Osteoporosis Flashcards
At risk group for diagnosis of osteoporosis?
> 50yo with fracture following minimal trauma e.g. fall from standing height or less
Who should be assessed for risk of osteoporosis?
Men >50yo and women post-menopause
Screening Qs for falls risk?
- Had 2 or more falls in past 12 months?
- Are you presenting after a fall?
- Difficulty with walking or balance?
How would you Ax for osteoporosis?
Medical Hx, clinical exam, BMD via DXA, can also consider lab tests and xray of thoracic and lumbar spine
How is BMD best measured?
DXA scanning on at least 2 skeletal sites including lumbar spine and hip (unless unsuitable e.g. prosthesis)
How would you Ax absolute fracture risk?
Using either Garvan Fracture Risk Calculator (GFRC) or Fracture Risk Assessment Tool (FRAX) both available online
Name some indications for referring to a specialist?
Unusual features of osteoporosis at time of initial Ax
Intolerance of 1st/2nd line Rx
Fracture or significantly low BMD on 1st line Rx despite adherence
Secondary causes
Initiating teriparatide Rx
Poor access to DXA
List important lifestyle modifications for those at risk of osteoporosis
Adequate calcium and protein intake Adequate but safe sun exposure to sunlight for Vit D Maintain healthy weight and BMI Smoking cessation Avoid excessive ETOH consumption
Name one approach for reducing the risk of falls
Conducting falls assessment and initiating targeted fall-prevention programs in older adults
What are some of the risk factors for falls in older adults?
Hx of falls Polypharmacy, use of psychotropic/opiates Impaired gait/balance/mobility Impaired VA, cataracts Issues with bifocal/multifocal specs Reduced visual field Other neuro impairment Muscle weakness Cardiac dysrhythmias Postural hypotension Foot deformities, unsafe footwear Home hazards Reduced Vit D
What is involved in a falls prevention program?
Education on risk of falling, prevention strategies
Exercise program
Meds review
Prescribe Vit D
Podiatry if deformed feet
Wear single lens specs outdoors instead of bifocal/multifocal
Refer for Cataracts removal
OT Ax
Rx for postural hypotension and CV disorders
What would you recommend for exercise in terms of preventive measures for osteoporosis?
Adults >50yo without osteoporosis should do regular progressive resistance and balance training exercises
What exercise would you recommend to older adults who have osteoporosis?
High-intensity progressive resistance and balance training to prevent further bone loss and/or improve BMD, improve function, treat sarcopenia and reduce fall and fracture risk
What exercise would you recommend to those who have already had a hip fracture?
Extended exercise therapy, including resistance and balance training to improve mobility, strength and physical peformance
True or False:
Calcium and Vit D supplements should be used routinely in non-institutionalised elderly people
False.
The benefit is low, evidence of significant benefit is only in those at risk of deficiency particularly institutionalised individuals
When would bisphosphonates be recommended?
To reduce risk of vertebral and non-vertebral fractures in post menopausal women and men >50yo at high risk of fracture (i.e. osteoporosis Dx based on BMD or previous minimal trauma fracture)
When would Denosumab be recommended?
In treatment of osteoporosis in post menopausal women at increased risk of minimal trauma fracture
**Can be considered in men >50yo also at increased risk of minimal trauma fracture as an alternative to bisphosphonates
Pharmacological Rx options for osteoporosis?
Bisphosphonates (oral, IV) - alendronate, risedronate, zoledronic acid
Denosumab (SC)
Hormone therapy (oral, transdermal) - oestrogen, progestogen, tibolone, SERMs (raloxifene)
Parathyroid hormone (SC) - teriparatide
Strontium ranelate (oral)
When would hormone therapy be recommended?
Consider in post menopausal women to reduce risk of fractures, weigh benefits and risks, long-term use not recommended
When would SERMs be recommended?
In postmenopausal women with osteoporosis where vertebral fractures are the major osteoporosis risk (i.e. low spine BMD or existing vertebral fracture) and other agents are poorly tolerated
Particularly useful in younger postmenopausal women and women with prior or FHx of breast Ca
When would teriparatide be recommended?
In postmenopausal women and men >50yo with osteoporosis who have had another fracture whilst on anti-resorptive Tx or where anti-resorptive Tx is contraindicated
When would strontium ranelate be recommended?
2nd line option for reducing risk of further osteoporotic fractures in postmenopausal women with prevalent fractures
Contraindicated in those with active CVD or uncontrolled HTN
What is the recommendation for monitoring?
Regularly Ax fracture risk and requirement of anti-osteoporotic Tx in those not receiving Tx but remain at high risk of fracture
Review patient 3-6months after initiating Rx then annually
Ideal to perform BMD testing with DXA at least 2yrs apart and at the same provider
Recommended dietary intake for Calcium?
1300mg/day
Recommended dietary intake for Vit D via supplements?
800-1000 IU/day
How would you minimise rate of falls in community-dwelling elderly?
Multifactorial Ax of falls risk, exercise programs, home-safety interventions in those >75yo
Why is calcium often given with Vit D supplementation in the elderly?
Because calcium deficiency also seen in this population
What exercise is recommended in the elderly for managing osteoporosis?
Evidence-based exercise modalities that progress in intensity as capacity improves helps to maintain bone strength, muscle function and balance in those >75yo
What is the significance of aromatase inhibitor Tx in osteoporosis?
It can induce hypogonadism and accelerate bone loss, hence all women undergoing aromatase inhibitor Tx should have baseline Ax of fracture risk prior to commencing Tx
Indications for starting anti-resorptive Tx for those on aromatase inhibitor Tx
> 70yo and T score 50yo with minimal trauma fracture or high estimated 10yr risk of fracture
What is the significance of androgen deprivation Tx on osteoporosis?
All men commencing this should have baseline Ax of fracture risk including BMD with DXA, same principle as aromatase inhibitor in women
True or false:
All men receiving androgen deprivation therapy with a Hx of minimal trauma fracture should be commenced on anti-resorptive Tx
True, unless contraindicated
Sources of dietary calcium?
Dairy: milk, cheese, yoghurt (preferably low fat) at least 3 servings per day
Tofu, almonds, sesame seeds, tinned fish, some leafy green vegetables, dried figs
Calcium supplements
Absolute fracture risk vs relative fracture risk?
Absolute fracture risk is individual’s % chance of fracture over period of time whereas relative fracture risk is comparing individual’s risk of an event to a risk of that event in a reference group or to a baseline risk at a given point in time
Define osteoporosis
Reduced bone mineral density and micro-architectural deterioration of bone tissue leading to reduced bone strength and increasing bone fragility which can increase risk of fracture
What is a T-score?
T score compares BMD to that of a young healthy adult of the same sex
> 1.0 = normal
-1.0 to -2.5 = osteopenia
< -2.5 = osteoporosis
