Osteoporosis Flashcards
Rate of osteoporosis fractures in ppl over 50: ratio for men and women?
About 1 in 2 women, about 1 in 4 men
Why are treatment rates for osteoporosis declining?
-Providers not prescribing as frequently
-Patients nonadherent
-Rare adverse effects
What does low bone density refer to?
Osteopenia, BMD lower than normal, but not classified as osteoporosis
1 in ___ women and 1 in ___ men are no longer living one year after hip fracture
____-fold increase risk of future fractures after a hip fracture
Pts with fractures are at an increased risk of?
5, 4
2.5
Infection, death, recurrent fractures, depression due to immobility
Define primary osteoporosis
Caused by advanced age and sex hormone deficiency
Age-related osteoporosis is caused by continuous determination of _________ bone
Sex-hormone deficiency-
Women: caused by a reduction in ___________ production resulting in increased bone loss
Men: caused by ___________________ inactivating testosterone and estrogen as men age
Trabecular
Estrogen
Sex-hormone-binding globulin
Secondary osteoporosis is caused by?
More common in men or women?
Drugs or disease states
Equally at risk
What disease states cause secondary osteoporosis?
What types of reactions to drugs would cause it?
Chronic liver/kidney failure, hyperthyroidism, hyperparathyroidism, Cushing’s, GI resection, malabsorption, rheumatoid arthritis, ankylosis spondylitis, and lupus
Reducing sex hormone, bone formation, and increasing bone resorption
Bone is a depot for what minerals/ions?
Calcium, phosphorus, magnesium, sodium, and carbonate
Types of bone: cortical (compact) bone
Provide structural support
___% of total skeletal mass
________ metabolic activity
75
Decreased
Types of bone: cancellous (trabecular) bone
____% of total skeletal mass
________ metabolic activity
High ______/_______ ratio
25
Increased
Surface/volume
What is the function of bone multicellular units?
What are the 5 phases?
Repair damage and calcium homeostasis
Resting/quiescence
Activation/resorption
Reversal
Formation
Mineralization
What is the role of osteoclasts?
Activated by?
Inhibited by?
Bone resorption: takes about 2-3 weeks
PTH, vit D, osteoblasts, IL-1, lymphotoxin, glucocorticoids, thyroid hormone, TNF, RANKL
Calcitonin, estrogen, TGF- beta
What is the role of osteoblasts?
Activated by?
Inhibited by?
Bone formation- 3 to 4 months and mediate osteoclast function
PTH, vit D, IGF, TGF-beta, platelet derived growth factor
glucocorticoids
What are the nonmodifiable risk factors for osteoporosis?
Advanced age, female gender,
Race: white = Asians > Hispanics > blacks
Heredity, small stature, early menopause or oophorectomy
What are modifiable risk factors for osteoporosis?
Sedentary lifestyle, decreased mobility, excessive alcohol use (over 2 daily), cigarette smoking, low body weight, meds, medical disorders, low calcium intake, low vit d intake
What meds are known to reduce bone mass?
Corticosteroids
Anticonvulsants
Furosemide
Long term heparin
Aluminum antacids
Excessive levothyroxine
Lithium
Chemotherapy
Cyclosporine and tacrolimus
PPIs
Opioids
Who is considered high risk and should have their BMD tested?
Women over 65 and men over 70. Men or women over 50 with recent low-trauma fractures.
Postmenopausal Women under 65 or men 50-69 with risk factors.
Men or women taking chronic glucocorticoid therapy (prednisone for 3 months or more)
What are the Postmenopausal Women under 65 or men 50-69 risk factors to consider for BMD testing?
Delayed puberty, family history of fracture, hypogonadism , COPD, hyperthyroidism, meds that decrease BMD, excessive alcohol, immobility, smoking, repeated falls, fracture risk of 9.3% or greater on FRAX tool
What is a DEXA scan?
A tool used to determine BMD that measures femoral neck, total hip, lumbar spine, and distal radius to determine fracture risk
Bone density is reported both as the standard deviations of bone mineral density compared to a _________, ________ adult of the same _______ and ____-matched
Young,healthy,gender,age
What is the T score and who is it used for? Z score? What is the Z score additionally useful for diagnosing?
Shows patients peak bone mass. It is used for patients 40 or older
Age/gender matched control. Used for patients under 40.
Secondary osteoporosis in children and young adults
According to WHO, what is a normal T score? Low bone density score? Osteoporosis? Severe osteoporosis?
Normal: above -1.0
Low: -1.00 - -2.5
Osteo: below or equal to -2.5
Severe: below -2.5 and one or more fractures
Describe what FRAX is and who/when we use it
Calculates 10 year probability of hip fracture and 10 year probability of major osteoporotic fracture.
Used for post menopausal women and men 50 and older. Applies only to untreated patients to determine if they should receive treatment
Where do we get FRAX measurements from?
Femoral neck BMD measurements, useful for low hip BMD
T/F there are different types of DEXA scans and conversion to FRAX requires indication of which type
True
according to the bone health and osteoporosis foundation clinical guidelines of 2022. For treating primary fracture prevention:
If T-score is _______ and ______ radius by DXA. Or low bone density (osteopenia: T-score between ____ and ___) by DXA with a 10-year hip fracture risk ______ or a 10-year major osteoporosis-related fracture risk ______ based on FRAX
Initiate _______ therapy following discontinuation of denosumab, teriparatide, abaloparatide, or romosozumab
-2.5 or less, 33%
-1, -2.5, 3% or more, 20% or more
antiresorptive
according to the bone health and osteoporosis foundation clinical guidelines of 2022. For treating secondary fracture prevention:
fracture of the ___ or ___ regardless of BMD.
Fracture with low bone density (osteopenia: T-score between ____ and ___) by DXA.
Initiate _______ therapy following discontinuation of denosumab, teriparatide, abaloparatide, or romosozumab
hip, vertebra
-1,-2.5
antiresorptive
according to the bone health and osteoporosis foundation, which treatments are FDA approved?
-bisphosphonates
-PTH analogues
-RANK-ligand inhibitor
-sclerostin inhibitor
-estrogen related therapy
-calcitonin salmon
according to the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), the guidelines for postmenopausal female osteoporosis include:
Diagnosis:
T-score ______
or
T-score between ____ and ____ and FRAX ______ or hip fracture probability _____
or
history of previous ___ or _____ fracture
or
history of _________ fracture
In addition:
-evaluate secondary causes
-correct _____ and vitamin __ deficiency and address secondary osteoporosis
-recommend pharmacotherapy and educate on lifestyle measures
-2.5
-1,-2.5, over 20%, over 3%
hip, spine
fragility
calcium, D
American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE):
Treatment recommendations: High risk/no prior fractures
First line:
Second line:
Reassess ______ for response to therapy
Obtain DEXA scores every _____ years
**Goal is to have BMD stabilize or increase and no fractures.
-if BMD stabilized and no fractures, consider drug holiday after ___ years of oral therapy or ___ years of IV bisphosphonate therapy.
-if BMD decreases or recurrent fractures, assess adherence, re-evaluate for causes and: switch to _____ agent if on an oral agent, or switch to ________, ______, or _______ if on an injectable agent or at a very high risk for fracture
first: alendronate, risedronate, zoledronic acid, denosumab
second: ibandronate or raloxifene
annually
1-2
5, 3
injectable, abaloparatide, romosozumab, teriparatide
American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE):
Treatment recommendations: Very high risk/prior fractures
Use these guidelines if pt has had a fracture in the past ___ months, fractures while on osteoporosis therapy, very low T-score (less than ____), high risk for falls or history of injurious falls, and very high fracture probability on FRAX (osteoporotic fracture _____, hip fracture ____).
First line:
Second line:
Reassess _____ for response to therapy and fracture risk.
Guidelines for med therapy:
Abaloparatide/teriparatide: __ year(s) treatment then switch to oral or injectable _________ agent
Denosumab: continue therapy until pt no longer high risk, if stopped, must use another ________ agent
Romosozumab: __ year(s) treatment then switch to oral or injectable _________ agent
Zoledronic acid: if stable, continue for __ year(s), if not, consider switching to ______, _______, or _________
12, -3, over 30%, over 4.5%
first: abaloparatide, denosumab, romosozumab, teriparatide, or zoledronic acid
second: alendronate or risendronate
annually
2, antiresorptive
antiresorptive
antiresorptive
6, abaloparatide, teriparatide, romosozumab
American College of Physicians: Women and men with low BMD and osteoporosis guidelines:
Women with known osteoporosis:
First line:
Treat for __ years
recommend against menopausal ______ therapy, menopausal _____ plus _______, or _______
recommend against monitoring BMD during the ___ years of treatment
Men with known osteoporosis:
First line:
alendronate, risedronate, zoledronic acid, or denosumab
5
estrogen, estrogen, progesterone, raloxifene
5
any bisphosphonate
what are nonpharm recommendations for all patients to prevent/treat osteoporosis?
-exercise
-increase muscle strength
-minimize/eliminate alcohol and smoking
-adequate calcium and vit D
Calcium recommendations:
mg/day for men 50-70?
mg/day for women over 51 and men over 71?
what are the different forms of calcium supplements? how much elemental calcium is in each? special consideration?
1000
1200
Calcium carbonate: 40% elemental calcium. reduced absorption when used with PPI, improved absorption with food
Calcium citrate: 21% elemental calcium. absorption less affected by GI pH or food
Vitamin D:
required for ____ absorption.
Good food sources?
Recommended daily intake of vid D3:
younger than 50?
over 50?
Use _____ for pts with advanced renal disease
calcium
salmon, tuna, orange juice, cereal, yogurt, eggs
400-800 IU
800-1000 IU
calcitriol
what is the MOA of antiresorptive agents? med names?
inhibit osteoclast-mediated bone resorption to prevent bone loss
Bisphosphonates, denosumab, estrogens, and selective estrogen receptor modulators
what is the MOA of anabolic agents? med names?
stimulate osteoblast production and function resulting in increased bone formation
teriparatide, abaloparatide, and romosozumab
Alendronate:
Increases bone density in ____ and ____
Dose for:
prevention?
treatment?
counseling points?
spine, hip
prevention: 5mg daily or 35mg weekly
treat: 10mg daily or 70mg weekly
take on empty stomach with 8 oz of water, remain in upright position and do not eat or drink for at least 30 minutes
Risendronate:
how is it different from alendronate?
prevention and treatment dose is 5mg daily or 35 mg weekly.
can also take 75mg for 2 consecutive days per month, or 150mg once a month. delayed release formulation is taken after food
Ibandronate:
how is it different from alendronate?
prevention and treatment dose is 2.5mg daily or 150mg monthly
must wait 60 minutes before lying down or eating
pts should not take bisphosphonates if they have?
hypocalcemia or renal insufficiency
which bisphosphonate can be used IV? administration/dose?
ibandronate
5ml every 3 months
names of all bisphosphonates?
adverse effects?
alendronate, ibandronate, risendronate, and zoledronic acid
ulcerative esophagitis, GI upset, jaw osteonecrosis
Zoledronic Acid:
how is it different from alendronate?
IV only: 5mg/100ml IV infusion over 15 minutes given once yearly for treating or every 2 years for prevention
how can jaw osteonecrosis be prevented in pts taking bisphosphonates?
dental exams
RANKL inhibitor- Denosumab:
MOA?
when do we use it?
dose/administration?
adverse effects?
inhibit osteoclast formation, function, and survival to reduce bone resorption
if we can’t give pt bisphosphonates…. men with prostate cancer or women with breast cancer
60mg/ml SC every 6 months
hypocalcemia, infection, osteonecrosis of jaw, back pain
PTH analogues- Teriparatide and Abaloparatide:
MOA?
dose?
duration of therapy?
stimulates bone formation and resorption by regulating calcium and phosphate metabolism in bone
Teri: 20mcg SC daily
Abalo: 80mcg SC daily
should only be used for 2 years in a lifetime
Sclerostin inhibitor - Romosozumab:
MOA?
dose?
black box warning?
antiresorptive and anabolic- builds bone and slows bone breakdown
2 SC injections of 105mg every month for 12 months
increased risk of myocardial infarction, stroke, and CV death
Hormone replacement therapy - Estrogen replacement therapy:
duration of therapy?
MOA?
no more than 5 years post menopause
increase bone mass and prevent loss, reduce fracture risk
SERMS - Raloxiphene:
when do we use it?
dose?
adverse effect?
as a second line agent
60mg daily
hot flashes
Calcitonin:
MOA?
when do we use it?
inhibit osteoclast activity
treat osteoporosis as a later line therapy
In summary: what are the first line agents for treating osteoporosis for postmenopausal women and men?
why don’t we usually use ibandronate?
when do we use zoledronic acid?
alendronate and risendronate
it only decreases spine fractures
cannot use orals
In summary: what are the second line agents for treating osteoporosis for postmenopausal women and men? what’s third line?
last line?
Denosumab, abaloparatide or teriparatide
romosozumab
raloxifene or bazedoxifene or calcitonin
bone loss is highest in the first __ to __ months of glucocorticoid use
3,6
treatment recommendations for adults taking prednisone?
calcium + vitamin D
What are the goals of treating osteoporosis?
Prevent fracture
Stabilize or increase bone mass/density
Relieve symptoms of fracture and skeletal deformity
