Osteo TX Flashcards
Strategies to prevent fracture
Exercise stimulates
Stimulates osteoblast activity
Exercise clinical benefit
Lowers fall risk
Decreases risk of fractures
Possibly better maintenance of BMD
Exercise type s
Encourage a variety of types and intensities but prioritize balance, functional and resistance training > twice weekly
- Increase over time
Functional exercises
Exercises that improve ability to perform everyday tasks, or do activities for fun or fitness (e.g., chair stands for sit-to-stand ability, stair-climbing to train for hiking).
Exercise that the patients wants to do
For patients who wish to participate in other activities (e.g, walking, impact exercise, yoga, plates) for enjoyment or other benefits
They should be encouraged if they can be done safely or modified for safety
They should be in addition to, but not instead of balance, functional and resistance training
Exercise guidelines
getting ≥ 150 min of moderate to vigorous physical activity per week, but prioritize balance, functional and resistance training.
Impact exercise?
only progress to moderate (e.g., running, racquet sports, skipping) or high (e.g., drop or high vertical jumps) impact exercise if appropriate for fracture risk or physical fitness level;
safety or efficacy is uncertain in individuals at high fracture risk
Reduce alcohol intake to….
Les sthan 2 drinks per day
caffeine
Avoidexcess - >4 cups per day may lower BMD by 4%
No fracture risk increase found
Calcium RDA’s
Men
51-70 years: 1000 mg calcium /day
> 70 years: 1200 mg calcium /day
Women:
> 50: 1200 mg calcium /day
Is calcium always need to be supplemented?
For people who meet the recommended dietary allowance for calcium with a variety of calcium-rich foods, we suggest no supplementation to prevent fractures
Calcium supllemnt chpoices
Calcium absorption
Prefer Calcium Citrate if patient on PPI or wants to take without food
Consuming ≤ 550mg elemental calcium at one time maximizes abs
Drug Interactions Calcium
PPI’s can decrease Ca absorption
Decreased absorption of ciprofloxacin, iron, protease inhibitors, tetracycline, thyroid medications
What is recommended: DIetary, SUpplement? Why?
Dietary sources are preferred over supplementation as excess supplementation can have adverse effects
Calcium supllement safety
Calcium may have safety issues if exceeding 2000mg/day
Nephrolithiasis
Cardiovascular disease
Dyspepsia
Constipation
Vitamin D RDAs
Men and women
< 70 years: 600 IU vitamin D/ day
> 70 years: 800 IU vitamin D/day
Health Canada recommendation for vit d supplementation
To meet the RDA, Health Canada recommends a supplement of 400 IU/day
For people at risk of vitamin D deficiency additional supplementation should be provided
Typse of vitamin? Which preferred?
Vitamin D3 = cholecalciferol; Vitamin D2= ergocalciferol
Vitamin D3 preferred
Usually 400iu or 1000iu tablets, also drops and liquids
Monitoring of vitamin D
Routine monitoring of Vitamin D is not necessary
Most Canadians are deficient
Possibly monitor if patient may require higher doses, eg. malabsorption disorders, sig. renal impairment, hypo/hyperparathyroidism, CF
If monitoring, do not repeat any sooner than 3 months after supplementation
Serum Vitamin D levels
The optimal serum 25-hydroxyvitamin level for bone health is uncertain, however the following definitions are widely accepted:
<30 nmol/L - high risk of vitamin D deficiency
30 to <50 nmol/L - potential risk of inadequacy for bone health
≥50 nmol/L - generally considered adequate for bone and overall health in healthy individuals
>125 nmol/L - linked to potential adverse effects
When to recommend pharmacotx?
First Line Mod-High
Bisphosphonates first line, denosumab second line
Very High Risk
VERY HIGH RISK (Recommend pharmacotherapy)
Recent severe vertebral fracture or >1 vertebral fracture and T-score < -2.5
Recent fracture” is defined as a fracture occurring within the past 2 yr, and “severe vertebral fracture” as vertebral body height loss of > 40%.
Very High Risk TX
Teraparatide or Romosumab should be followed by a bisphosphonate
Fracture risk guidelines re-test
5 – 10 yr if the risk of major osteoporotic fracture is < 10%
5 yr if the risk of major osteoporotic fracture is 10%–15%
3 yr if the risk of major osteoporotic fracture is > 15%.
For those on pharmacotherapy
3 years
A shorter retesting interval may be appropriate for those with secondary osteoporosis or new clinical risk factors, such as a fracture
First-line all pt’s. WHy?
Bispphosphonates
Halts BMD decline and slightly reverses loss
Fracture risk decreases independent of BMD changes
Indications bisphosphonates
Postmenopausal osteoporosis treatment and prevention
Osteoporosis treatment in men
Treatment and prevention of glucocorticoid-induced osteoporosis
Paget’s disease
Examples bisphosp
Alendronate
Risedronate
Zoledronic Acid
MOA of bisphosph
Are analogues of pyrophosphate which allows for incorporation into bone
Binds strongly to hydroxyapatite undergoing remodeling
Inhibits osteoclast activity at site
2nd generation bisphosphonates additionally inhibit farnesyl pyrophosphate synthase osteoclast apoptosis
May also prevent osteoblast apoptosis
Dose Bisphosphonates
Bioavail Bisphosph
Extremely poor bioavailability – space from all medications
Admin Bisphosp
Immediate-release tablets: empty stomach with 1 cup of water, >30 minutes before food, drink and other medications. Remain upright for 30 minutes.
Delayed-release tablets: take with 1 cup of liquid immediately after breakfast. Remain upright for 30 minutes.
Zoledronic acid: once yearly IV infusion over 15 minutes
Bisphosphonates Onset
Weeks to observe bone changes
Years to observe clinical benefit
Common S/e Bisphosphonates
GI complaints - Abdominal pain(7%), Dyspepsia(2%), Nausea(4%), Diarrhea/Constipation (3%)
Headache (2%)
Dizziness (4%)
Musculoskeletal pain (5%)
Zolderonic CAid S/E
Infusion reaction – fever, myalgia, headache, flu-like symptoms, arthralgia
Free from GI issue
What do all bisphosphonates do?
All cause transient decrease in blood calcium levels
