Osteoporosis Flashcards
definition of osteoporosis
low bone mass + microarchitectural disruption + skeletal fragility = dec bone strength and inc risk of fracture
which osteocyte secretes matrix to make new bone (remodeling)?
activated with bone usage to conserve energy
osteoblasts
which osteocyte is a multinucleated cell which absorbs bone thru use of acids recycling Ca back into the bloodstream?
osteoclasts
what hormone is responsible for inhibiting osteoclast activity
estrogen
cancellous bone can be found in: (4)
- end of long bones
- vertebrae
- pelvis
- skull
osteoporosis is the loss of BOTH ____ and ____
- bone mineral
- matrix (collagen, ground substance, inorganic salts, mainly hydroxyapatite)
cause of osteoporosis?
- postmenopausal - dec estrogen, normal bone loss
- adolescence - poor bone mass acquisition
- disease
- malnutrition (disease > food)
- inactive life
RF for primary osteoporosis
- old age
- caucasian/asian - smaller bone structure
- smoking
- malnutrition (vitamin D/Ca)
- dec physical activity
common medications that can cause secondary osteoporosis
- Steroids
- Valproic Acid
- Heparin
- Depo-Provera
- Aromatase Inhibitors
- Cyclosporine
- Antacids
- Lithium
- MTX
common conditions that can cause secondary osteoporosis
- Hyperparathyroidism
- Hyperthyroidism
- Liver disease / Alcoholism - improves with 2 years of abstinence
- CKD
- Hypogonadism
- Low Estrogen - both sexes
- Low Testosterone - males - Hypercortisolism (Cushing’s)
- Malignancy
- DM
- Disease states causing immobility
s/s of osteoporosis
- Pathologic fx - Compression of vertebrae, Hip, Distal radius (Colle’s)
- Loss of vertebral ht >1.5cm (MC upper lumbar or thoracic) - Shortening of stature, Kyphosis
- Back Pain - +/- fx; Most back pain is NOT osteoporosis
USPSTF screening guidelines for osteoporosis
- women >65
- postmenopausal women < 65 at increased risk of osteoporosis
no recommendations for men
The following organizations advocate screening men ≥70:
- National Osteoporosis Foundation
- The International Society for Clinical Densitometry
- American Academy of Family Physicians
- The Endocrine Society
how to dx osteoporosis
- 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 - z-score - compares to person of same gender age
A osteoporosis dx also can be made with a ____ Fx - what are they?
fragility
spine, hip, wrist, humerus, rib, and pelvis - Often with little trauma (i.e. fall from standing position)
how to dx fragility fx?
- 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.
tx for hip fx
surgery
disposition and prognosis of hip fx
- 8.4-36% increase in mortality - Greatest risk in first 6 months
- ⅔ of pts return home after fracture - < 50% will return to pre-fracture mobility
- 2-5 fold inc in lifetime risk of fractures
adjunct w/u for osteoporosis
- plain films - may show demineralization; axial skeleton predominatly MC
- Ca, Phosphate, Vitamin D - 25-OH Vitamin D
- PTH levels
- A1c
- TSH
- Kidney / Liver Function
- Celiac Disease (TTG, IGA Endomysial Antibodies)
labs MC nml - Differentiates between primary and secondary osteoporosis.
s/s hyperparathyroidism causing otseoporosis
- High normal to ↑Ca
- Fatigue
- Body Aches
- Kidney, Biliary Stones
s/s Vit D deficiency causing osteoporosis
- Fatigue
- Bone Pain
- Muscle Weakness
- Lifestyle without sun exposure
s/s DM causing osteoporosis
- Fatigue
- Increased Urination
- Increased Thirst
- Blurred Vision
- Numbness / Tingling
- Erectile Dysfunction
s/s of hyperthyroidism causing osteoporosis
- Tachycardia
- Diarrhea
- Weight Loss
- Elevated temperature
- Proptosis
- Tremors
s/s of celiac disease causing osteoporosis
- GI Upset - N/V/D/C
- Canker Sores
- Skin Manifestations
- Joint Pain
- Weight Loss
- Fatigue
s/s alcoholism causing osteoporosis
- Insomnia or Sleep concerns
- Depression
- CAGE Questionnaire
- ↑ MCV
- ↑ AST/ALT (2:1)
w/u for osteopenia or has a decent T-score but has multiple RF?
FRAX score
Consider tx with 10 year Osteoporotic fx risk ≥20% or Hip ≥3%.
mgmt or osteoporosis and osteopenia
- lifestyle changes - exercise, wt loss, smoking cessation, ETOH moderation, fall prevention
- mineral replacement - Vit D, Ca
Exercise & Weight Loss recommendations
- wt bearing Exercise increases Osteoblast Activity
- Walking 1 hr / wk → 20% reduction in risk of hip fx compared with no activity.
- wt loss reduces load on bones
ETOH moderation recommendations for osteoporosis
- > 2 drinks / day decreases bone density; Women should limit to 1 drink / day
- Moderate use is thought to be OK
recommendations to prevent falls?
- Wear shoes inside and outside
- Have proper eyeglass prescription
- Stand up slowly and give yourself a couple seconds before walking (orthostatic hypotension)
- Remove throw rugs
- Handlebars in showers and bathrooms
- Many other suggestions are available online
Generally, most postmenopausal women and men should be expected to ingest ? IU of Vit. D daily. (D3 preferred over D2)
800 IU
Vitamin D replacement recommendations for osteoporosis
- 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)
Avoid how much for annual bolus of vitamin D - concerns for Vitamin D toxicity.
500,000
diagnostic findings of osteoporosis
- 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.
which calcium replacement should be taken with food, and which does not matter with food?
PPI?
- Calcium Citrate - with or w/o food + PPI
- Calcium Carbonate - should be with food, if PPI used, less uptake will occur
Ca recommendations
- 1200 mg Ca total intake/day is sufficient usually
- 300 mg is in every dairy serving
- Aim for >50% intake from diet
Only supplement Ca if ?
serum Calcium is low or diet is insufficient
Excessive Ca can cause hypercalcemia; Toxic Calcium levels = arrhythmias
tx for osteoporosis and osteopenia w/ +Frax
- antiresorptives - bisphosphonates, denosumab, estrogen/progesterone HR, SERM
- anabolics - PTH / PTH Protein Analog
The greatest effect of Bisphosphonates will be seen when?
- early on while osteoclast activity is diminished
- allows for bone building but there is a trade off with bone flexibility diminishing.
Bisphosphonate Patient Education
- 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
SE of bisphosphonates
- abd pain
- acid regurg
- gas
- N/V/D
- dyspepsia
- constipation
- esophageal ulcer
- dysphagia
- abd distention
major SE of bisphosphonates
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
avoid Bisphosphonates (PO/IV) in who?
alternative?
- patients with eGFR < 30-35
- significant esophageal or GI disorders including history of Roux-en-Y gastric bypass surgery.
- unable to sit up for 30-60 minutes post ingestion
Consider annual IV Zoledronic Acid for CI other than kidney disease
indications of taking a drug holiday from bisphosphonates
- low risk fx and on tx x 2-3 yrs
- mild risk of fx and on tx x 2-5 yrs
- moderate risk of fx and on tx x 3-5yrs
- high risk of fx and on tx up to 10 yrs
- 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
Denosumab (Prolia, Xgeva)
Only used for women as a last resort - increases the risk of blood clots, endometrial cancer, breast CA and possibly heart disease
Estrogen / Progesterone Hormone Replacement (Estradiol)
pros and cons of SERM
- Pros: Inhibits bone resorption; reduces risk of vertebral fracture; Reduces Breast Cancer risk
- Cons: Increased incidences of thromboembolic events / hot flashes
when is SERM considered as osteoporosis tx?
Usually only chosen when there is a need for significant Breast Cancer Reduction along with osteoporosis.
what must you do beforehand when using Romosozumab?
correct Ca and Vit D
- 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)
Romosozumab
Monitoring of Therapy of New DEXA after 2 years
- If improved or stable - continue with therapy
- If worsening - referral or change of therapy. combo pharm not recommended
Indications for Referral to Endocrinology
- 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
