Osteoporosis Flashcards
what is osteoporosis?
what is osteopenia?
What is it?
bone disorder characterized by low bone density, impaired bone architecture, and compromised bone strength that predisposes a person to increased fracture risk. Four fold risk of fracture
Osteopenia: AKA low bone mass but not to the point of osteoporosis
epidemiology
Epidemiology
mostly occurs in non-hispanic white women.
disease prevalence greatly increases with age.
occurs more frequently in women than men
Pathophysiology of Osteoporosis
what contributes to peak bone mass?
what are the 2 main causes and their patho for osteoporosis?
Pathophysiology of Osteoporosis
a persons peak bone mass is attributed to multiple factors such as physical activity, genetic factors, nutrition
Postmenopausal osteoporosis: a.estrogen deficiency increases proliferation, differentiation, and activation of new osteoclasts (responsible for absorption of bone)
b. increase of IL-1, IL-6, TNF level result in more RANKL .
increased expression of RANK, RANKL (increase osteoclasts activity)
Aging
a. decreased replicative activity of osteoprogenitor cells
b. decreased synthetic activity of osteoblasts
c. decreased biologic activity of matrix-bound growth fctors
d. reduced physical activated
Types of Osteoporosis
Primary
Secondary
Types of Osteoporosis
Primary
a. post menopausal female
b. age related (female >male
Secondary
a. medications: glucocorticoids, anti epileptic drugs, depo,edrxyprogesterone, Heparin,aromatase inhibitors, PPI, TZD, SGLT-2i (canagliflozin)
b. medical conditions: hypogonadism, hyperthyroidism, hyperparathyroidism, malnutrition, rheumatoid arthritis, COPD, vitamin D deficiency, diabetes, renal insufficiency
AACE/ACE Diagnostic criteria for osteoporosis
AACE/ACE Diagnostic criteria
- T-score -2.5 or below in the lumbar spine, femoral, neck, or radius
- Low trauma spine or hip fracture (regardless of BMD and T-score)
- Osteopenia/ low bone mass (T-score between -1 and -2.5) AND a fragilty fracture of the proximal humerus, pelvis, or distal forearm
- Osteopenia/ low bone mass AND high FRAX fracture probability
WHO Fracture Risk Algorithm (FRAX)
WHO Fracture Risk Algorithm (FRAX)
a. measures 10 year probability of hip fracture
10 year probability of a major OP fracture (vertebral, HIP, Forearm or proximal humerus.
FRAX score includes
age, gender, prior op fracture, femoral neck BMD, low BMI, oral glucocorticoids (5 mg or more of prednisone or equivalent for 3 months or more, RA, secondary OP, parental hx of hip fracture, current smoking, alcohol intake of 3 or more drinks/day
what factors are included in the WHO FRAX score
11 of them
age, gender, prior op fracture, femoral neck BMD, low BMI, oral glucocorticoids (5 mg or more of prednisone or equivalent for 3 months or more, RA, secondary OP, parental hx of hip fracture, current smoking, alcohol intake of 3 or more drinks/day
Clinical representtion
Clinical representtion
Symptoms:
pain
immobility
depression, fear, low self-esteem
signs:
shortened stature (loss of >/= 1.5 inches from tallest recorded height)
kyphosis
lordosis
vertebral, hip, wrist, or forearm fractures
low bone mineral density (BMD) on radiology
Interpeting T-scores
Interpeting T-scores
normal: -1.0 and above
low bone mass(osteopenia): between -1.0 and -2.5
osteoporosis: at or below -2.5
severe or established osteoporosis: at or below -2.5 with one or more fractures
Nonpharmacologic Treatment
Nonpharmacologic Treatment
- balanced diet
- limit caffeine to 1-2 servings per day
- cessation of tobacco use
- avoidance of excessive alcohol intake
- regular weight bearing and muscle strengthening exercise
a. improve agility, strength, posture, balance
b. reduce risk of falls
c. modestly increases bone density
d. benefits are lost when a person stops exercising - fall prevention
- calcium intake:
- Vitamin D intake
- calcium intake through diet
- calcium intake:
a. adults aged 50+-> 1200 mg/day. dietary intake preffered.
b. best absorbed in amounts of 500-600 mg or less
I. 300 mg of calcium is one serving. so need 4 servings of calcium a day
- Vitamin D intake
sources:
risk factors for deficiency:
formulations:
recommendations:
optimal Vitamin D levels:
deficient vitamin D levels:
- Vitamin D intake
a. ingested from food (egg yolks, fish liver supplements, fortified milk and cereals). synthesize din skin but not reliable as sole source of vitamin. D
b. risk factors for deficiency: malabsorption disorders, chronic renal insufficiency, meds that increase vitamin. d metabolism (i.e antiepileptics), housebound pts, obesity.
c. recommendations: adults >/= 50 y.o: 1000 IU/day
d. D2 OR D3. D2 plant derived.
optimal level: 25(OH) Vit D >/30 ng/mL
e. if deficient (<20 ng/mL)
I. treat with 5000 IU of d3 DAILY FOR 8-12 WEEKS, FOLLOWED BY 1000-2000 iu OF d3 Daily
II. OR 50,000 IU of D3 weekly for 8-12 weeks, followed by 1000-2000 IU of D3 daily
f. safe upper limit for general adult intake=4000 IU/da
g. can also be used as adjunct to osteoporosis therapy, or in pts who cannot tolerate osteoporosis therapy
Goals of Therapy
Goals of Therapy
- stop or reverse bone loss
- increase bone mamss
- decrease osteoporotic fractres
- decrease falls
- pain control, increase QOL in pts. with fractures
Osteoporosis Pharmacotherapy agents
what are the 2 categories
Osteoporosis Pharmacotherapy agents
- Antiresorptive Agents
- Anabolic Agents
antiresorptive agents
- Antiresorptive Agents
a. Biphosphonates
b. RANK-ligand inhibitors
c. Estrogens
d. EAA
e. Mixed estrogen agonist and tissue selective estrogen complexes
f. calcitonin
g. Romosozumab
Anabolic Agents
Anabolic Agents
- parathyroid hormone analogs
- Romosozumab
Biophosphonates
Examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy:–
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
include first line agents in this group, how to take, CI, rare side effects
Biophosphonates
Examples: END IN-DRONATE (except zeledronic acid)
Oral agents-Alendronate (Fosomax, Binosto),Risedronate (actonel, altevia), Ibandronate (Boniva)
once a year- Zoledronic acid (recast)
Class: Biophosphonate
Indication: Treatment of osteoporosis in postmenopausal females and to increase bone mass in males with osteoporosis
Mechanism of Action: Binds to bone hydroxyapatite and specifically inhibits the activity of osteoclasts
Effects of mechanism of Action: decrease rate of bone resorption and indirect increase in bone mineral density.
Adverse Effects: Nausea/ dyspepsia (oral), transient influenza-like illness (arthralgia, myalgia, headaches, fever. may pretreat with APAP) (injectable). Rare -> GI perforation/ulceration/ oral bleeding, musculoskeletal ain, osteonecrosis of the jaw (make sure to put in flash cards), atypical fracture (PUT IN FLASH CARDS)
Absolute Contraindications:Crcl < 30-35 mL/min, hx of esophageal cancer
Pregnancy:–
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): calcium and other multivalent cations decrease absorption, other foods/ drugs can decrease absorption when given simultaneously
Monitoring Parameters: –
Pearls:
FIRST LINE for osteoporosis. specific first line agents are Alendronate and risendronate
require drug holidays after 3 years (IV) or 5 years (oral) in those with stable BMD and no fractures to prevent osteonecrosis of jaw (ONJ) and other side effects. duration of holiday unknown, but sondierresatrting if fracture or significant BMD loss
1.administration issues:
a. have pt sit up for 30-60 minutes after administration
b.alendronate/ resendronte IR: take on empty stomach first thing in AM, wait atleast 30 min before eating/ drinking, remain upright for 30 min
c. Risendronae DR: take with plain water immediately after breakfast, remain uprgight for 30minute
d. Ibandronate: empty stomach, take first hinge in the a, wait at least 60 minutes before eating/ drinking, remain upright for 60 minutes
2. not recommended in CrcL < 30-35 mL/min
3. avoid PO therapy if esophageal stricture, achalasia, inability to remain upright for 30-60 minus, increased risk for aspiration
4. rare incidence of osteonecrosis of the jaw in pts. taking higher doses or IV. recommend completion of major dental work prior to beginning therapy
5.rare instance of atypical fractures. therapy of >3-5 years increases risk. discontinue BP therapy uf atypical fractures occur
Pearls for biophosphonates
Pearls:
FIRST LINE for osteoporosis. specific first line agents are Alendronate and risendronate
require drug holidays after 3 years (IV) or 5 years (oral) in those with stable BMD and no fractures to prevent osteonecrosis of jaw (ONJ) and other side effects. duration of holiday unknown, but sondierresatrting if fracture or significant BMD loss
1.administration issues:
a. have pt sit up for 30-60 minutes after administration
b.alendronate/ resendronte IR: take on empty stomach first thing in AM, wait atleast 30 min before eating/ drinking, remain upright for 30 min
c. Risendronae DR: take with plain water immediately after breakfast, remain uprgight for 30minute
d. Ibandronate: empty stomach, take first hinge in the a, wait at least 60 minutes before eating/ drinking, remain upright for 60 minutes
2. not recommended in CrcL < 30-35 mL/min
3. avoid PO therapy if esophageal stricture, achalasia, inability to remain upright for 30-60 minus, increased risk for aspiration
4. rare incidence of osteonecrosis of the jaw in pts. taking higher doses or IV. recommend completion of major dental work prior to beginning therapy
5.rare instance of atypical fractures. therapy of >3-5 years increases risk. discontinue BP therapy uf atypical fractures occur
Alendronate class brand name route doses
biophosphonate
Fosomax, Binosto
PO
5-10 mg daily or 35-70 mg weekly
Risendronate class brand name route doses
Biophosphonate
Actonel, Atelvia
PO
5 mg daily, 35 mg weekly, 75 mg 2 consecutive days/month, 150 mg monthly
Ibandronate class brand name route doses
biophosphonate
Boniva
PO, IV
vary
Zoledronic acid class brand name route doses
biophosphonate
Reclast
IV
VARY
Osteonecrosis of Jaw
what is it
risk factors
management
exposed necrotic bone in the maxillofacial region (jaw bone is exposed. bone cells of jajw start to break down)
invasive bone procedures, cancer, concomitant chemotherapy, corticosteroids, poor oral hygiene, ill-fitting dentures, comorbid disorders (anemia, coagulopathy, infection, preexisting dental or periodontal disease
recommend completion of major dental work prior to beginning osteoporosis therapy
atypical femur fractures
what is it ?
when do they occur?
incidence?
fractures that are characterized by unique radiographic features and locations such as
subtrochantric femur
Diaphyseal femur
occur after little or no trauma
low incidence. rare
