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Ortho > Metabolic Bone Diseases > Flashcards

Metabolic Bone Diseases Flashcards

1
Q

Metabolic Bone Diseases

A 
Osteoporosis
Paget's disease
Osteomalacia
Rickets
Renal osteodystrophy
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2
Q

Pathophysiology of Osteoporosis

A

Bone resorption outpaces bone deposition

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3
Q

Negative Feedback Loop for Bone Remodeling

A

Hormonal process that maintains calcium homeostasis

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4
Q

Types of Stress on the Skeleton

A

Mechanical

Gravitational

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5
Q

What is osteoclast activity stimulated by?

A 
PTH
Calcitonin (low levels)
GF
IL-6
Lack of gonadal hormones
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6
Q

Osteoblasts

A

Builders of bone matrix

Decreased number with aging

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7
Q

How can the thyroid gland stimulate or inhibit osteoclast activity?

A

Hyperthyroidism: stimulate osteoclast activity

Increased plasma calcium: release of calcitonin

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8
Q

Risk Factors for Osteoporosis

A 
Age (>50)
Gender
Race (white, Asian)
Activity level
Diet
Hormonal
Meds: gonadal hormones
Family history
Medical history
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9
Q

Components of Diet in Osteoporososis

A

ETOH
Tobacco
Low calcium intake or altered ability to absorb

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10
Q

Hormonal Aspects with Osteoporosis

A 
Amenorrhea
Late menarche
Early menopause
Post menopausal state
Low testosterone
Low estrogen
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11
Q

Medical Conditions Associated with Osteoporosis

A 
Rheumatologic conditions
Malabsorption syndromes
Hypogonadism
Hyperthyroidism
Chronic kidney disease
Chronic liver disease
COPD
Neurologic disorders (unable to ambulate or exercise)
DM
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12
Q

Medications that can Decrease Bone Density

A 
Heparin
Warfarin (+/-)
Cyclosporine
Medroxyprogesterone acetate (Provera)
Vitamin A
Loop diuretics
Chemo drugs
Antiseizure meds
PPIs
H2 blockers
Antidepressants (TCA's & SSRI's)
Glucocorticoids
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13
Q

Prevention of Osteoporosis

A 
Exercise
Appropriate vitamin D and calcium intake
Cessation of tobacco use
ETOH in moderation
Screening tests
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14
Q

What is the standard test for the evaluation of bone mineral density?

A

DEXA scan

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15
Q

Indications for a DEXA Scan

A

Currently treated or considering pharmacologic therapy for osteoporosis
Anyone not receiving therapy in whom evidence of bone loss would lead to treatment
Screening for osteoporosis

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16
Q

DEXA Scan Screening Guidelines

A

Women >65
Men >70
Younger postmenopausal women and men with risk factors
Adults with fragility fractures
Condition associated with low bone mass
Medications associated with low bone mass

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17
Q

Define T-Score

A

Bone mineral density compared to what is normally expected in a young healthy adult based on gender

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18
Q

What T-score indicates osteoporosis?

A

Less than 2.5

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19
Q

In what populations is a Z-score used instead of a T-score?

A 
Premenopausal women
Men younger than 50
Children
African Americans
Native Americans
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20
Q

What is quantitative calcaneal ultrasonography effective at predicting?

A

Femoral neck, hip, & spine fractures

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21
Q

Pros of Quantitative Calcaneal Ultrasonography

A

Lower cost than DEXA scan
Portable
No radiation exposure
Screening test NOT diagnosis

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22
Q

Indications for Vertebral Imaging for Osteoporosis Screening

A

Bone testing not available in women >70 and men >80
T-scores of -1.5 in women 65-69 and men 75-79
Women 50-64 and men 50-69 with risk factors
Low trauma fracture
Historical height loss of 1.5”+
Prospective height loss of 0.8”+
Recent/ongoing long term glucocorticoid treatment

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23
Q

After initial vertebral imaging, when should you reemerge to evaluate?

A

Loss of height
Suspect new vertebral fracture
New back pain
Postural change

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24
Q

Work Up of Osteoporosis

A

H&P
Labs
+/- x-rays
DEXA scan

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25
Q

History in the Workup of Osteoporosis

A

Any history of disease
Family history
History of low vitamin D, prior bone density testing, or prior fractures
Medication review

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26
Q

Signs and Symptoms of Osteoporosis

A

Asymptomatic unless fracture
Gradual loss of height
Dowager’s hump

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27
Q

Possible Labs to Diagnose Osteoporosis (Depends on comorbidities & history)

A 
CBC
CMP
Serum magnesium
TSH
25-OH vitamin D
PTH
Testosterone (younger men)
24 H urine calcium
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28
Q

Indications for X-ray to Look for Osteopenia

A

Symptomatic patients

Asymptomatic patients if vertebral fracture suspected

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29
Q

Non-Pharmacologic Treatment of Osteoporosis

A

Calcium
Vitamin D
Exercise

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30
Q

SE of Calcium

A

Nephrolithiasis
Dyspepsia
Constipation
Interfere with absorption of iron and thyroid hormone

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31
Q

Calcium Citrate vs. Calcium Carbonate

A

Citrate better with H2 blockers and PPIs
Citrate less likely to cause nephrolithiasis
Citrate harder to take

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32
Q

SE of Excessive Vitamin D Levels

A

Hypercalcemia
Hypercalciuria
Kidney stones

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33
Q

Guidelines for Pharmacologic Treatment of Osteoporosis

A

Age 50 and older + hip or vertebral fracture OR T-scores less than -2.5
T-score -1 to -2.5 in postmenopausal women and men 50 and older + 10 year hip fracture possibility >3% OR 10 year major fracture probability of >20%

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34
Q

Pharmacologic Options for Treatment of Osteoporosis

A 
Bisphosphonates
Calcitonin
Estrogen agonist/antagonist
Hormone therapy
PTH 1-34
RANKL inhibitor
Tissue selective estrogen complex
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35
Q

Oral Bisphosphonates

A

Alendronate (Fosamax)

Risedronate (Actonel)

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36
Q

IV Bisphosphonates

A 
Zoledronic acid (Reclast)
Ibandronate (Boniva)
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37
Q

MOA of Bisphosphonates

A

Inhibit bone resorption by decreasing number and function of osteoclasts

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38
Q

What portion of oral bisphosphonates are taken up by the bone?

A

1-5% absorbed

30% of absorbed taken up by bones

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39
Q

Bisphosphonates Pre-treatment Screening and Testing

A

GFR >30-35 mL/min
Correct calcium and vitamin D deficiencies prior to administration
Review history for symptoms of abnormalities of esophagus or delayed gastric emptying
Ability to be upright for 30-60 minutes post oral dose
Recent fracture (wait)
Plans for dental extractions

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40
Q

Contraindications for Oral Bisphosphonates

A

Barrett’s esophagus
Active upper Gi disease
D/C if symptoms of esophagitis occur
GFR less than 30-35 mL/min

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41
Q

Aldronate (Fosamax)

A 
Generic
Low cost
Greater increase in BMD than Actonel
Well tolerated
Effective for 5-10 years
Daily or weekly
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42
Q

Risedronate (Actonel)

A

Less GI side effects
Well tolerated
Effective for up to 7 years
Daily, weekly, or monthly

43
Q

Zoledronic Acid (Reclast)

A

Cannot tolerate oral therapy
Failure to respond to oral therapy
15 min IV infusion once a year

44
Q

Ibandronate (Boniva)

A

No evidence of decreased hip fracture

Q 3 months

45
Q

SE of Bisphosphantates

A 
Reflux
Esophagitis
Ulcers
Hypocalcemia
Musculoskeletal pain (large muscle groups)
Eye pain
Blurred vision
Conjunctivitis
Uveitis
Scleritis
Atypical fractures: subtrochanteric or lateral
Osteonecrosis of jaw
Flu-like symptoms post infusion
46
Q

Risk Factors for Osteonecrosis of the Jaw

A 
IV bisphosphonates
Anti-cancer therapy
Dental extractions
Dental implants
Poorly fitting dentures
Glucocorticoids
Smoking
Pre-existing dental disease
47
Q

Duration of Oral Bisphosphonate Therapy

A

Reassess at 5 years
T-score >-2.5 discontinue
T-score less than -3.5 continue up to 10 years

48
Q

Raloxifene (Evista): estrogen agonist/antagonist

A

Decrease risk of vertebral fracture by 30% with prior history of fracture
Decrease risk of vertebral fracture by 55% with no history of previous fracture
Less effective than estrogen and bisphosphonates

49
Q

Indications for Raloxifene (Evista)

A

Reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis

50
Q

SE of Raloxifene (Evista)

A

DVT
Hot flashes
Endometrial cancer

51
Q

Indications for Calcitonin

A

Osteoporosis in women >5 years post menopause

52
Q

Calcitonin and Vertebral Fractures

A

Reduction by about 30% in persons with previous fractures

53
Q

Contraindications of Calcitonin

A

History of allergy to salmon

54
Q

SE of Calcitonin

A

Rhinitis
Epistaxis
Allergic reactions

55
Q

Example of Hormone Replacement Therapy

A

Prempro (estrogen/progesterone)

56
Q

Prempro and Osteoporosis

A

5 years duration
Decrease vertebral and hip fractures by 34%
Decrease other osteoporotic fractures by 23%

57
Q

SE of Hormone Replacement Therapy

A

Increased risks of MI, CVA, invasive breast cancer, PE, DVT during treatment
No MI risk if within 10 years post menopause

58
Q

MOA of Teriparatide (Forteo)

A

Stimulates bone formation

59
Q

Indications for Teriparatide (Forteo)

A

Severe osteoporosis when other treatments have failed

60
Q

Effects of Teriparatide (Forteo)

A

Decrease risk of vertebral fracture by 65%

Decrease non-vertebral fracture by 53%

61
Q

Administration and Duration of Teriparatide (Forteo)

A

A: subQ injection daily
D: 24 months max

62
Q

SE of Teriparatide (Forteo)

A

Leg cramps
Nausea
Dizziness
Increased incidence of osteosarcoma (animal studies)

63
Q

Contraindications of Teriparatide (Forteo)

A 
At risk for osteosarcoma
Paget's disease
Prior RT of skeleton
Bone mets
Hypercalcemia
Hx of skeletal malignancy
64
Q

MOA of Denosumab (Prolia)

A

Decreases bone absorption by inhibiting osteoclast activity

65
Q

Indications for Denosumab (Prolia)

A

Postmenopausal women and men at high risk for fracture

Cancer patients

66
Q

Follow Up on Pharmacologic Therapy for Osteoporosis

A

Monitor for SE
Monitor for recurrent fractures
Yearly height management
Serial DEXA scans (every 2 years)

67
Q

Treatment of Osteoporosis for Special Populations

A

Glucocorticoid induced
Renal failure (calcitriol)
Androgen deficiency (testosterone)
Malabsorption

68
Q

What part of the body does Paget’s Disease (Osteitis deformans) commonly involve?

A 
Axial skeleton
Skull
Thoracolumbar spine
Pelvis
Long bones of the lower extremity
69
Q

Pathophysiology of Paget’s Disease

A

Increased rate of bone remodeling
Overgrowth of bone at a single or multiple sites
Impaired integrity of affected bone

70
Q

Epidemiology of Paget’s Disease

A 
Genetic disorder
Etiology: possibly viral
Age: 55+
Men > women
Associated with osteosarcoma
71
Q

Symptoms of Paget’s Disease

A 
Arthritis
Pain
Bone deformity
Fractures
Radiculopathy
Chronic back pain
Impaired functional status
Hearing loss
Headache
Vertigo
Tinnitus
Asyptomatic
72
Q

Labs for Paget’s Disease

A

Increased serum alkaline phosphatase
Normal calcium
Normal phosphorus

73
Q

Imaging for Paget’s Disease

A

X-ray

Bone scan

74
Q

Findings on X-rays for Paget’s Disease

A

Mixed lytic and sclerotic lesions
Long bone bowing
Bone thickening and enlargement

75
Q

Findings on Bone Scans for Paget’s Disease

A

Increased bone remodeling and blood flow

76
Q

Diagnosing Paget’s Disease

A 
H&P
X-rays
Elevated alkaline phosphatase
Baseline bone scan
Baseline calcium, 25-OH vitamin D, phosphorus
77
Q

Goals of Treatment of Paget’s Disease

A

Decrease pain

Slow bone remodeling

78
Q

Treatment of Paget’s Disease

A

Supportive: calcium, vitamin D

Bisphosphonates

79
Q

Define Osteomalacia

A

Decreased mineralization of newly formed bone (soft bones)

80
Q

Causes of Osteomalacia

A

Disorders that result in hypocalcemia, hypophosphatemia, or direct inhibition of the mineralization process

81
Q

2 Main Causes of Osteomalacia

A

Insufficient calcium absorption from the intestine

Phosphate deficiency

82
Q

Etiology of Osteomalacia

A 
Malabsorption
Gastric bypass surgery
Celiac sprue: malabsorption of vitamin D
Chronic hepatic disease: vitamin D stored in liver
Chronic kidney disease
83
Q

Symptoms of Osteomalacia

A 
Asymptomatic
Bone pain and muscle weakness
Bone tenderness
Fracture
Difficulty walking and waddling gait
Muscle spasms, cramps
Positive Chvostek's sign
Tingling/numbness
Inability to ambulate
84
Q

Positive Chvostek’s Sign

A

Twitching of the facial muscles in response to tapping over the area of the facial nerve

85
Q

Work Up for Osteomalacia

A 
Calcium
Phosphate
Alkaline phosphatase
25-OH vitamin D
PTH
Electrolytes
BUN and creatinine
Possible biopsy
86
Q

Nutritional Deficiency and Osteomalacia Labs

A 
Increased alkaline phosphatase
Decreased serum calcium and phosphorus
Decreased urinary calcium
Decreased 25-OH vitamin D
Increased PTH
87
Q

X-ray Findings for Osteomalacia

A

Reduced bone density with thinning of the cortex
Looser pseudofractures
Fissures
Loss of radiologic distinctness of vertebral body trabecular and concavity of the vertebral bodies

88
Q

Define Looser’s Pseudofractures

A

Cortical infarctions

Wide transverse lucencies traversing bone usually at right angles to involved cortex

89
Q

Treatment of Osteomalacia

A

Correction of underlying cause

Vitamin D supplementation

90
Q

Most Common Fractures in Osteomalacia

A

Distal radius

Proximal femur

91
Q

What vitamin D supplement is used in renal and hepatic disease to treat osteomalacia?

A

Calcitriol

92
Q

Define Rickets

A

Deficient mineralization at the growth plate
Prior to closure of the growth plates
Osteomalacia after closure of growth plates

93
Q

Cause of Rickets

A

Decreased calcium
Decreased vitamin D
Renal phophate wasting

94
Q

Define Renal Osteodystrophy

A

Bone disease secondary to chronic kidney failure

95
Q

Types of Bone Disease Secondary to Renal Osteodystrophy

A

Osteitis fibrosa
Mixed uremic osteodystrophy
Osteomalacia
Adynamic bone

96
Q

Effects of Renal Osteodystrophy

A

Calcium, phosphorus, vitmain D metabolism
PTH
Bone turnover
Bone mineralization, volume, linear growth
Bone strength
Extraskeletal calcification

97
Q

Major Contributor to Renal Osteodystrophy

A

Secondary hyperparathyroidism

98
Q

Secondary Hyperparathyroidism in Chronic Kidney Disease

A 
GFR below 60 mL/min
Calcitriol deficiency
Hyperphosphatemia
Hypocalcemia
Increase in PTH
99
Q

Pathophysiology of Osteitis Fibrosis

A

High turnover secondary to hyperparathyroidism

100
Q

Pathophysiology of Dynamic Bone Disease

A

Low turnover due to suppression of the parathyroid glands

Most common CKD related bone disease

101
Q

Pathophysiology of Osteomalacia

A

Low turnover with abnormal mineralization

102
Q

Pathophysiology of Mixed Uremic Osteodystrophy

A

Either high or low turnover and abnormal mineralization

103
Q

Treatment of Parathyroidism in CKD

A

Dietary restriction of phosphorus
Supplemental active form of vitamin D
Phosphate binders

Ortho (22 decks)

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