osteoporosis Flashcards
what is the definition of metabolic bone disease
any bone disorder resulting from chemical aberrations - hormones, minerals
what are the two main types of metabolic bone disease
osteopenia and osteoporosis
what is the definition of osteopenia and osteoporosis
low bone density
reduction of total bone mass
thinning of cortical and trabecular bone
increase porosity of cortical and trabecular bone
what type of fractures arise from osteopenia and osteoporosis
fragility fractures
what are the subsets of osteoporosis
Primary vs Secondary
what is primary osteoporosis
post-menopausal (F ages 50-70) -
Senile (age related; >70)
what is secondary osteoporosis
due to presence or treatment of other diseases
what increases with increasing age
overall risk of developing osteopenia and osteoporosis
what things can expedite bone loss
hormone deficiency (primarily estrogen)
excessive alcohol use
tobacco
malignancy
genetic disorders
lack of physical activity
GI disorders
medications
what hormone is associated with increased risk of osteoporosis/osteopenia
estrogen
what medications most commonly affect bone loss
corticosteroids
SSRI’s (anti-depressants)
PPI’s (protein pump inhibitors - gerd)
when is peak bone mass achieved
around age 30
what reduces bone density decline in women
reduced estrogen after menopause
what are the 6 steps to bone remodeling
Quinesence
Resorption
Reversal
formation
mineralization
quinesence
what changes after age of 30 for bone remodeling
increase bone resorption and decreased bone formation
what is activated when there is low levels of calcium within the blood
PTH is stimulated to release PTH which increases the osteoclasts to break down bone and increase serum calcium
what is stimulated when there is too high levels of calcium within the blood
thyroid is stimulated to release calcitonin to inhibit osteoclasts, increase excretion and decrease absorption of calcium to decrease serum calcium
what is osteomalacia
softening of bone due to impaired mineralization
what is dysregulated during osteomalacia
calcium activates osteoclasts
what is the typical presentation of osteopenia/osteoporosis
via screening or fragility fracture
what is a fragility fracture
any fracture that results from low-energy
what is the gold standard screening test for osteoporosis/osteopenia
dual-energy x-ray absorptiometry (DEXA)
what patients obtain DEXA scans
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
what does a DEXA scan assess
measures bone mineral density (BMD)
what patients get a wrist DEXA
non-dominant wrist when spine or hip measurements are unreliable
-arthritis
-lumbar compression fracture
-hardware
-hyperparathyroidism
-men on androgen deprivation therapy
Who it T score used for
most patients
who is Z score used for
pre-menopausal women, young males
add in age, race, sex matched controls for the mean
what are DEXA scan scores converted to
T or Z scores
what is inclusive on Z score
age, race, sex matched controls for the mean
what score categorizes osteoporosis
less than or equal to NEGATIVE -2.5 standard deviation below 0
what score categorizes osteopenia
less than or equal to NEGATIVE -1 standard deviation below 0
if a patient has a DEXA with a standard deviation of -2.8, what is their diagnosis
osteoporosis
if a patient has a DEXA with standard deviation of -1.2, what is their diagnosis
osteopenia
how much does the fracture risk increase per standard deviation below normal
fracture risk is increased 2x for each standard deviation below normal
how often do patients with a DEXA T score of -1 to -1.5 have follow up
every 5 years
how often do patients with a T score under -2.9 have to follow up
every 1-2 years
how often to patients with a T score of -1.5 to -2.0 follow up
every 3-5 years
what is a co-occuring deficiency associated with osteopenia/osteoporosis
co-occuring vitamin D deficiency is common
what is the best measurement of vitamin D
25-hydroxyvitamin D (25(OH)D)
determines circulating (active) form of vitamin D
what is normal vitamin D levels
25-80 mg/mL
what level is vitamin D deficiency
< 20ng/mL
what is the calculation tool used for fracture risk with osteoporosis
FRAX (fracture risk assessment tool)
what is the first line treatment of osteoporosis
risk reduction/prevention
who gets pharmacologic treatment
based off of the DEXA scores
T-score less than -2.5 gets referred for treatment
what patients automatically get pharmacologic treatment
any patient with a fragility fracture
when are osteopenic patients referred for pharmacologic treatment
10 year hip fracture risk of 3+%
10 year major fracture risk 10+%
Based on FRAX calculation
what are the primary pharmacological treatment options
vitamin D + calcium
Bisphosphonates
Denosumab (monoclonal antibody)
Teriperatide (PTH analogue)
Selective estrogen receptor modulators (SERMs)
calcitonin
why is vitamin D and calcium important
adequate levels necessary to optimal bone health, medication efficacy
what does vitamin D and calcium not do
reduce fracture risk
how much calcium do we need per day
about 1200mg/day
what patients might need calcium supplementation
malabsorption, special calcium deficient diets
how is calcium to be taken
only 500 mg absorbed at one time,
divide doses or meals
what does calcium carbonate require for absorption
acid - take with food and avoid with H2, PPIs
what is the benefit of using calcium citrate
does not require acid for absorption - okay for patients on anti-acid medications to use
how much vitamin D do you need daily
about 800-1,000IU/day
what is the first line pharmacologic treatment
Bisphosphonates
what is the MOA of bisphophonates
inhibit bone resorption via osteoclasts
when are bisphosphonates indicated
prevention/treatment of post-menopausal osteoporosis/due to long term steroid use and in men
what are the most common bisphosphonate medicatison
alendronate, risedronate, zolendronic acid and ibandronate
what is ibandronate approved for
only approved for use of prevention/treatment of post-menopausal osteoporosis
when is aldendronate used over risedronate
for non-vertebral fracture
what medication does not reduce non-vertebral fracture risk
ibandronate
how often is aldendronate used
weekly PO
how often is risedronate used
once monthly PO
how often is ibandronate used
once monthly PO
how often is zolendronic acid used
IV once per year
what are the side effects of the PO bisphosphonates medications
erosive esophagitis
N/V/abd pain
osteonecrosis of the jaw (IV>Oral)
atypical femur fractures
what are the side effects of IV bisphosphonates
fever, chills, flushing
myalgias
N/V/D
fatigue, dyspepsia, edema
headache, dizziness, osteonecrossis of the Jaw (IV> oral)
what are important factors with bisphosphonates
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
when do bisphosphanates need to be adjusted
Renal dose adjustement with CrCl <35
when do patients taking bisphosphonates have a rechecked DEXA
at 3 years
what is the maximum length of bisphosphonate usage
5 years due to half life of 10 years within the bone
what is the primary fracture types are we preventing with bisphosphonates
hip fractures
what is denosumab
moniclonal antibody
what is the MOA of denosumab
inhibits osteoclast maturation
Rank L inhibitor
what are the indications for Denosumab
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
what does Rank L do
activates osteoclasts
what is the beneif of denosumab
reduces vertebral and hip fractures (vertebral > hip)
how is denosumab prescribed
SubQ every 6 months
no renal adjustments needed
how long is denosumab prescribed for
only given for 3-5 years
what are the side effects of denosumab
flu-like symptoms
hypocalcemia
hypercholesterolemia
eczema/dermatitis
infections
malignancies
pancreatitis
osteonecrosis of the jaw
atypical femur fractures
more immune system like symptoms
What is teriperatide
an PTH analog for osteoporosis
what is the MOA for teriperatide
decreases osteoblast apoptosis and promotes production of new bone matrix
what are the inidcations for teriperatide
treatment of osteoporosis (M and F) and ATYPICAL FEMUR FRACTURES (side effect of other medications)
how is teriperatide prescribed
Sub Q daily
only approved for 2 years of treatment
what medications can teriperatide be used in combo with
Denosumab or follow with bisphosponates
what are the side effects of teriperatide
BLACK BOCK WARNING - INCREASED RISK FOR OSTEOSARCOMA
injection site irritation
orthostatic hypotension
arthralgias
myalgias
depression
pneumonia
hypercalcemia
what patients are not given teriperatides
patients with Paget’s, skeletally immature, history of sarcoma, or hx significant radiation
What does SERMs stand for
Selective estrogen receptor modulators
what does modulate mean
turn it on or off
what is the mechanism of action for SERMs
bind estrogen receptor -> protective effects
what is the indications for SERMs
PREVENTION not treatment of osteoporosis
what is SERMs given in replacement of
full estrogen replacement therapies
what are the two major SERMs medicatiosn
Raloxifene and Tamoxifen
when is Tamoxifen commonly given after
after breast cancer treatment
what is the benefit of SERMs
reduces vertebral fractures - but not hip/other non-vertebral fractures
how are SERMs prescribed
orally daily
when are SERMs contraindicated
pregnancy/potential pregnancy, VTE risk (venous thrombus embolus)
what are the side effects of SERMs
hot flashes
thromboembolism
reduced LDL
reduced breast cancer risks
what is calcitonin do
inhibits osteoclasts and reduce serum calcium
what is the MOA for calcitonin
decreases bone resorption
when is calcitonin indicated
primary for pain associated with vertebral compression fracture - least effective agent for treatment or prevention
how is calcitonin prescribed
daily intranasal or SubQdaily
how long is calcitonin prescribed for
up to 3 months
what are the side effects of calcitonin
rhinitis/epistaxis
flu-like symptoms
allergy
arthralgia/back pain
headaches
