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Clin Med MSK: > osteoporosis > Flashcards

osteoporosis Flashcards

1
Q

what is the definition of metabolic bone disease

A

any bone disorder resulting from chemical aberrations - hormones, minerals

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2
Q

what are the two main types of metabolic bone disease

A

osteopenia and osteoporosis

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3
Q

what is the definition of osteopenia and osteoporosis

A

low bone density

reduction of total bone mass
thinning of cortical and trabecular bone
increase porosity of cortical and trabecular bone

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4
Q

what type of fractures arise from osteopenia and osteoporosis

A

fragility fractures

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5
Q

what are the subsets of osteoporosis

A

Primary vs Secondary

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6
Q

what is primary osteoporosis

A

post-menopausal (F ages 50-70) -
Senile (age related; >70)

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7
Q

what is secondary osteoporosis

A

due to presence or treatment of other diseases

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8
Q

what increases with increasing age

A

overall risk of developing osteopenia and osteoporosis

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9
Q

what things can expedite bone loss

A

hormone deficiency (primarily estrogen)
excessive alcohol use
tobacco
malignancy
genetic disorders
lack of physical activity
GI disorders
medications

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10
Q

what hormone is associated with increased risk of osteoporosis/osteopenia

A

estrogen

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11
Q

what medications most commonly affect bone loss

A

corticosteroids
SSRI’s (anti-depressants)
PPI’s (protein pump inhibitors - gerd)

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12
Q

when is peak bone mass achieved

A

around age 30

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13
Q

what reduces bone density decline in women

A

reduced estrogen after menopause

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14
Q

what are the 6 steps to bone remodeling

A

Quinesence
Resorption
Reversal
formation
mineralization
quinesence

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15
Q

what changes after age of 30 for bone remodeling

A

increase bone resorption and decreased bone formation

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16
Q

what is activated when there is low levels of calcium within the blood

A

PTH is stimulated to release PTH which increases the osteoclasts to break down bone and increase serum calcium

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17
Q

what is stimulated when there is too high levels of calcium within the blood

A

thyroid is stimulated to release calcitonin to inhibit osteoclasts, increase excretion and decrease absorption of calcium to decrease serum calcium

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18
Q

what is osteomalacia

A

softening of bone due to impaired mineralization

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19
Q

what is dysregulated during osteomalacia

A

calcium activates osteoclasts

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20
Q

what is the typical presentation of osteopenia/osteoporosis

A

via screening or fragility fracture

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21
Q

what is a fragility fracture

A

any fracture that results from low-energy

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22
Q

what is the gold standard screening test for osteoporosis/osteopenia

A

dual-energy x-ray absorptiometry (DEXA)

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23
Q

what patients obtain DEXA scans

A

anyone with risk factors
anyone with a pathologic fracture
all post-menopausal women > 65
younger post-menopausal women with +FH and/or risk factors
all men >70

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24
Q

what does a DEXA scan assess

A

measures bone mineral density (BMD)

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25
Q

what patients get a wrist DEXA

A

non-dominant wrist when spine or hip measurements are unreliable
-arthritis
-lumbar compression fracture
-hardware
-hyperparathyroidism
-men on androgen deprivation therapy

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26
Q

Who it T score used for

A

most patients

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27
Q

who is Z score used for

A

pre-menopausal women, young males

add in age, race, sex matched controls for the mean

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28
Q

what are DEXA scan scores converted to

A

T or Z scores

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29
Q

what is inclusive on Z score

A

age, race, sex matched controls for the mean

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30
Q

what score categorizes osteoporosis

A

less than or equal to NEGATIVE -2.5 standard deviation below 0

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31
Q

what score categorizes osteopenia

A

less than or equal to NEGATIVE -1 standard deviation below 0

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32
Q

if a patient has a DEXA with a standard deviation of -2.8, what is their diagnosis

A

osteoporosis

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33
Q

if a patient has a DEXA with standard deviation of -1.2, what is their diagnosis

A

osteopenia

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34
Q

how much does the fracture risk increase per standard deviation below normal

A

fracture risk is increased 2x for each standard deviation below normal

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35
Q

how often do patients with a DEXA T score of -1 to -1.5 have follow up

A

every 5 years

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36
Q

how often do patients with a T score under -2.9 have to follow up

A

every 1-2 years

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37
Q

how often to patients with a T score of -1.5 to -2.0 follow up

A

every 3-5 years

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38
Q

what is a co-occuring deficiency associated with osteopenia/osteoporosis

A

co-occuring vitamin D deficiency is common

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39
Q

what is the best measurement of vitamin D

A

25-hydroxyvitamin D (25(OH)D)
determines circulating (active) form of vitamin D

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40
Q

what is normal vitamin D levels

A

25-80 mg/mL

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41
Q

what level is vitamin D deficiency

A

< 20ng/mL

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42
Q

what is the calculation tool used for fracture risk with osteoporosis

A

FRAX (fracture risk assessment tool)

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43
Q

what is the first line treatment of osteoporosis

A

risk reduction/prevention

44
Q

who gets pharmacologic treatment

A

based off of the DEXA scores
T-score less than -2.5 gets referred for treatment

45
Q

what patients automatically get pharmacologic treatment

A

any patient with a fragility fracture

46
Q

when are osteopenic patients referred for pharmacologic treatment

A

10 year hip fracture risk of 3+%
10 year major fracture risk 10+%

Based on FRAX calculation

47
Q

what are the primary pharmacological treatment options

A

vitamin D + calcium
Bisphosphonates
Denosumab (monoclonal antibody)
Teriperatide (PTH analogue)
Selective estrogen receptor modulators (SERMs)
calcitonin

48
Q

why is vitamin D and calcium important

A

adequate levels necessary to optimal bone health, medication efficacy

49
Q

what does vitamin D and calcium not do

A

reduce fracture risk

50
Q

how much calcium do we need per day

A

about 1200mg/day

51
Q

what patients might need calcium supplementation

A

malabsorption, special calcium deficient diets

52
Q

how is calcium to be taken

A

only 500 mg absorbed at one time,
divide doses or meals

53
Q

what does calcium carbonate require for absorption

A

acid - take with food and avoid with H2, PPIs

54
Q

what is the benefit of using calcium citrate

A

does not require acid for absorption - okay for patients on anti-acid medications to use

55
Q

how much vitamin D do you need daily

A

about 800-1,000IU/day

56
Q

what is the first line pharmacologic treatment

A

Bisphosphonates

57
Q

what is the MOA of bisphophonates

A

inhibit bone resorption via osteoclasts

58
Q

when are bisphosphonates indicated

A

prevention/treatment of post-menopausal osteoporosis/due to long term steroid use and in men

59
Q

what are the most common bisphosphonate medicatison

A

alendronate, risedronate, zolendronic acid and ibandronate

60
Q

what is ibandronate approved for

A

only approved for use of prevention/treatment of post-menopausal osteoporosis

61
Q

when is aldendronate used over risedronate

A

for non-vertebral fracture

62
Q

what medication does not reduce non-vertebral fracture risk

A

ibandronate

63
Q

how often is aldendronate used

A

weekly PO

64
Q

how often is risedronate used

A

once monthly PO

65
Q

how often is ibandronate used

A

once monthly PO

66
Q

how often is zolendronic acid used

A

IV once per year

67
Q

what are the side effects of the PO bisphosphonates medications

A

erosive esophagitis
N/V/abd pain
osteonecrosis of the jaw (IV>Oral)
atypical femur fractures

68
Q

what are the side effects of IV bisphosphonates

A

fever, chills, flushing
myalgias
N/V/D
fatigue, dyspepsia, edema
headache, dizziness, osteonecrossis of the Jaw (IV> oral)

69
Q

what are important factors with bisphosphonates

A

must be taken in the AM with atleast 8oz of water and 40 minutes before food
patient must remain upright after taking to avoid esophagitis

70
Q

when do bisphosphanates need to be adjusted

A

Renal dose adjustement with CrCl <35

71
Q

when do patients taking bisphosphonates have a rechecked DEXA

A

at 3 years

72
Q

what is the maximum length of bisphosphonate usage

A

5 years due to half life of 10 years within the bone

73
Q

what is the primary fracture types are we preventing with bisphosphonates

A

hip fractures

74
Q

what is denosumab

A

moniclonal antibody

75
Q

what is the MOA of denosumab

A

inhibits osteoclast maturation
Rank L inhibitor

76
Q

what are the indications for Denosumab

A

treatment of osteoporosis (M and F)
treatment of major fragility fracture
treatment of osteopenia with high FRAX scores
high risk with breast cancer, prostate cancer or hormone deprivation treatment

77
Q

what does Rank L do

A

activates osteoclasts

78
Q

what is the beneif of denosumab

A

reduces vertebral and hip fractures (vertebral > hip)

79
Q

how is denosumab prescribed

A

SubQ every 6 months
no renal adjustments needed

80
Q

how long is denosumab prescribed for

A

only given for 3-5 years

81
Q

what are the side effects of denosumab

A

flu-like symptoms
hypocalcemia
hypercholesterolemia
eczema/dermatitis
infections
malignancies
pancreatitis
osteonecrosis of the jaw
atypical femur fractures

more immune system like symptoms

82
Q

What is teriperatide

A

an PTH analog for osteoporosis

83
Q

what is the MOA for teriperatide

A

decreases osteoblast apoptosis and promotes production of new bone matrix

84
Q

what are the inidcations for teriperatide

A

treatment of osteoporosis (M and F) and ATYPICAL FEMUR FRACTURES (side effect of other medications)

85
Q

how is teriperatide prescribed

A

Sub Q daily
only approved for 2 years of treatment

86
Q

what medications can teriperatide be used in combo with

A

Denosumab or follow with bisphosponates

87
Q

what are the side effects of teriperatide

A

BLACK BOCK WARNING - INCREASED RISK FOR OSTEOSARCOMA

injection site irritation
orthostatic hypotension
arthralgias
myalgias
depression
pneumonia
hypercalcemia

88
Q

what patients are not given teriperatides

A

patients with Paget’s, skeletally immature, history of sarcoma, or hx significant radiation

89
Q

What does SERMs stand for

A

Selective estrogen receptor modulators

90
Q

what does modulate mean

A

turn it on or off

91
Q

what is the mechanism of action for SERMs

A

bind estrogen receptor -> protective effects

92
Q

what is the indications for SERMs

A

PREVENTION not treatment of osteoporosis

93
Q

what is SERMs given in replacement of

A

full estrogen replacement therapies

94
Q

what are the two major SERMs medicatiosn

A

Raloxifene and Tamoxifen

95
Q

when is Tamoxifen commonly given after

A

after breast cancer treatment

96
Q

what is the benefit of SERMs

A

reduces vertebral fractures - but not hip/other non-vertebral fractures

97
Q

how are SERMs prescribed

A

orally daily

98
Q

when are SERMs contraindicated

A

pregnancy/potential pregnancy, VTE risk (venous thrombus embolus)

99
Q

what are the side effects of SERMs

A

hot flashes
thromboembolism
reduced LDL
reduced breast cancer risks

100
Q

what is calcitonin do

A

inhibits osteoclasts and reduce serum calcium

101
Q

what is the MOA for calcitonin

A

decreases bone resorption

102
Q

when is calcitonin indicated

A

primary for pain associated with vertebral compression fracture - least effective agent for treatment or prevention

103
Q

how is calcitonin prescribed

A

daily intranasal or SubQdaily

104
Q

how long is calcitonin prescribed for

A

up to 3 months

105
Q

what are the side effects of calcitonin

A

rhinitis/epistaxis
flu-like symptoms
allergy
arthralgia/back pain
headaches

Clin Med MSK: (14 decks)

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