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
What meds can cause osteoporosis?
What are causes of osteoporosis:
ABCD!
A=anticoagulant, anticonvulsant, aromatase inhibitors
B=barbiturates
C= chemotherapeutic drugs
D=depo
Other causes:
GI: IBD, gastric bypass, celiac
Genetic: CF, OI
endocrine/heme: DM, thyroid
Heme: hemophilia
Hypogonad: anorexia, klinefelter, primary ovarian failure
Lifestyle: smoker, thin, chronic steroids
What to do if pt not improving w/ treatment for osteoporosis?
- check for medication compliance
eval for secondary causes:
- metabolic profile, 24hr urine calcium, 25-hydroxy Vit D, TSH, celiac panel, serum protein electrophoresis (r/o multiple myeloma)
What is differential and tx for GERD?
Differential: GERD, infectious esophagitis, pill and eosinophilic esophagitis.
Tx: 1st line lifestyle and dietary modification (weight loss, elevated hOB, avoid meals 2-3 before bedtime), eliminate triggers.
Meds:
- H2 blockers=pepcid (famotidine)
- PPI: if fail H2 blocker (omeprazole) - can incr absorption and cause kidney disease if long-term use.
What is hormone therapy indicated for?
mod-severe vasomotor sx
Vaginal dryness
prevent early osteoporosis bone loss
women who start HR < age 60 and <10 yrs from onset of menopause have no increased risk of CVD and benefits outweighs risks
- transdermal estrogen
- oral micronized progesterone
- oral provera: increases breast cancer + lipids
