Module 3: Osteoporosis treatment

Question 1

What is the diagnostic criteria for osteoporosis?

Answer 1

Fragility # - at spine, hip, wrist, humerus, rib or pelvis, regardless of bone mineral density

BMD - a T-score <2.5

High # risk - for patients with low bone mass not meeting first two criteria

Question 2

What are therapeutic goals in osteoporosis?

Answer 2

Prevention of #’s

Question 3

What are lifestyle factors to reduce bone loss?

Answer 3

Adequate intake of Ca (1200 daily from diet or diet + 500-1000mg supplement daily) and Vit D (800 units daily)
Exercise
Smoking cessation
Avoid heavy alcohol use
Falls prevention counselling

Question 4

Who is pharmacotherapy indicated in?

Answer 4

Postmenopausal women with diagnosis of osteoporosis based on BMD, fragility #, or high # risk

Question 5

What pretreatment evaluation needs to be done?

Answer 5

Confirm dx
Serum tests:
- Calcium (normal range)
- Creatinine (eGFR > 30)
- 25-hydroxyvitamin D
Confirm ongoing supplements of Ca and Vit D

Correct underlying Vit D deficiency with repeat test in 8 weeks

Question 6

What is recommended as first line therapy?

Answer 6

Oral bisphosphonates for efficacy, cost, and long-term safety data. Alendronate is preferred.

Question 7

Who is oral bisphosphonates contraindicated in?

Answer 7

Esophageal disorders or known malabsorption.

Bariatric sx in which surgical anastomoses are present in GI tract

Question 8

What is recommended as first line therapy for high # risk?

Answer 8

T score <3
T score <2.5 with fragility #
Severe or multiple fragility #’s

anabolic agent is recommended.

Question 9

What is done for patients with contraindications or intolerance to bisphosphanates?

Answer 9

Try IV
If not tolerated at all - anabolic agent

Question 10

What is osteoporosis?

Answer 10

Caused by the cumulative effect of bone resorption in excess of bone formation.

Question 11

What special population considerations for use of biphosphanate therapy?

Answer 11

CKD - not recommended for creatinine clearance below 30-35

Immediately following # - theoretical concern that bisphosphanates may impair # healing. Typically initiated 2 weeks post # and when pt can sit for 30 mins post oral administration.

In patients taking bisphosphanates that experience an atypical femur # - discontinue use for delayed healing. Prolonged use may cause oversuppression of bone turnover in increase skeletal fragility = atypical #’s

Question 12

What is the drug formulary for alendronate?

Answer 12

Partial coverage

Question 13

What are adverse effects to bisophosphanates?

Answer 13

GI - reflux, esophagitis, reflux (incidence low if taken properly)

Conflicting studies on link to esophageal cancer

Transient hypocalcemia

Musculoskeletal pain

Impaired kidney function

Ocular side effects

AFib (conflicting data)

Osteonecrosis of the jaw

Atypical femur #

Cutaneous reactions

Question 14

What are compliance concerns with bisphosphanates?

Answer 14

Must be taken first thing in the morning on an empty stomach with 8oz of water, stay upright for 30 mins and no other food or meds within 30 mins after.

Increases bioavailability of drug and decreases GI adverse effects.

Question 15

What is the dose and duration of therapy?

Answer 15

Dose =
High # risk: 70mg once weekly or 10 mg once daily
Others: 35mg once weekly or 5mg OD

Recommended to stop after 5 years (alendronate) for low risk (no history of # and Tscores better than 2.5). Need to be monitored closely.

For high risk continue up to 10 years.

Take a ‘drug holiday’ for 3-5 years and restart.