Osteoporosis Flashcards by Linda Chen

what is osteoporosis

A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture

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osteoporosis is a skeletal disorder characterized by _____________ predisposing to an increased risk of fracture

compromised bone strength

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only ____% of fragility fractures are assessed for osteoporosis and only ____ of that will be treated

5-25%
half

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bone strength is comprised of

bone quality + bone quantity

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what makes up bone quality

microarchitecture, microfracture, turnover, mineralization

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what makes up bone quantity

BMD

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why is peak bone mass important

major determinant of fracture later in life- determinants not well understood

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what determines peak bone mass

Genetics is primary factor, nutritional status, physical activity, hormones

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in osteoporosis, less of _____ is greater than ____ bone

trabecular is greater than cortical

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which of the following is true
1. in menopause, there is low bone turnover
2. in the elderly, there is low bone turnover
3. early in osteoporosis, cortical bone is lost faster than trabecular bone
4. 1+2

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fractures are multifactorial (3)

low BMD
impaired bone quality
falls

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what is the trend of fractures from 50-60s and >70yrs old

50-60s = more wrist fractures
>70s = more hip fractures

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what is the fracture cascade

fractures predict future fractures

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the impact of fractures
1. results in temporary physical sx
2. reduced mobility is seen in 100% of hip fractures
3. results in worsening of osteoporosis
4. associated with decreased survival after hip or vertebral fracture

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list 3 RF for fractures

Age
Genetics: FHx (esp parental hip fracture)
Fragility fracture (falling from standing height) after 40yrs
Low BMI <20
Rheumatologic conditions; rheumatoid arthritis, systemic lupus
GI conditions: IBS, celiacs
Other: CKD, HIV, COPD, malignancy
Endocrine conditions: hypothyroidism, hyperparathyroidism, cushing’s syndrome, T1/2DM
Lifestyle: low calcium, vit D, current smoker (↑ osteoclasts), physical inactivity, too much alcohol (=>3 glasses/d), high caffeine
Hypogonadal states: early menopause (<45yrs), premature ovarian insufficiency, previous amenorrhea (ex- eating disorders), hypogonadism in men

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which of the following is not a RF for osteoporosis
1. low caffeine use
2. premature ovarian failure
3. diabetes
4. IBS
5. antiandrogen therapy

1- high caffeine use

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which 7 medications are strongly associated with osteoporosis

glucocorticoids
aromatase inhibitors
anticonvulsants
chemo
antiandrogen therapy
excess thryroid therapy
LT heparin therapy

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prevention of osteoporosis is required with using these 3 medications

glucocorticoids, aromatase inhibitors, antiandrogen therapy

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what is glucocorticoid induced osteoporosis

Use of systemic steroid for cumulative ≥3mths
MOA: ↑ bone resorption, ↓ bone formation, ↓ Ca absorption
At risk if ≥ 7.5mg prednisone daily for over 3mths (cumulative dose)

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what decrease in height is significant in osteoporosis

historical >6cm (from peak height), prospective >2 cm (loss per year) is significant

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what are normal rib-pelvic and occiput to wall distances

<2cm
0cm

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name 2 physical tests to do with osteoporosis patients

Rib- pelvis (>2cm) and occiput to wall (>0cm) distances
Timed up and go (TUG) test

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in the TUD test, a time of > ____ indicates higher risk of falls

> 12s

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vit D levels should me measured in those who (4)

Will be on pharmacologic tx for osteoporosis
Have sustained recurrent fractures
Have continued bone loss despite treatment
Have comorbid conditions that affect absorption or vit D action

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serum vit D should be measured after ______ mths of adequate supplementation

3-4

if optimal vit D levels are achieved 1. repeat levels qyr to monitor 2. repeat levels in 3-4mths fter continued supplementation 3. add calcium supplementtion 4. do no repeat levels

BMD is measured by

DEXA

BMD is usually measured as

lumber spine, hip (femoral neck)

bone mass =

bone mineral content / bone area (gm/cm2)

there is an ____ relationship between BMD and fractures

inverse

what is the T score

number of SD a person’s BMD from the mean BMD in a young normal reference mean with beak bone mass

what is the Z score

number of SD a person’s BMD varies from the mean BMD (matched for age, gender, ethnicity)

a T score of +2.5 to -1.0 means

normal

a T score of -1.0 to -2.5 means

osteopenia

what are the T scores for osteoporosis

<-2.5

what classifies as severe osteoporosis

< -2.5 with fragility fractures

how to assess for vertebral fractures

spine Xray to look for compression fractures (ex- thoracic and lumbar spine X ray is commonly ordered)

if a 50yr old and a 70yr old have the same BMD, who's fracture risk is higher?

70yrs

2 tools in canada used to assess 10yr risk of major osteoporotic fracture

CAROC FRAAX

which characteristics increase the CAROC risk to the next category

fragility fracture after 40yrs old, prolonged CS therapy

which characteristics increase the CAROC risk automatically to high risk

hip/ vertebral fracture, >1 nonvertebral fragility fracture

QUS is assessed at the

heel or wrist

when is QUS used

useful in osteoporosis risk assessment, esp in areas with limited access to DEXA

which of the following is not true 1. DEXA is the gold standard for measuring BMD 2. T and Z scores are ways to classify BMD compared to those in the same age group or in peak bone mass times 3. QUS may be used for treatment monitoring of BMD 4. QUS is especially useful in areas with limited access to DEXA

3- not for monitoring or dx

list the steps from bottom to top of the osteoporosis treatment pyramid

lifestyle address secondary causes of disease pharmacotherapy

lifestyle management of osteoporosis includes

exercise calcium vut D smoking cessation, minimize caffeine and alcohol fall prevention

in terms of supplementing calcium in osteoporosis 1. recommended is 1200mg/d 2. preferred source is from supplements 3. carbonate and citrate have the same absorbability, but carbonate requires an acidic environment (food)3 4. recommended for people >60 or with osteoporosis 5. 1, 3 6. all of the above

elemental calcium of _____ mg daily is recommended for people _____yrs or with _____

1200mg >50yrs with osteoporosis

what is the preferred source of calcium

diet

which is preferred if patient is on PPI or H2 blocker 1. calcium carbonate 2. calcium citrate

T or F: calcium citrate should be taken with food or absorption is bad

F- calcium carbonate should be taken with food

Doses _________ mg elemental calcium should be divided BID

>500-600

you have a low risk of vit D deficiency if you're ____, no __________

<50yrs no osteoporosis or conditions affecting vit D

how much vit D should you take if you're low risk

400-1000IU daily

how much vit D should you take if you're >50yrs or at mod risk of deficiency

800-1000IU daily

those that are deficient may require ______ IU of vit D to reach >75nmol/L

2000IU

Vit D2, AKA, _________ is from a ____ source

ergocalciferol plant

Vit D3, also known as __________, is from an _______ source

cholecalciferol animal

which is more potent? vit D2 or D3

~40IU of vit D3 increases vit D levels by

1nmol/L

in lifestyle management of osteoporosis, caffeine should be limited to _________ and alcohol should be limited to __________

<4cups/d <2 drinks/d

hip protectors are recommended for

LTC residents who are mobile + at high risk of fracture

repeat BMD must be 1. measured by a calibrated and standardized DEXA machine 2. must be measured by the same DEXA as before 3. must be done q2-3yrs on established osteoporosis treatment 4. must be done q3-5yrs for new tx

FRAX recommends starting tx if (2)

Major osteoporotic fracture =>20% Hip fracture =>3%

what should be done if a FRAX comes back as <10%

do not tx, reassess in 5yrs

what should be done if a FRAX comes back as 10-20%

consider tx based on additional RF and pt preference

what should be done if a FRAX comes back as >20%, or prior fragility fracture, or multiple fractures

tx with pharmacologic tx

what is usually used as primary outcome when testing osteoporsis drugs

vertebral fracture risk

which 3 agents do not prevent all 3 of vertebral, nonvertebral, and hip fractures

etidronate and raloxifene vertebral only, teriparatide vertebral and nonvertebral only

BP MOA

Binds to bone to inhibit osteoclasts (causes apoptosis) Binds to areas with active bone remodeling- incorporated int bone with bone formation - released with bone remodeling to stop osteoclasts

rank he binding affinities of BPs

zoledronic acid > alendronate >risedronate >etidronate

which BPs are PO

alendronate, risedronate

which BP may be taken with food

risedronate (actonel DR)

PO BP SEs (list 3)

GI: abdominal pain/ distention, dyspepsia, diarrhea MSK: muscle, bone, joint aches/ pain (usually after few mths of use) Rare: esophagitis, ulcers with alendronate (unclear if risedronate same issues, but counsel the same)

what is a rare SE of PO BPs? which BP is higher risk/

esophagitis, ulcers with alendronate (unclear with risedronate)

how should you counsel a patient to take alendronate or risedronate

Take on empty stomach with full glass of water- best in morning 30min (1hr if weekly) before eating or drinking Do not lie down for at least 30min after taking to improve stomach absorption (PO BPs bioavail <1%)

how is zoledronic acid given

as a 15min infusion once a year

zoledronic acid AEs

acute phase reaction- flu like sx 1-3 days after last injection (fever, chills, bone pain, etc)- can last 3-4 days in 10-20% of pts, renal impairment

what can be used before ZA to prevent acute phase reaction

acetaminophen/ ibuprofen or diphenhydramine

what should be monitored before injection ZA

calcium, phospate, SCr, GFR

BP contraondications

Women of childbearing potential (not teratogenic, just incase) Alendronate ? risedronate: abnormalities of esophagus, inability to sit/ stand upright for 30 min (if must use, use risedronate)

if CrCL <35, avoid ________________ BPs

alendronate, zoledronic acid

if CrCL <30, avoid this BP

risedronate

what are 2 classes that interact with actonel DR

PPIs, H2RAs

BP interactions (list 3)

calcium, iron, laxatives containing magnesium, antacids with magnesium, aluminum, or calcium, vitamins supplements containing minerals

what is classified as BP induced ONJ

exposed bone in jaw that doesn't heal after 8wks due to BP slowing bone turnover and healing

BP induced ONJ is most common in ____ pts on ______

cancer pts on high dose IV BPs

BP induced ONJ is associated with

major dental issues

atypical femoral fractures typically occur along ___________ with ___________ trauma

distal femur with little or no trauma

what is the potential mechanism for AFF

alteration of normal tissue repair process from continuous bone suppression

AFF is associated with ____ BP use

LT (>5-7yrs)

with atypical femoral fractures 1 .pts may report prodromal pain in arms, hands, and wrists months before fracture 2. rarely (<10%) bilateral 3. may be due to continuous bone suppression, then sudden increase after d/c 4. can occur with no trauma

what class if denosumab

Human monoclonal antibody against RANKL

denosumab AEs

MSK pain, rash/ eczema, infections, hypocalcemia, reports of ONJ and AFF

there is an increased risk of _____ upon discontinuation of denosumab

vertebral fractures

denosumab 1. requires avoidance if CrCL <30 2. requires avoidance if CrCL <35 3. does not require dosage adjustments with renal impairment 4. should monitor for hypercalcemia

what is a SERM used in osteoporosis

raloxifene

raloxifene MOA

agonist effect on ER on bone, lipids. Antagonist effect on ER on breast and uterus

raloxifene (select all that apply) 1. decreases risk of breast cancer 2. is an agonist on bone, uterus 3. AEs include AFF, leg cramps, hypocalcemia 4. are contraindicated in pregnancy, past/ active VTE

1, 4

raloxifene SEs

hot flashes, leg cramps, risk of VTE

hormone therapy is currently an option for

women who have osteoporosis + mod-severe menopausal sx

how much estradiol must be used to prevent fracture or prevent further bone loss

Reduce fracture: 1mg estradiol or eq Prevent further bone loss; 0.5mg

what ar ethe 2 anabolic agents used in osteoporosis

teriparatide romosozumab

after teriparatide is d/c, you must

Continue with antiresorptive agent after d/c for 2yrs

teriparatide CIs

severe renal insuff, bone metastases, bone cancer, pts at risk of osteosarcoma (not shown in humans)

romosozumab class

sclerostin inhibitor

how is romosozumab injected

once a month SQ for 12mths

how is teriparatide dosed?

SQ daily for 24mths

romosozumab CIs

Hx of MI or stroke

what are first line osteoporosis tx

alendronate, risedronate, zoledronic acid, denosumab

anabolic agents in osteoporosis are usually reserved for

often reserved for pts with severe osteoporosis who have not responded to other tx (usually not covered + v expensive)

when should you consider GIOP prophylaxis? what agents should be used?

if =>3mths of cumulative tx + 7.5mg prednisone qd (2.5-5mg if at risk already) can use alendronate, risedronate, ZA, denosumab (+ teriparatide if not responding to other agents)

how often should BMD be repeated in new tx? what about established tx?

New tx in 2-3yrs Established tx in 3-5yrs

which of the following is false 1. new osteoporosis tx should be monitored with a DEXA machine q2-3yrs 2. 50% adherence o osteoporosis medication has the same fracture risk as no tx 3. drug holidays may only be done with bisphosphonates 4. duration of drug holidays may be 2-4mths

4- 2-4yrs

drug holiday duration ____, must start monitoring at _____

2-4yrs monitor at 1-2ysr