthyroidism, DM, hyperprolactinemia, vitamin D deficiency, alcohol, malabsorption, chronic liver disease, primary biliary cirrhosis, gastrectomy, multiple myeloma, OI, Marfan, RA, immobilization

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31
Q

Osteoporosis is most common at age?

A

> 70

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32
Q

Osteoporosis is common at what age in post-menopausal women?

A

50-70

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33
Q

Wrist fractures due to osteoporosis are common at what age?

A

50-59

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34
Q

Vertebral fractures due to osteoporosis are common at what age?

A

seventh decade

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35
Q

Hip fractures due to osteoporosis are common at what age?

A

50+; most common in eighth decade

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36
Q

Non-modifiable osteoporosis risk factors

A

personal history of fracture as adult; history of fracture in primary relative, white race, advance age (>50), female, dementia, poor health, amenorrhea

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37
Q

Modifiable risk factors for osteoporosis

A

current cigarette smoking, low body weight (<127 lbs/BMI), estrogen deficiency, low lifetime calcium intake, alcoholism, recurrent falls, inadequate physical activity, poor health

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38
Q

Osteoporosis symptoms

A

silent with no signs or symptoms

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39
Q

Major osteoporotic fracture sites

A

spine T11-L2 (don’t even have to fall), proximal femur, distal forearm, proximal humerus

40
Q

Careful evaluation of what for osteoporosis?

A

measure height loss (>4 cm since young adult maximum height suggest prior vertebral fractures or scoliosis); BMI; Kyphosis; spinal TTP and percussion

41
Q

FRAX takes into account what?

A

demographics, previous fracture, parent fractured hip, current smoking status, glucocorticoids, RA, secondary osteoporosis, alcohol (>3 units/day), femoral neck BMD from DEXA

42
Q

Osteoporosis work up labs

A

serum BMP (evaluate renal/hepatic function), parathyroid levels, CBC (nutritional status and myeloma), thyroid function tests, 25-hydroxyvitamin D-25(OH)D, serum calcium levels, consider 24 hour urine calcium, testosterone levels in men

43
Q

What are all the labs for osteoporosis really looking at?

A

secondary causes of bone loss

44
Q

What do we look for in a 24 hour urine for osteoporosis?

A

calcium (excess skeletal loss, vitamin D deficiency, malabsorption), creatinine, sodium, and free cortisol (Cushings)

45
Q

What are the biochemical markers of bone remodeling?

A

bone-specific alkaline phosphatase (BSAP) and Osteocalcin (OC) in serum; N-Telopeptide cross-links (NTX) and C-telopeptides (CTX) in urine

46
Q

What do we think of biochemical markers of bone remodeling?

A

controversial

47
Q

Imaging for osteoporosis?

A

x-ray symptomatic area; DEXA to measure BMD

48
Q

What’s the gold standard for screening and monitoring changes for osteoporosis?

A

DEXA

49
Q

What sites should you evaluate with DEXA?

A

hip, spine, wrist

50
Q

Dexa T-score

A

value compared to that of control subjects at peak BMD

51
Q

Dexa z-scores

A

value compared to that of patient matched for age and sex

52
Q

DEXA indications

A

women 65 years and older and men 70 years and older; younger postmenopausal women; women in menopausal transition with clinical RF for fracture; men 50-69 y/o clinical RF for fracture; adults with conditions or medications associated with secondary osteoporosis

53
Q

A T-score within x SD of healthy young adult is normal bone density.

A

1

54
Q

A T-score between x and x means a low bone density or osteopenia.

A

-1.0 and -2.5 SD

55
Q

A T-score of x is a diagnosis of osteoporosis.

A

-2.5 SD or below

56
Q

T-score of x + a fragility fracture Severe (established osteoporosis)

A

-2.5 SD or below + a fragility fracture

57
Q

The lower a person’s T-score, the lower

A

the bone density:

58
Q

A Z-score above x is normal

A

-2.0

59
Q

NOF does not recommend routine bone density testing in these age groups.

A

children, teens, women still having periods and younger men, premenopausal women with no RF, men <70 without RF; women <65 w/o RF

60
Q

DEXA limitations

A

doesn’t distinguish between low bone density vs. undermineralized bone matrix (osteomalacia); BMD varies between regions (spinal vs. distal radius)

61
Q

Repeat testing for women with normal BD or mild osteopenia

A

up to 10-15 years

62
Q

Repeat testing for women with moderate osteopenia

A

3-5 years

63
Q

Repeat testing for women with advanced osteopenia

A

usually annually

64
Q

Repeat testing for women undergoing treatment for osteoporosis

A

annual BMD

65
Q

People larger than x pounds DEXA reads may not be as accurate

A

300 pounds

66
Q

What can be done to analyze bone density in those larger than 300 lbs

A

peripheral bone density test at wrist (radius) and heel

67
Q

Bone density screenings other than DEXA

A

QCT (quantitative CT of spine), pQCT (wrist and tibia), finger DXA, ultrasound of calcaneus or wrist

68
Q

First line treatment of osteoporosis

A

supplemental calcium; women 19-50 and men 19-70 = 1000 mg; women >50 and men >70 = 1200 mg…. supplemental vitamin D: anyone 18-70 = 600 IU/Day, anyone >71 = 800 IU

69
Q

Which gender is more likely to die within a year after breaking a hip

A

men

70
Q

Why are men less likely to experience osteoporosis?

A

Androgens do not wane abruptly, like menopause; Slow decline in testosterone and estrogen levels

71
Q

Men’s risk of fracture increases after

A

70

72
Q

Osteoporosis risk factors in men

A

Age >70, low BMI (<20-25), weight loss >10% body weight, physical inactivity, androgen deprivation therapy (treatment of prostate CA), previous fragility fracture, spinal cord injury

73
Q

What’s osteomalacia?

A

softening of the bone; decreased mineralization between calcified bone and osteoid

74
Q

What’s Rickets?

A

Defective mineralization of cartilage in the epiphyseal growth plates in children

75
Q

Etiology of osteomalacia?

A

vitamin D deficiency…hypophosphatemia….Low Vit D/calcitriol levels= decreased Ca+ absorption= hyperparathyroidism= increased urinary phosphate excretion/wasting; chronic renal or liver disease; mineralization inhibitors (aluminum, fluoride)

76
Q

RF for osteomalacia

A

living in cold climates (little sun exposure); insufficient dietary ca and vitamin D; malabsorption disorders; hereditary vitamin d deficiency

77
Q

CM of osteomalacia

A

asymptomatic, bone pain/tenderness, deformity, muscle weakness, fracture, antalgic gait/difficulty ambulating, muscle spasms, numbness/tingling, + chvostek’s sign

78
Q

what sign is associated with osteomalacia?

A

Chvostek’s sign: tap on facial nerve, see twitching of facial muscles, hyperexcitability

79
Q

Work up for osteomalacia?

A

CMP, LFTs, phosphate, calcium, alkaline phosphatase, PTH (start to rise with 25(OH)D ais around 31 ng/ml); 25-hydroxyvitamin D (<30 = insufficient; <15-20 = deficient), 1,25 dihydroxyvitamin D

80
Q

Imaging for osteomalacia?

A

x-ray, bone biopsy (maybe)

81
Q

Osteomalacia treatment

A

Vitamin D replacement

82
Q

Target vitamin D serum in osteomalacia

A

> 30 ng/ml

83
Q

age 0-1 osteomalacia treatment

A

Initial: 2000 IU q day vs 50,000 IU q week x 6 weeks
Maintenance: 400-1000 IU q day

84
Q

1-18 osteomalacia treatment

A

Initial: 2000 IU q day vs 50,000 IU q week x 6 weeks
Maintenance: 600-1000 IU q day

85
Q

> 18 osteomalacia treatment

A

initial: 6,000 IU q day vs 50,000 IU q week x 8 weeks
Maintenance: 1500-2000 IU q day

86
Q

what if a person is getting osteomalacia treatment and has malabsorption?

A

2-3 x higher dose

87
Q

What’s paget disease?

A

Localized bone remodeling disorder; Excessive resorption, then increased bone formation; Disorganized bony structure- weaker and more susceptible to fracture

88
Q

Etiology of Paget Disease

A

genetic predisposition; maybe viral, autoimmune, connective tissue disorder, vascular disorder

89
Q

phases of paget disease

A

1) lytic phase: osteoclast activity-resorption; increase in number, size, and number of nuclei 2) mixed phase–osteoclast and osteoblast activity; bone resorption and formation leading to disorganized bone formation 3) sclerotic phase–disorganized bone formation becomes vascular, fibrous connective tissue

90
Q

Paget affects which bones?

A

PELVIS, lumbar spine, thoracic spine, femur, sacrum, skull, tibia, humerus

91
Q

Who is more affected by Paget men or women?

A

men

92
Q

CM of Paget disease

A

asymptomatic, bone pain is location specific, if skull (hearing loss, HA, tinnitus, increased hat size, cranial nerve palsies), pathologic fractures

93
Q

PE of Paget disease

A

deformities (bowing, kyphosis), decreased ROM, localized TTP, conductive vs. sensorineural hearing loss, abnormal gait

94
Q

Complications of paget disease

A

fractures, neoplasms (rare, but osteosacroma from fibrotic tissue), spinal cord compression, cerebellar compression, cranial nerve palsies, degenerative joint disease, left ventricular hypertrophy, calcific aortic stenosis

95
Q

Imaging of paget

A

plain films, possibly bone scan

96
Q

Labs for paget

A

alkaline phosphatase (bone specific), [calcium, vitamin D, phosphate] = normal, urinary markers (hydroxyproline, deoxypyridinoline, c-telopeptide

97
Q

Treatment of paget

A

Bisphosponates ->
Zoledronate acid (Reclast) 5 mg IV
Alendronate (Fosamax) 40 mg x 6 months
Risedronate (Actonel) 30 mg q daily x 2 months

Clinical Medicine (13 decks)

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