osteoporosis

Question 1

Osteoporosis

Answer 1

A skeletal disease characterized by low bone mass, disruption of skeletal microarchitecture, and increased skeletal fragility resulting in fractures occurring with a fall from standing height or less or with no trauma

Question 2

risk factors non-modifiable

Answer 2

age (>65), female, asian/caucasian, FH, atrumatic fx hx, estrogen def from postmenopause

Question 3

risk factors modifiable

Answer 3

low wt, ca/vit D def, inadquate physical acitivty, cig. smoke, etoh >2 drinks, meds

Question 4

high risk meds cause osteoporosis

Answer 4

steroids
anticoagulants
aromatase inhibitors
chemtherapy drugs- immunosuppressants
PPI (nexium, prilosec, prevacid) decrease CA absorption
gnRH (lupron, zoladex)
thiazolidinedione
heparin
excessive thyroid hormone replacement, medroxyprogesterone acetate,
chronic opiates, 
lasix (loose CA in urine), 
DepoProvera (stop estrogen stop CA)

Question 5

patho

Answer 5

osteoclasts- cutting

osteoblasts- build

Question 6

PMH

Answer 6

rheum diseases, ca, seizures, neuro diseases, DM ,GI, depression (ssri affect bone ), endocrine

Question 7

workup includes

Answer 7

1)risk using FRAX
2) medical hx
3) psychosocial ass
4) med hx
5) osteoporosis hx - fx, FH, therapy
^6)DXA
7) lab
8)PE

Question 8

labs

Answer 8

serum: vit D 25, CMP(ca, phos,alb, protein,liver,crt, bun,elytes), TSH, CBC, 24 hour urine for CA, ESP, tissue transglutaminase antibodies (ro celiac), urinary cortisol

Question 9

FRAX

Answer 9

40-90YO
country
ethincity
age/sex/wt/ht/previous fx/ FH/smoker/rheum arthritis

Question 10

gold standard

Answer 10

DEXA scan >-1.0 normal, -.1- -2.5 osteopenia, >-2.5 osteoporosis

Question 11

prevention of osteo

Answer 11

• Exercise (weight-bearing, aerobic, and strength training) increases bone mineral density (BMD), although unclear if it prevents fractures – 30min 4x/wk or balance/strengthening
• Calcium (1,200 mg) and vitamin D (800 IU) daily (max 5000/day)
• Avoid smoking.
• Limit alcohol use (<2 drinks/d).
• Screen all women ≥65 years of age and women ≥60 years of age who are at high risk for fracture (2)[B].
• Consider screening elderly men at high risk for fracture
• Correct treatable medical conditions and other risk factors

Question 12

CA rich foods

Answer 12

milk 8 oz
yogurt 6 oz
cheese
fortified foods/juices
supplelments- citrate- more acidic, better aborbed for elderly or GI s&S
carbonate- constipation SE
4-5 cups/day (1200mg-1500mg/day)

Question 13

PE

Answer 13

ht/wt/bmi
bp
HEENT- teeth?
spine- kyposis, scolosis
extremities- strength>
neuro
mobility
balance- 12 sec on 1 leg
gait

Question 14

alendronate (fosamax)

Answer 14

biphosphonates

Question 15

risedronate (actonel, atelvia)

Answer 15

biphosphonates

Question 16

ibandronate (boniva)

Answer 16

biphosphonates

Question 17

zolendronate(reclast)

Answer 17

IV biphosophantes monthly

Question 18

denosumab(prolia)

Answer 18

monoclonal antibody
6month injection
NOT for renal patients

Question 19

Raloxifene(evista)

Answer 19

SERM- acts like estrogen- stablizes bone turnover

NOT for elderly due to increase PE risk, dvt, cva

Question 20

teriparatide( forteo)

Answer 20

stimulate bone formation
anabolic med
daily inj for 2 yrs to stimulate osteoblasts
frax -2.9 use

Question 21

biphosphonates education

Answer 21

empty stomach 30 mins, sit upright 30 mins
contraindications- DO of esophagus, barrets esophagus, hypocalcemia, untreated vit D deficency and renal disease( ct clearance <35)

Question 22

normal levels in osteo of ca, cit D and PTH

Answer 22

CA- 8.4-10.2
vit D 25- 35-105 (<32 insufficiency)
PTH- 10-65 pg/ml

Question 23

levels per day ca, vit d,

Answer 23

ca-1200 mg/day >70…1000mg/day

vit d 800 IU daily for >70…600 IU /day or 50,000IU vit D MWF/week x4 weeks

Question 24

referral

Answer 24

fx managemaent, pain control

Endocrinology for secondary…decreased hypogonadism like muscle waste, fatigue, hair loss

Question 25

differential dx

Answer 25

• Primary- bone loss from menopause/aging , secondary- acquired or inherited disease affects bone remodeling or turnover
• Multiple myeloma or other neoplasms
• Osteomalacia
• Type I collagen mutations
• Osteogenesis imperfect
• DM
• Paget’s Disease- normal BMD but fx
• Osteopetrosis – normal BMD but fx

Question 26

goal

Answer 26

prevention then DX- stabilize/improve bone strength/ prevent fx, fx – prevent future falls, fx, reduce pain/deformity, improve QOL

Question 27

tx when

Answer 27

Treat patients with a T-score ≤-2.5 with no risk factors, patients with a T-score ≤-2.0 and 1 or more risk factors, and patients with a prior history of osteoporotic fracture at the spine or hip.