Osteoporosis Flashcards
What vaccines should a 62 year old need?
Flu, Tdap q10 years, zoster (ages 50+), covid. If 65+, one dose of pneumococcal 20 or pneumococcal 15 + pneumococcal 23 1 yr later.
What are risk factors for osteoporosis?
- Age
- white race
- parental hx of hip/spine fracture
- BMI <20
- smoking
- RA
- excessive alcohol use (>3 drinks/day)
- steroids
- inadequate physical activity
- estrogen deficiency
- gastric bypass (malabsorption)
- thyroid disease.
Drugs: anticonvulsants, steroids, TPN, aromatase inhibitors, lithium, long-acting progesterone.
Others: GI (celiac, gastric bypass, eating disorders), endocrine (thyroid), heme (SCD), ID (HIV), Pulm (COPD)
What is the definition of osteoporosis?
What is the workup?
T-score < -2.5 or fragility fracture (falling from less than standing height) regardless of T-score.
1st line bisphosphate (5yr only bc risk mandible osteonecrosis).
Treat if prior fragility fracture, T-score < -2.5.
Workup: CBC, CMP (including calcium, Mag, LFTs), 25-OH Vit D3 level, 24hr urine calcium, TSH. If excluding secondary causes: PTH.
- peak bone mass at age 18-21.
What is the definition of low bone mass?
Formerly osteopenia. T score between -1 and -2.5
How do you diagnose osteoporosis?
DEXA scan if >65. If <65 and RF, 10yr FRAX risk >8.4%, then get DEXA.
Scan should be of central bones (hip and spine).
Repeat q2yr unless new risk factors
If treatment: q1-3 yrs until stable.
Tx: non-pharmacologic and pharmacologic options!!
- prescribe calcium, vit D, weight bearing exercises, fracture/fall prevention
What is a T-score?
standard deviations from mean peak bone mineral density compared to young, healthy population.
Z-score: standard deviations from reference population of same AGE, SEX, AND RACE. Useful for premenopausal women (UNDER 35) at risk for secondary causes of osteoporosis. Z score < 2.0 needs evaluation.
Contraindications to bisphosphonates?
Esophageal disorder, CKD, gastric bypass.
Mechanism of action of bisphosphonates?
What are side effects?
Inhibits bone resorption via action on osteoclasts.
eg. Aledronate=1st line. 10mg daily.
SE: muscle pain/aches, GI irritation, osteonecrosis of jaw.
What calcium/Vit D recommended daily allowance should the patient be taking?
Not effective for osteoporosis prevention.
Calcium 1000 mg. or 1200 mg/day if 50+. Average diet contains ~800. supplements incr risk kidney stones and don’t reduce fracture risks.
Vit D is 600mg or 800 if 70+
What are the types of medication to treat osteoporosis?
When do you treat osteoporosis?
Anti-resorptive (bisphosphonates, RANK-L inhibitor, SERM, calcitonin) and anabolic (if very high risk fracture): PTH-analog, sclerosin-binding inhibitor.
Treat if T score <-2.5 OR T score <1.0 (LBM) and FRAX score >3% hip or >20% major fx OR hx fragility fracture (regardless of T-score).
What is normal bone loss?
pre-menopausal: 0.5% per yr
post-menopausal: 5% per year.
What is a FRAX?
What factors are included in FRAX assessment?
fracture risk screening tool for women >40, predicts fracture risk in next 10 yrs.
What is included in FRAX: age, sex, BMI, prior fracture, parental hx, current smoking, alcohol, steroid use, RA.
- Use to determine if pt w/ low bone mass needs tx: if FRAX >3% hip fracture of >20% major fracture
- Use to determine if pt <65 w/ risk factors should get DEXA. if FRAX >8.4%, get DEXA
Limitations: doesn’t include hx recent falls or quantify risk for smoking/alcohol/meds.
What are anti-resorptive treatments (besides bisphosphonates)?
HRT: only use if other options fail.
SERM (raloxifene): pro-estrogen on bone and uterus, anti-estrogen in breast. reduces fracture rate and breast cancer rate by 50%. use if woman in 50s!! - incr risk VTE!!!!
bc bisphosphonate can only be on for 5 years!
Calcitonin: 200 IU/day nasal spray or subs. rarely used. incr risk malignancy.
rank-ligand inhibitor: denosumab (monoclonal Ab): subQ q6mo, incr vertebral fracture and bone loss w/ discontinuation. Better for higher risk of fractures. BLACK BOX for int risk hypocalcemia w/ CKD.
Zoledronic acid (IV yearly): give pt pt non-compliant with bisphosphate PO or contraindications to oral bisphosphonates! for 3 yrs.
What are anabolic therapies?
PTH-analog (abaloparitide) tx of very high fracture risk. avoid if hypercalcemia and incr risk osteosarcoma.
Sclerostin inhibitor: tx of high fracture risk. monoclonal Ab: avoid if hypocalcemia, hx MI/stroke.
“very high risk” : T score < -3.0 or <2.5 w/ fracture in past yr, or multiple fractures.
What are causes of height loss?
aging
osteoporosis
hyperPTH
osteomalacia
herniated disc
vertebral fracture
degeneratie disc disease
scoliosis, kyphosis
