Osteoporosis

Question 1

What are thresholds for bone disease per DEXA scan?

Answer 1

T-score -2.5 or lower = osteoporosis, start pharmacotherapy for most
T-score -1 to -2.5 = osteopenia
*Use FRAX scoring to determine risk and decide whether or not to start therapy

Z scores used for younger patients (premenopausal) and compares patients bone mineral density to someone with same age and sex
T Scores for older adults (post menopausal) and compares patients bone mineral density to a 30 year old of the same sex

FRAX score combines clinical risk factors
*age, use of meds like corticosteroids, low BMI, smoking, previous fractures etc
* higher risk >=3% 10 year risk of hip fracture or >= 20% risk of osteoporotic fracture

Question 2

What medications are risk factors for osteoporosis?

Answer 2

Corticosteroids
PPIs
Seizure meds
Tenofovir disoproxil fumarate (TDF)
Medroxyprogesterone acetate

Question 3

Bone density is max at 30yo and then is stable until menopause T/F?

Answer 3

True, after menopausal there is more bone resorption activity vs bone building activity (more osteoclasts than osteoblasts)
*RANKL responsible for osteoclasts development, activation, lifespan (so goal of therapy would be to inhibit these)

Question 4

T/F: PTH causes more reabsorption of Ca and activates more Vit D

Answer 4

True

Question 5

What is the target does of Calcium to prevent osteoporosis?

Answer 5

1200 to 2000/day
Citrate better absorbed vs carbonate
Binding interactions (quinolones, levo, tetracyclines, etc)
Constipating

Question 6

What is Vitamin D dosing for osteoporosis?

Answer 6

Replacement: 50k u weekly for 8-12 weeks
Maintenance: 1-2k u/day
*Vit D depleting meds: phenytoin, phenobarbital, carbamazepine, primidone

Question 7

Who should be screened for osteoporosis?

Answer 7

All women by age of 65
All men over age 70
All post-menopausal women >=50
All men and women age >= 50 with risk factors

Question 8

What is the FRAX score?

Answer 8

11/12 questions to determine 10 yr probability of major osteoporotic fracture AND hip fracture
Results in 2 percentages
*May underestimate due to some risk factors not being asked on questionnaire
*Elevated FRAX = 10 year probability >= 3% in hip, 20% in major osteoporotic fracture

Question 9

What are the 3 ways osteoporosis can be diagnosed?

Answer 9

1. T score < -2.5
2. Fragility fracture (falling from standing height and receiving fracture in spine, hope, numerous, pelvis, wrist)
3. Osteopenia + elevated FRAX or fragility fracture

*FRAX 10 year probabilities of >=
- 3% in hip fracture
- 20% in major osteoporotic fracture

Question 10

T/F: Ca citrate should be preferred for older adults and PPI use patients

Answer 10

True, they are more effective in low acid environments

Question 11

What is the elemental amounts of Ca in carbonate, citrate, and gluconate versions of Ca?

Answer 11

Carbonate 40% elemental
Citrate 21%
Gluconate 9%

Higher percentage is higher is of constipation

Question 12

T/F: For calcium supplementation that do not include Ca in ingredient list as elemental, you must convert with percentage.

Answer 12

True. For a 500mg calcium carbonate in antacid, it is about 200mg elemental calcium (since carbonate is about 40% elemental)

Question 13

What is vitamin D role for the bones?

Answer 13

Enhance calcium absorption thus fracture and fall prevention

Question 14

What is the monitoring parameters for osteoporosis treatment?

Answer 14

BMD every 1-2 years after starting therapy and then every 2 years

Question 15

Which bone med is best choice for renal function?

Answer 15

Denosumab. SC injection upper arm, thigh, or abdomen every 6 months by a healthcare provider, targets RANKL
*no drug holiday recommended, must correct ca and vit D before initiation

Question 16

Which bisphosphonate is given once yearly?

Answer 16

Zoledronic acid, Reclast —> Zometa is for cancer

Question 17

T/F: Ibandronate indicated for vertebral fracture ONLY

Answer 17

True

Question 18

T/F: Alendronate, Zoledronic acid, risedronate are indicated for all types of fractures (vertebral, non-vertebral, and hip)

Answer 18

True.

Question 19

Bisphosphonates have inc risk of AFIB and CV events/ T/F?

Answer 19

False, new evidence and meta-analysis show no inc in either AFIB or CV events

Question 20

What are the PTH-analogs used in osteoporosis?

Answer 20

Tymlos, abaoparatide: treatment of post menopausal women, 80 mcg SC QD

Fortes, teriparatide: treatment of men, steroid induced, 20 mcg SC QD

*For vertebral and non-vertebral only (no hip fracture risk reduction)
*Use should be followed by immediate treatment with anti-resorptive therapy: bisphosphonate or denosumab
*Use should not be after treatment with anti-resorptive therapy, lower BMD increases
*Use for 2 years only!! Then followed by anti-resorptive treatment

Question 21

What is romosozumab?

Answer 21

Anabolic drug used for osteoporosis, brand name EVENITY
Treatment for post menopausal women at high risk for fracture (hip, vertebral, nonvertebral
210mg Qmonth (two consecutive 105 mg inj) in upper arm, thigh, or abdomen by healthcare professional
12 month duration ONLY (use can follow or be followed by anti resorptive therapy bisphosphonate/denosumab
BB warning for inc risk of MI, stroke, CV death
Useful in renal dysfunction

Question 22

Do osteoporosis medications need to be tapered upon discontinuation?

Answer 22

NO, can call be stopped without taper

Question 23

Which osteoporosis therapy are not used any longer?

Answer 23

Estrogens, calcitonin, and raloxifene (usually only seen to reduce risk of breast cancer)

Question 24

T/F: Dietray calcium > supplement

Answer 24

True

Question 25

T/F: switching from bisphosphonate to anabolic agent can be done whereas switching from denosumab to an anabolic agent is NOT recommended

Answer 25

True. Inc risk of osteoporosis for patients who switch from denosumab to anabolic therapy (Tymlos, Forteo)

Question 26

T/F: Anabolic agents not indicated for hip fractures?

Answer 26

True