osteoporosis

Question 1

routine screening for osteoporosis

Answer 1

> =65 y.o
earlier for above average risk (other than menopause)
USPTF and AFP recommend age 60 in higher risk women

Question 2

osteoporosis def

Answer 2

T-score<=-2.5 at lumbar spine, total hip or femoral neck on bone mineral density scan
or hx of fragility fracture

Question 3

osteopenia

Answer 3

-1.0 <-2.5

Question 4

who to consider w/u for secondary osteoporosis

Answer 4

all premenopausal women with oeteoporosis
men
postmenopausal women with low z-scores ,-2.0 or less
women who do not respond adequately to initial therapy

Question 5

Meds that cause secondary osteoporosis

Answer 5

glucocorticoids
aromatase inhibitors
depo-medroxyprogesterone acetate
unfractionated heparin
GnRH agonist
anticonvulsants - phenobarbital, phenytoin,carbamezapin (accel vit D metabolism)
phenothiazine
methotrexate (not with low RA doses, 20 mg OK)
excessive vit A intake
cyclosporine-severe trabecular bone loss
tacrolimus

Question 6

secondary causes of osteoporosis (food/disease)

Answer 6

malnutrition/malabsorption
IBD (vit D largely absorbed in jejunum
celiac disease
gastric and bowel resection - ca absorbed in duodenum
eton - inhibits osteoblasts
vitamin D def/insuf

Question 7

Role of Vitamin D

Answer 7

inc calcicum absorption in the gut
suppress PTH release
Dec renal ca and phosp excretion$)

Question 8

generation of bioactive Vit D

Answer 8

exposure to UV light cholecalicferol (D3)
cholecalciferol and ergocalciferol (D2) obtained from diet
D2 and D3 converted in liver to 25-OH vit D (calcidiol- use in liver disease)
1,25-OHD (calcitrol) formed in kidneys through renal conversion (use in kidney disease, $$

Question 9

25-OHD levels

Answer 9

normal > 30
deficiency < 20
insufficiency 20-30

high prevalence esp in elderly, northern latitudes, pregnancy, IBD, celiac disease

Question 10

average daily cholecalciferol need

Answer 10

3000-5000/day

Question 11

choleocalciferol

Answer 11

vitamin D3
preferred therapy
800-1000IU per day for insufficiency

Question 12

VIt D deficiency therapy

Answer 12

50,000 IU Q week for 8 weeks, then 500-1000 IU if deficient

monitor Vit D metabolites levels 3 months after starting therapy - 25-OHD

Question 13

Vit D supplement if kidney disease

Answer 13

Vitamin D metabolites - calcitrol (1-25 OHD)

Question 14

endocrine causes of secondary osteoporosis

Answer 14

hyperthyroidism
hyperparathyroidism - surgical resection improves BMD
Cushings
Hyperprolactinemia

Question 15

misc osteoporosis causes

Answer 15

immobilization
smoker
post organ transplant (esp first 3-6 months
chronic disease - multiple myeloma (inc osteoclast activity)
RA
Chronic renal disease
chronic liver disease
systemic mastocytosis

Question 16

Prevention/tx options for osteoporosis

Answer 16

Ca and Vit D
Weight bearing exercise
Meds: Bisphosphenates, SERM, PTH analogue, Calcitonin, Denosumab

Question 17

calcium recommended intake

Answer 17

1000-1200mg WD for pre-meno and post-meno on anti-resorptive therapy
1500 mg QD for post-meno not on anti-resorptive

Question 18

Vit D recommended intake

Answer 18

800 IU at least

Question 19

Bisphosphonate

Answer 19

analogue of naturally occurring pyrophosphate
accelerates osteoclast turnover
inc BMD and reduces vertebral and non-vert fracture rates
inexpensive, lont-term needs a holiday, usually 12-18 month holiday, no guidelines, base on BMD

Question 20

alendronate (fosamax)

Answer 20

10 mg QD, 70 mg po Q week
44% dec in vert frax
56% dec in hip fx over 4 years

Question 21

risedronate (Actonel)

Answer 21

5 mg po q day
41% dec vert fx in 3 years, 39% dec nonvert fx
35 mg po q week, 75 mg po 2x/mo
as effective as daily dosing
well tolerated

Question 22

ibandronate (boniva)

Answer 22

oral 2.5 mg/day or 20 mg QOD
50% dec in vert gx, no dec in nonvert fx
150 mg PO once monthly
IV 3 mg q 3 mo

Question 23

zoledronic acid

Answer 23

5 mg IV once yearly

70% dec in ver fx, 41% dec hip fx

Question 24

IV bisphosphonate SE

Answer 24

flu like syndrome after infusion
hypocalcemia after infusion
inc r/f afib
no inc r/f jaw necrosis
safety over 3 years not established

Question 25

GI SE of oral bisphosphinates

Answer 25

poorly absorbed, must take on empty stomach 30 before eating, 60 min for ibandronate ESOPHAGITIS - remain upright for one H afteringestion CI in those with achalasia and esophageal stricture GERD is a relative CI

Question 26

duration of tx

Answer 26

consider trial of stopping after 5 years, unless very high risk

Question 27

osteonecrosis of the jaw

Answer 27

most with IV bisphosphenate, associated with dental procedures stop oral therapy 3 months before procedures, on patients taking oral therapy > 3 years, then restarting after healing is complete dental exam before starting IV therapy

Question 28

A fib and bisphos

Answer 28

higher a fib, pathogenesis not clear

Question 29

bisphosphonate in renal disease

Answer 29

not recommended with cr cl < 35, lots of secondary osteo, more appropriately managed by endo these drugs stay in your body for a long time at baseline, greater r/f dynamic bone disease

Question 30

SERM

Answer 30

raloxifene: for prevention and tx of osteoporosis binds estrogen receptors - antagonist/agonist 2.4 % inc of lumbar spine and hip 30-50 % reduction in vertebral fxs NO reduction in NON-VERTEBRAL fx

Question 31

SERM SE

Answer 31

inc thrombosis risk, vasomotor sx dec r/f invasive breast CA 2nd line agent behind bisphos, less potent anti resorptive agent, doesn't help with hip fx

Question 32

calcitonin

Answer 32

``` potent antiresorptive agent rapid action on osteoclast intranasal dose, dec vert fx risk by 33% not as effective as bisphos or PTH unclear long-term efficacy analgesic effect for acute or chronic pain from fx ```

Question 33

parathyroid hormone (Teriparatide)

Answer 33

``` recombinant PTH intermittent dosing stimulates osteoblasts inc GI Ca absorption inc renal tubular resorption of Ca leading to bone formation no more than 1-2 yr tx dec vert and non-vert fx dec fx risk after tx discontinued very expensive, last resort 20 mcg/day SQ ```

Question 34

PTH SE

Answer 34

N/V, dizziness, hypercalcemia (CI kidney stones), leg cramps

Question 35

PTH monitoring

Answer 35

BMD one year after starting Ca levels 1,6 and 12 mos renal function uric acid

Question 36

PTH and bisphos?

Answer 36

not recommended coexistent therapy blunts response of PTH 3 month washout period of bisphos sequential therapy may be beneficial

Question 37

candidates for PTH therapy

Answer 37

T score <-2.5 with fragility fx | those who fail other tx options or are not able to tolerate other tx modalities

Question 38

Denosumab

Answer 38

human IgG antibody to RANKL | controls osteoclast differentiation, activation and survival

Question 39

monitoring osteoporosis therapy

Answer 39

recheck BMD in 1 year, then q2 years can also check levels of bone turnover after 6 mos urinary NTX excretion - dec > 50% serum carboxy-terminal collagen crosslings if BMD stable or imp - successful if BMD decreases - confirm compliance, look for further causes, can recheck in one year or change therapy

Question 40

monitoring therapy, pt on corticosteroid

Answer 40

baseline BMD monitor q6mo, then q 6-12 months if not on therapy annual follow-up measurements once on therapy

Question 41

oosteoporosis in Men

Answer 41

incidence of fx inc with age, though 10 yrs later than women mortality from hip and vert fx higher in men 2nd causeID in 40-60% of fx

Question 42

osteo screening in men

Answer 42

screen >70, radiographis osteopenia, loss of height, fragility fx, long term steroids, intestinal disorders

Question 43

therapies for osteoporosis approved for men

Answer 43

bisphos and PTH analogue