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Bone/Joint and Rheumatology > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Factors associated with decreased BMD and/or osteoporotic fractures

A

1) Age
2) Hormonal deficiency
3) Body habitus
4) Social history
5) Medical history
6) Drug induced causes
7) Sex-specific factors

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2
Q

Age related factors in osteoporosis

A

Women older than 65 years

Men older than 70 years

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3
Q

Hormonal deficiency factors in osteoporosis

A

Estrogen deficiency in women

Androgen deficiency in men

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4
Q

Body habits factors in osteoporosis

A

Decreased BMI

Calorie-restricted weight loss

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5
Q

Social history factors in osteoporosis

A 
Smoking
Alcohol use (>2 drinks per day)
High caffeine intake
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6
Q

Medical history factors in osteoporosis

A 
Rheumatoid arthritis
Cardiovascular disease
Type 2 diabetes mellitus
Celiac disease
Asthma/COPD
Autoimmune disorders
Hepatic disease
History of falls
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7
Q

Drug induced causes of osteoporosis

A 
Antiepileptic agenst
Immunosuppressants
Lithium
Proton Pump Inhibitors
Systemic corticosteroids (>5mg /day of prednisone or equivalent for 3 months or more
SSRI's
Excessive thyroid hormone supplementation
Tricyclic antidepressants
Warfarin or heparin (long term use)
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8
Q

Sex-specific factors in osteoporosis

A 
Women:
  - Anorexia nervosa
  - Medroxyprogesterone depot use
  - Excessive Vitamin A intake
  - Gastrointestinal malabsorption syndromes
  - Personal history of osteoporosis
Men:
  - Loop diuretic use
  - Gonadotropin-releasing hormone agonists (prostate cancer)
  - Psoriasis
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9
Q

T-score

A

Reports how many standard deviations separate a patients’s BMD compared with the BMD of a young, healthy adult of the same sex

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10
Q

z score

A

Reports how many standard deviations separate a patient’s BMD compared with the BMD of another patient matched for age, sex, and ethnicity

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11
Q

Diagnosis based on T-Score

A

“Normal”: 0-1 SDs below the mean value
Osteopenic: 1-2.5 SDs below the mean value
Osteoporosis: >2.5 SDs below the mean value

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12
Q

Lumbar spine T-score

A
  • reported as the average of L1-L4
  • consider dx of osteoporosis if two individual lumbar spine measurements are greater than 2.5 SDs below the mean regardless of lumbar spine average
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13
Q

Osteoporosis diagnosis based on z score

A

If a patient’s z scores are greater than 2 SDs below the mean, the result is usually indicative of accelerated bone loss unrelated to menopause and/or aging

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14
Q

Quantitative Ultrasonography

A
  • does not measure BMD
  • assesses fracture risk using SOS (speed of sound and BUA (broadband ultrasound attenuation)
  • Not associated with radiation exposure
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15
Q

Quantitative computed tomography

A

Able to predict fracture risk but with greater radiation than DXA (dual-energy x-ray absoptiometry)

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16
Q

Addition tests when evaluating for secondary causes of osteoporosis

A 
25-hydroxy-vitamin D
Creatinine
Estradiol
Serum protein electorphoresis
Alkaline phosphatase
Phosphate
Free testosterone
Calcium, serum
TSH
Parathyroid hormone
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17
Q

Calcium STEPS Analysis in Osteoporosis

A

Safety:
- questionable inc in MI with or without Vit D
- Nephrollithiasis risk slightly inc with carbonate
- Hypercalcemia in pts with late stage CKD
Tolerability
- constipation
- GI discomfort
Efficacy
- Calcium citrate preferred in instances of:
- Chronic acid suppression therapy
- Intolerance to Ca carbonate formulations
- NOF recommends daily intake of 1000-1500mg and should consider dietary calcium (max 600mg/dose)
- Calcium citrate usually requires 2 tabs/dose
- Should be used (at a minimum) in patients receiving chronic corticosteroid therapy
- Should be administered with an appropriate dose of vitamin D.
Simpliciaty:
- Various formulations available to meet patient needs:
- Tablets (varying sizes)
- Chewable tablets
- Soft chews and “gummy” formulations
- Liquid

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18
Q

Vitamin D available formulations

A

Vitamin D2 - ergocalciferol

Vitamin D3 - cholecalciferol

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19
Q

Vitamin D STEPS

A

Safety:
- Annual dosing alternatives (500,000 units) may result in higher rates of falls and fractures in older patients

Tolerability:

  • Hypercalcemia
  • Constipation

Preference (Pearls)

  • Unclear whether vitamin D without calcium supplementation is effective for fracture prevention
  • Toltal daily dose should be at least 800 Units

Simplicity:

  • coformulated with calcium, but be sure patients are receiving at least 400 units/dose
  • Administered daily as 400- to 1000- unit tabs/caps
  • Option for quarterly dosing (100,000 units every 3 month) is available, but evidence show only in composite (any site NNT 44), not individual outcomes.
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20
Q

Bisphosphonates: Available agents

A

1) Alendronate (Fosamax)
2) Idandronate (Boniva)
3) Risedronate (Actonel, Atelvia [delayed release])
4) Zeldronic acid (Reclast)

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21
Q

Bisphosphonate STEPS - safety

A
  • concerns regarding osteonecrosis of the jaw with bisphosphonates still in question
  • FDA issed warning regarding increased risk of atypical femur fractures in patients using bisphosphonates (More prevalent in patients on therapy for greater than 5 years
  • Cautious us in patients with impaired renal function (<30ml/min for risedronate and ibandronate or less than 35ml/min for alendronate and zeledronic acid) or low serum calcium
  • IN patients with hypocalcemia, resolve low calcium before starting.
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22
Q

Bisphosphonate STEPS - tolerability

A
  • abdominal pain
  • Acute-phase reaction (zoledronic acid and ibandronate infusions)
  • arthralgias
  • dyspepsia
  • Cautious use in patients with sever esophageal reflux disease, Barrett esophagus, or esophageal strictures
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23
Q

Bisphosphonate STEPS - efficacy

A
  • all bisphosphonates have evidence to support use for preventing vertebral fractures
  • alendronate, risedronate, and zoledronic acid have evidence for preventing non-vertebral and hip fractures
  • Ibandronate has not yet been proven efficacious for preventing non-vertebral fractures
  • Limited data regarding preventing corticosteroid-induced osteoporotic fractures, but good efficacy to prevent decline in BMD
  • Used in patient taking chronic systemic chorticosteroids to prevent BMD loss and subsequent fracture
24
Q

Bisphosponate STEPS - Preference (Pearls)

A
  • most oral doses should be taken with 6-8 oz of water at least 30-60 minutes before food, drink, or other medications risedronate delayed release should be taken with 4 oz of water right after breakfast)
  • Patients should remain upright for at least 30 minutes after the administration of an oral dose (60 minutes with ibandronate)
  • If a patient is unable to tolerate an agent, discontinue the agent until the adverse effect resolves, and off the patient the option to try another available agent
  • Questionable efficacy beyond 5 years; may warrant reavaluation and possible discontinuation of therapy
25
Q

Bisphosphonate STEPS - Simplicity

A
  • once-daily, once-weekly and once-monthyly tablet
    Alendronate: Prevention (5mg/day or 35mg/week and treatment (10mg/day or 70mg/week)
    Risedronate: Prevention and treatment (5mg/daily, 35mg weekly, or 150mg monthly)
    Ibandronate: Prevention (150mg monthly) and treatment (150mg monthly OR 3mg IV every 3 months
    Zoledronic acid: Prevention (5mg IV every 2 years) and treatment (5mg IV every year)
  • All dosage fomrs and intervals are equally effective, so consider the patient’s prescription drug coverage (or lack of) when choosing a medication
  • Alendronate and risedronate are available as generic medications
26
Q

Estrogen Replacement STEPS - Saftey

A
  • Based on information form the Women’s Health Initiative trial, the risk of using HRT exceeds the benefits associated with HRT use
  • HRT is more likely to be associated with:
    • CHD (estrogen/progesterone only)
    • Stroke
    • Invasive breast cancer (estrogen/progesterone only)
    • Venous thromboembolic events
27
Q

Estrogen Replacement STEPS - Tolerability

A
  • breast discomfort
  • GI symptoms
  • headache disorders
  • vaginal bleeding
  • venous thromboembolism
28
Q

Estrogen Replacement STEPS - Efficacy

A
  • reduced risk of vertebral fractures

- reduced risk of nonvertebral fractures

29
Q

Estrogen Replacement STEPS - Preference (Pearls)

A
  • Results of the WHI found the benefit of fracture prevention to be similar-to-less than the patient’s risk of heart disease, stroke, venous embolism, and breast cancer
  • Acts in conjunction with a bisphosphonate to increase BMD more than either agent alone
30
Q

Estrogen Replacement STEPS - Simplicity

A
  • once-daily oral dosing

- transdermal patch is approved for postmenopausal osteoporosis

31
Q

SERMs

A

Selective Estrogen Receptor Modulators
Raloxifene (Evista)
lasofoxifene (Fablyn) - Not FDA approved

32
Q

SERM STEPS - Safety

A
  • increased risk of fatal stroke in women with a history of coronary heart disease
  • increased risk of venous thromboembolism
33
Q

SERM STEPS - Tolerability

A
  • arthralgias
  • hot flashes / flushes
  • peripheral edema
  • sweating
34
Q

SERM STEPS - efficacy

A
  • increased BMD

- reduced incidence of clinical vertebral fractures

35
Q

SERM STEPS - Preference (Pearls)

A
  • The rates of venous thromboembolism are about the same as the rates of clinical vertebral fracture prevention
  • Evidence to support its use in patients to prevent invasive breast cancer
36
Q

SERM STEPS - Simplicity

A

Fixed-dose, once-daily dosing

37
Q

Parathyroid hormone - available agents

A

Teriparatide (biosynthetic parathyroid hormone 1-34) (Forteo)

38
Q

Parathyroid Hormone STEPS - Safety

A

Avoid use in patients with:
-Alkaline phosphatase elevation (unexplained)
-Open epiphysis
-Paget’s disease
-Prior skeletal radiation
Associated with osetosarcoma (in rats) after 24 months of therapy (3-60 times the human dose)

39
Q

Parathyroid Hormone STEPS - Tolerability

A

Influenza-like symptoms
Hypercalcemia
Injection site pain and/or rash
Urolithiasis

40
Q

Parathyroid Hormone STEPS - Efficacy

A
  • decreased incidence of new or worsening vertebral fractures in postmenopausal women
  • Increases vertebral and total hip BMD
  • Prevents BMD loss and vertebral fractures in patients receiving chronic systemic corticosteroid therapy
41
Q

Parathyroid Hormone STEPS - Preference (Pearls)

A
  • diminished efficacy if used concurrently with bisphosphonate
  • after discontinuing teriperatide, adding a bisphosphonate preserves BMD benefits
42
Q

Parathyroid Hormone STEPS - Simplicity

A

Once-daily injection

Available as a prefilled (3ml) pen

43
Q

RANKL antagonist

A

Denosumab (Prolia)

44
Q

RANKL antagonist STEPS - Safety

A
  • Cellulitis was the most common serious adverse event in clinical trials
  • Osteonecrosis of the jaw
45
Q

RANKL antagonist STEPS - Tolerability

A
  • eczema

- flatulence

46
Q

RANKL antagonist STEPS - Efficacy

A
  • decreased incidence of cerebral, nonvertebral, and hip fractures in patients with osteoporosis
  • increases bone mineral density in the hip and lumbar spine
47
Q

RANKL antagonist STEPS - Preference (Pearls)

A
  • National Institute for Health and Clinical Excellence (NICE) in the United Kingdom recommends denosumab for patients at risk of an osteoporotic fracture and unable to adhere to the dosing recommendations or tolerate and oral bisphosphonate
48
Q

RANKL antagonist STEPS - Simplicity

A

Subcutaneous injection every 6 months

49
Q

Calcitonin (brands)

A

Miacalcin, Fortical

50
Q

Calcitonin STEPS - Safety

A

Anaphylactoid and anaphylaxis reactions associated with injection

51
Q

Calcitonin STEPS - Tolerability

A 
Injection:
  - GI sympoms
  - Injection site reaction
  - Flushing
Nasal spary
  - Rhinitits
  - Nasal congestion
  - Mucosal irritation
52
Q

Calcitonin STEPS - Efficacy

A
  • Reduced incidence of vertebral fractures

- Beneficial effects on BMD

53
Q

Calcitonin STEPS - Preference (Pearls)

A
  • Inferior with respect to BMD effects compared with alendronate
  • May help relieve bone pain associated with fractures, but is not an indication to choose as the primary treatment
54
Q

Calcitonin STEPS - Simplicity

A

Nasal administration is only ONE nostril per day, alternating nostrils each day

55
Q

Osteoporosis follow-up

A

1) Dual-energy x-ray absorptiometry (DXA)
- recheck @ ~24mo to evaluate changes
- not tx failure if initial, solitary evaluation shows net bone loss
- patients NOT receiving drug therapy may recheck DXA every 5 years unless patient has developed risk factors

2) Medication adherence
- review at least every 6 months
- as may as 50% will d/c therapy within first 6 months

3) Resources
- handouts from American Family Physician website
- National Library of Medicine Medline Plus has patient oriented materials at no cost
- National Osteoporosis and Prevention Campaign examination room booklets and posters

Bone/Joint and Rheumatology (4 decks)

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