Osteoporosis Flashcards
pathology of osteoporosis (3)
reduction in bone mass
disruption of skeletal microarchitecture
fragility of skeleton
which component of bone is affected by osteoporosis
trabecular bone
2 mc causes of postmenopausal osteoporosis
estrogen deficiency
age
→ bone tissue is lost progressively
lifetime osteoporotic fracture risk for a woman at age 50
50%
lifetime osteoporotic risk for a man who reaches 50
20%
secondary osteoporosis is caused by
anything outside of age/hormones
being a woman
4 common causes of secondary osteoporosis
meds
vit D deficiency
etoh
chronic illness
2 common meds that cause osteporosis
steroids
antiepileptics
bone mass is determined by
genetics
rf for osteoporosis
white/asian
<127 lb or BMI <20
fh
personal hx fx
>2-3 etoh drinks/day
estrogen deficiency < 45 yo (induced surgical menopause)
testosterone deficiency
low Ca intake
vit D deficiency
sedentary lifestyle current tobacco use
what doe FRAX stand for
fracture risk assessment tool
what does FRAX calculate
pt’s 10 year probability for fx
what pt populations can FRAX be used for
postmenopausal women
men 40-90 yo
who is FRAX validated for
untreated pt’s
not currently undergoing tx for OP
what is included in the FRAX assessment
age
sex
weight
height
previous fx
parent fx’ed hip
current smoking
glucocorticoids
RA
secondary OP
etoh > 3/day
femoral head BMD
according to FRAX when do you treat OP
risk at or above 3%
OR
any other 10 year probability of major OP related factor
gold standard test for bone density
bone densitometry (DXA)
bones measured with bone densitometry
lumbar spine
hip
what is normal bone loss
~1%/year
who gets screened for OP
women 65 or older
younger but at risk for osteoporosis/malacia
pathologic fx
radiographic e.o diminished bone density (xray)
+/- men → no evidence
how do you decide the interval between DXA screening scans
T score
T score -1 to -1.5
screen every 5 years
T score -1.5 to -2.0
every 3-5 years
T score < -2.0
every 1-2 years
when would you use z score
premenopausal women
younger men/kids
people who do not meet standard screening criteria
how does the z score express bone density
standard deviation from age-matched, race-matched, and sex-matched means
memorize this
early symptoms of OP
typically asymptomatic/silent until fx
common first fx in OP
vertebral fx
sx of OP related vertebral fx (3)
height loss/kyphosis
+/- pain if acute
pain localized to midline spine, varying quality
can OP related vertebral fx occur in the absence of trauma
yes!
also minor trauma like speed bump, sudden lifting, coughing, bending
where does vertebral fx pain refer to (3)
flank
anterior abd
PSIS
what referred pain is rare for vertebral fx
legs
if pain does radiate into legs w. vertebral fx, consider
neurologic status
what do you think when you see, radiolucency, cortical thinning, occult fx
radiographic e.o OP
what is the problem w. radiographs in OP
bone loss must be >30% to be detected
lifestyle modification recs for OP
smoking cessation
limit etoh intake
regular weightbearing and muscle strengthening exercise
consume at least 1,200 mg Ca/day
adequate calorie intake
take measures in home to avoid falls
wear a brace
strength training has to be at lease __ min
__ x/week to help prevent OP
30
3
guidelines for pharm intervention in postmenopausal women 50 years or older
hx hip/vertebral fx
T-score -2.5 or less at femoral neck or spine (excluding secondary causes)
T-score btw -1 and -2.5 at the femoral neck or spine PLUS 10-year probability of hip fx 3% or higher OR 10-year probability of any major OP related fx 20% or higher
is age plus hx of fx enough for pharm intervention
yes! → 50 yo or older PLUS any one guideline is enough for pharm intervention
total Ca intake/day rec
1200 mg
total vit D intake/day rec
800 IU
s.e of Ca supplements
nephrolithiasis
dyspepsia
constipation
interfere w. iron and thyroid hormone absorption
+/- increased risk for CVD
Ca interferes with the absorption of (2)
iron
thyroid hormone
s.e of vit D supplements if excessive
hypercalcemia
hypercalciuria
nephrolithiasis
chronically high levels of vit D may lead to
increased ca risk
mortality
falls
vit D levels are measured w.
25 (OH) D
first line tx for OP
bisphosphanates
what med improves BMD AND decreases fx
bisphosphonates
mc used bisphosphonate
Alendronate (Fosamax)
also
Risendronate (Actonel)
suffix for bisphosphonates
-dronate
what do you need to do before beginning bisphosphonates
correct hypocalcemia and vit D deficiency
contraindications for bisphosphonates
esophageal d.o → including dysphagia
post bariatric surgery
unable to follow dosing guidelines
bisphosphonates must be taken __
with __
first thing in the AM
8 oz water
guidelines regarding eating/drinking/other meds with bisphosphonates
nothing for at east ½ hour after taking bisphosphonate
guideline regarding position when taking bisphosphonate
remain upright (sit or stand) for 30 mins after administration
what might happen if a pt does not follow position guidelines for bisphosphonates
may cause erosion of esophagus
how often are bisphosphonates taken
once weekly
what if a person can’t tolerate PO bisphosphonates
IV available
indications for d.c’ing bisphosphonates
if taking alendronate OR risendronate (Actonel) x 5 years
OR if taking zoledronic acid (Reclast) x 3 years
PLUS
stable BMD and no prvious vertebral fx
bisphosphonate rec for those at highest risk for fx
continue PO up to 10 years for PO
up to 6 years IV
max duration for PO bisphosphonate tx
- years
max duration for IV bisphosphonates tx
6 years
risks of PO bisphophonates
upper GI irritation
osteonecrosis of jaw
renal toxicity → contraindicated in pt w. CrCl <30
GI s.e related to bisphosphonates (3)
reflux
esophagitis
esophageal ulcers
IV bisphosphonates can cause
acute-phase rxn → fever, myalgia, arthralgia
besides bisphosphonates, another med used for OP tx
calcitonin
how does calcitonin work (2)
increases bone density
may decrease vertebral fx risk
is calcitonin first line tx for OP
no
when might you use calcitonin
short-term pain relief in pt w. acute pain related to several vertebral fx
s.e of calcitonin
rhinitis
increased malignancy risk
oral analgesics indicated for OP tx
acetaminophen
NSAIDs
narcotics → only for severe pain control
possible negative effect of NSAIDs in OP tx
may impair bone healing
2 surgical options for vertebral fx
kyphoplasty
vertebroplasty
when is vertebroplasty used
when little to no compression of vertebral body
benefits of vertebroplasty
cheaper
no balloon involved → faster
less post op pain
disadvantages of vertebroplasty
cement leakage
less effective vertebral heigh restoration → controversial
benefits of kyphoplasty
less cement leakage
more effective restoration of vertebral body height → prevents kyphosis
disadvantages of kyphoplasty
similar post op outcomes but much more expensive
requires overnight stay
more technically challenging → balloon tamponade + cement
who might be a candidate for vertebral augmentation surgery
those unable to achieve pain control
adverse events related to vertebral augmentation
cement PE
extravasation of cement
infxn
