Osteoporosis Flashcards
what is osteoporosis
A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture
osteoporosis is a skeletal disorder characterized by _____________ predisposing to an increased risk of fracture
compromised bone strength
only ____% of fragility fractures are assessed for osteoporosis and only ____ of that will be treated
5-25%
half
bone strength is comprised of
bone quality + bone quantity
what makes up bone quality
microarchitecture, microfracture, turnover, mineralization
what makes up bone quantity
BMD
why is peak bone mass important
major determinant of fracture later in life- determinants not well understood
what determines peak bone mass
Genetics is primary factor, nutritional status, physical activity, hormones
in osteoporosis, less of _____ is greater than ____ bone
trabecular is greater than cortical
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
2
fractures are multifactorial (3)
low BMD
impaired bone quality
falls
what is the trend of fractures from 50-60s and >70yrs old
50-60s = more wrist fractures
>70s = more hip fractures
what is the fracture cascade
fractures predict future fractures
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
4
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
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
which 7 medications are strongly associated with osteoporosis
glucocorticoids
aromatase inhibitors
anticonvulsants
chemo
antiandrogen therapy
excess thryroid therapy
LT heparin therapy
prevention of osteoporosis is required with using these 3 medications
glucocorticoids, aromatase inhibitors, antiandrogen therapy
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)
what decrease in height is significant in osteoporosis
historical >6cm (from peak height), prospective >2 cm (loss per year) is significant
what are normal rib-pelvic and occiput to wall distances
<2cm
0cm
name 2 physical tests to do with osteoporosis patients
Rib- pelvis (>2cm) and occiput to wall (>0cm) distances
Timed up and go (TUG) test
in the TUD test, a time of > ____ indicates higher risk of falls
> 12s
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
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
4
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
5
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
2
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
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
2
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
4
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
3
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
