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Clin Med III: MSK > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

definition of osteoporosis

A

low bone mass + microarchitectural disruption + skeletal fragility = dec bone strength and inc risk of fracture

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2
Q

which osteocyte secretes matrix to make new bone (remodeling)?
activated with bone usage to conserve energy

A

osteoblasts

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3
Q

which osteocyte is a multinucleated cell which absorbs bone thru use of acids recycling Ca back into the bloodstream?

A

osteoclasts

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4
Q

what hormone is responsible for inhibiting osteoclast activity

A

estrogen

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5
Q

cancellous bone can be found in: (4)

A
  1. end of long bones
  2. vertebrae
  3. pelvis
  4. skull
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6
Q

osteoporosis is the loss of BOTH ____ and ____

A
  • bone mineral
  • matrix (collagen, ground substance, inorganic salts, mainly hydroxyapatite)
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7
Q

cause of osteoporosis?

A
  1. postmenopausal - dec estrogen, normal bone loss
  2. adolescence - poor bone mass acquisition
    - disease
    - malnutrition (disease > food)
    - inactive life
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8
Q

RF for primary osteoporosis

A
  1. old age
  2. caucasian/asian - smaller bone structure
  3. smoking
  4. malnutrition (vitamin D/Ca)
  5. dec physical activity
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9
Q

common medications that can cause secondary osteoporosis

A
  1. Steroids
  2. Valproic Acid
  3. Heparin
  4. Depo-Provera
  5. Aromatase Inhibitors
  6. Cyclosporine
  7. Antacids
  8. Lithium
  9. MTX
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10
Q

common conditions that can cause secondary osteoporosis

A
  1. Hyperparathyroidism
  2. Hyperthyroidism
  3. Liver disease / Alcoholism - improves with 2 years of abstinence
  4. CKD
  5. Hypogonadism
    - Low Estrogen - both sexes
    - Low Testosterone - males
  6. Hypercortisolism (Cushing’s)
  7. Malignancy
  8. DM
  9. Disease states causing immobility
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11
Q

s/s of osteoporosis

A
  1. Pathologic fx - Compression of vertebrae, Hip, Distal radius (Colle’s)
  2. Loss of vertebral ht >1.5cm (MC upper lumbar or thoracic) - Shortening of stature, Kyphosis
  3. Back Pain - +/- fx; Most back pain is NOT osteoporosis
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12
Q

USPSTF screening guidelines for osteoporosis

A
  1. women >65
  2. postmenopausal women < 65 at increased risk of osteoporosis

no recommendations for men

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13
Q

The following organizations advocate screening men ≥70:

A
  1. National Osteoporosis Foundation
  2. The International Society for Clinical Densitometry
  3. American Academy of Family Physicians
  4. The Endocrine Society
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14
Q

how to dx osteoporosis

A
  1. T-score - Always use the lowest (worst) score to diagnose; compared to a healthy 30 y/o
    - ≤ -2.5: osteoporosis
    - -2.4 < T < -1.0
    - T > -1.0
  2. z-score - compares to person of same gender age
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15
Q

A osteoporosis dx also can be made with a ____ Fx - what are they?

A

fragility

spine, hip, wrist, humerus, rib, and pelvis - Often with little trauma (i.e. fall from standing position)

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16
Q

how to dx fragility fx?

A
  • stands w/o confirmation of a low T-score or even with a nml T-score
  • There is no way to measure Bone Quality, but the fracture shows it is poor.
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17
Q

tx for hip fx

A

surgery

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18
Q

disposition and prognosis of hip fx

A
  1. 8.4-36% increase in mortality - Greatest risk in first 6 months
  2. ⅔ of pts return home after fracture - < 50% will return to pre-fracture mobility
  3. 2-5 fold inc in lifetime risk of fractures
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19
Q

adjunct w/u for osteoporosis

A
  1. plain films - may show demineralization; axial skeleton predominatly MC
  2. Ca, Phosphate, Vitamin D - 25-OH Vitamin D
  3. PTH levels
  4. A1c
  5. TSH
  6. Kidney / Liver Function
  7. Celiac Disease (TTG, IGA Endomysial Antibodies)

labs MC nml - Differentiates between primary and secondary osteoporosis.

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20
Q

s/s hyperparathyroidism causing otseoporosis

A
  1. High normal to ↑Ca
  2. Fatigue
  3. Body Aches
  4. Kidney, Biliary Stones
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21
Q

s/s Vit D deficiency causing osteoporosis

A
  • Fatigue
  • Bone Pain
  • Muscle Weakness
  • Lifestyle without sun exposure
22
Q

s/s DM causing osteoporosis

A
  1. Fatigue
  2. Increased Urination
  3. Increased Thirst
  4. Blurred Vision
  5. Numbness / Tingling
  6. Erectile Dysfunction
23
Q

s/s of hyperthyroidism causing osteoporosis

A
  1. Tachycardia
  2. Diarrhea
  3. Weight Loss
  4. Elevated temperature
  5. Proptosis
  6. Tremors
24
Q

s/s of celiac disease causing osteoporosis

A
  1. GI Upset - N/V/D/C
  2. Canker Sores
  3. Skin Manifestations
  4. Joint Pain
  5. Weight Loss
  6. Fatigue
25
Q

s/s alcoholism causing osteoporosis

A
  1. Insomnia or Sleep concerns
  2. Depression
  3. CAGE Questionnaire
  4. ↑ MCV
  5. ↑ AST/ALT (2:1)
26
Q

w/u for osteopenia or has a decent T-score but has multiple RF?

A

FRAX score
Consider tx with 10 year Osteoporotic fx risk ≥20% or Hip ≥3%.

27
Q

mgmt or osteoporosis and osteopenia

A
  1. lifestyle changes - exercise, wt loss, smoking cessation, ETOH moderation, fall prevention
  2. mineral replacement - Vit D, Ca
28
Q

Exercise & Weight Loss recommendations

A
  1. wt bearing Exercise increases Osteoblast Activity
  2. Walking 1 hr / wk → 20% reduction in risk of hip fx compared with no activity.
  3. wt loss reduces load on bones
29
Q

ETOH moderation recommendations for osteoporosis

A
  • > 2 drinks / day decreases bone density; Women should limit to 1 drink / day
  • Moderate use is thought to be OK
30
Q

recommendations to prevent falls?

A
  1. Wear shoes inside and outside
  2. Have proper eyeglass prescription
  3. Stand up slowly and give yourself a couple seconds before walking (orthostatic hypotension)
  4. Remove throw rugs
  5. Handlebars in showers and bathrooms
  6. Many other suggestions are available online
31
Q

Generally, most postmenopausal women and men should be expected to ingest ? IU of Vit. D daily. (D3 preferred over D2)

A

800 IU

32
Q

Vitamin D replacement recommendations for osteoporosis

A
  • Labs < 20 - 50k IU wkly x 3-6 mo, then switch to daily supplementation
  • Vit D level safe up to 100, Toxicity >150 (impossible to attain w/o excessive supplementation)
33
Q

Avoid how much for annual bolus of vitamin D - concerns for Vitamin D toxicity.

A

500,000

34
Q

diagnostic findings of osteoporosis

A
  • T score on DEXA scan <-2.5 or
  • H/o fragility fx or
  • FRAX > 3% 10-year probability of hip fx or 20% 10-year probability of other major osteoporotic fx or
  • FRAX > 3% (any fx) with T-score <-1.5 or
  • Initiating bisphosphonates; osteosclerosis/petrosis; rickets; Vit D def on replacement therapy related to a condition listed above; to monitor the efficacy of treatment.
35
Q

which calcium replacement should be taken with food, and which does not matter with food?
PPI?

A
  • Calcium Citrate - with or w/o food + PPI
  • Calcium Carbonate - should be with food, if PPI used, less uptake will occur
36
Q

Ca recommendations

A
  1. 1200 mg Ca total intake/day is sufficient usually
    - 300 mg is in every dairy serving
    - Aim for >50% intake from diet
37
Q

Only supplement Ca if ?

A

serum Calcium is low or diet is insufficient

Excessive Ca can cause hypercalcemia; Toxic Calcium levels = arrhythmias

38
Q

tx for osteoporosis and osteopenia w/ +Frax

A
  1. antiresorptives - bisphosphonates, denosumab, estrogen/progesterone HR, SERM
  2. anabolics - PTH / PTH Protein Analog
39
Q

The greatest effect of Bisphosphonates will be seen when?

A
  • early on while osteoclast activity is diminished
  • allows for bone building but there is a trade off with bone flexibility diminishing.
40
Q

Bisphosphonate Patient Education

A
  • Due to poor absorption, should take with 8oz of water first thing in AM, no other foods or meds for 30 min. (60 min if Ibandronate)
  • Do not recline for 30 min after taking meds to minimize risk of reflux
  • DC if any reflux sx appear
41
Q

SE of bisphosphonates

A
  1. abd pain
  2. acid regurg
  3. gas
  4. N/V/D
  5. dyspepsia
  6. constipation
  7. esophageal ulcer
  8. dysphagia
  9. abd distention
42
Q

major SE of bisphosphonates

A

Osteonecrosis of the Jaw - Loss or Breakdown of the jaw - infection, pain, swelling - generally associated with tooth extraction and/or local infection with delayed healing

43
Q

avoid Bisphosphonates (PO/IV) in who?
alternative?

A
  1. patients with eGFR < 30-35
  2. significant esophageal or GI disorders including history of Roux-en-Y gastric bypass surgery.
  3. unable to sit up for 30-60 minutes post ingestion

Consider annual IV Zoledronic Acid for CI other than kidney disease

44
Q

indications of taking a drug holiday from bisphosphonates

A
  1. low risk fx and on tx x 2-3 yrs
  2. mild risk of fx and on tx x 2-5 yrs
  3. moderate risk of fx and on tx x 3-5yrs
  4. high risk of fx and on tx up to 10 yrs
45
Q
  • No drug holiday - bone regression occurs with stopping
  • If not fully covered, can be expensive
  • Good option for those who cannot tolerate Bisphosphonates or those with CKD
A

Denosumab (Prolia, Xgeva)

46
Q

Only used for women as a last resort - increases the risk of blood clots, endometrial cancer, breast CA and possibly heart disease

A

Estrogen / Progesterone Hormone Replacement (Estradiol)

47
Q

pros and cons of SERM

A
  • Pros: Inhibits bone resorption; reduces risk of vertebral fracture; Reduces Breast Cancer risk
  • Cons: Increased incidences of thromboembolic events / hot flashes
48
Q

when is SERM considered as osteoporosis tx?

A

Usually only chosen when there is a need for significant Breast Cancer Reduction along with osteoporosis.

49
Q

what must you do beforehand when using Romosozumab?

A

correct Ca and Vit D

50
Q
  • Is possible to use with significant CKD
  • Effect wanes after 12 mo - DC usage
  • Consider if needed during a Bisphosphonate drug holiday
  • Possible Cardiac SE (MI/CVA)
A

Romosozumab

51
Q

Monitoring of Therapy of New DEXA after 2 years

A
  • If improved or stable - continue with therapy
  • If worsening - referral or change of therapy. combo pharm not recommended
52
Q

Indications for Referral to Endocrinology

A
  • Osteoporosis in premenopausal women or men < 50
  • Hx of fragility fx + normal DEXA
  • Failed tx or continual fractures with tx
  • Conditions which make normal therapy difficult
  • Considerations of advanced therapies

Clin Med III: MSK (14 decks)

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