Module 15 - Osteoporosis

Question 1

• WHO Diagnostic Criteria for Osteoporosis (tscores)

Answer 1

Normal: tscore at -1.0 and above

Osteopenia: tscore -1.0 to -2.5

Osteoporosis: tscore at or below -2.5

Sev Osteoporosis: tscore is number of SDs above or below the average BMD value?

Question 2

• Calcium Intake Recommendations
  Calcium Citrate vs Calcium Carbonate

Answer 2

Calcium
- women > 51yo and men > 71yo
* at least 1200-1500mg daily
- all others at 1000mg/day
- dietary preferred

• supplemental
• calcium citrate: doesn’t need to take with food and preferred in elderly and those on PPI’s
• calcium carbonate: take with food

Question 3

• Vitamin D Intake Recommendations

Answer 3

Vit D
- women and men >50yo
* 800/100 IU/day
- all others at 400-800 IU/day
- Vit D3 plays major role in calcium absorption
- best way is through sun
- elderly don’t synthesize as well

• combo of vit d and calcium show reduces risk of fracture
• both primary and tertiary prevention !!!!!!!

Question 4

• Bisphosphonates

Answer 4

• FIRST LINE for OSTEOPOROSIS
• All bisphosphonates reduce risk of vertebral fracture

Agents FDA approved for:
* prevention AND treatment of osteo in post menopausal women !!!!!!!!!!!!!!
- treatment to increase bone mass in men with osteo
- treatment of glucocorticoid induced osteo in men and women !!!!!!!!!!!!!!!!!!!!!!!!!
- treatment of pagets disease of bone in men and women

MOA: inhibits bone reabsorption by attaching to bony surfaces undergoing active resorption and inhibiting action of osteoclasts

Question 5

Contraindications and S/E for Bisphosphonates

Answer 5

Contraindications:
- CrCl < 35 (aldendronate, zole)
- HYPOCALCEMIA
- GERD: caution (not absolute contra)

oral tablets:
- esophageal abnormalities
- inability to stand or sit for at least 30 min after dose
- ibandronate is 60 min

S/E:
- abdominal pain
- dyspepsia
- scleritis
- uveitis
- acute phase reaction (IV)

Question 6

• Safety Concerns for Bisphosphonates

Answer 6

Reasons for drug holiday:
1. osteonecrosis of jaw (exposed jaw)
* usually after dental extraction
* increase risk after 5 years

2. Atypical femoral fracture
   * especially after long term use

• Increase risk of aspiration with oral solution and effervescent

Question 7

• Bisphosphonate Administration

Answer 7

• At least 30min before first food OR drink OR med of day
• With 6-8oz of clear water
• Should only be taken upon rising for day (cant go to bed after)
• Should remain upright for at least 30 min after admin
• CORRECT HYPOCALCEMIA before treatment
• Should supplement with calcium and vit D
• Patient education is key to reducing side effects
• Ibandronate: 1hr before first FDM for monthly dosing
• Ibandronate: 1hr standing after monthly dosing
• Risendronate DR with 4 oz of water IMMEDIATELY after breakfast

Question 8

• RANKL Antagonist

Answer 8

Denosumab
- MAB binds to RANK ligand and prevents development of osteoclasts
- Comparable to bisphosphonates BUT less frequent dosing for TREATMENT of osteo (60mg SQ q 6mo)
- reverses after 6 mo
- no drug holiday recommended

Contraindications: preggo, hypocalcemia
Safety: ONJ, serious infections like cellulitis
S/E: eczema, GI symptoms, muscle or joint pain

Question 9

• Parathyroid Hormone (PTH) and PTH Analog

Answer 9

Indications:
- Treatment of high risk fracture
- Patient who had fracture while on bisphosphonate
- CORTICOSTEROID INDUCED OSTEOPOROSIS

Contraindications: None
Safety: Osteosarcoma (rats)
S/E: injection rash, flu-like symptoms, hypercalcemia, hypercalcuria, hyperureimia, hypotension

• Diminished efficacy in concurrent use of bisphosphonates
• After discontinuing therapy, add bisphosphonate to preserve BMD benefits
• Enhances intestinal absorption
• Teriparitide: SQ daily x 2 years
• Abaloparatide: SQ daily x 2 years (WOMEN ONLY)
• • either are recommended for post menopausal women with osteoporosis who have high risk of fracture