Osteoporosis

Question 1

What is osteoporosis?

Answer 1

microarchitectural deterioration of bone tissue leading to decreased bone mass
bone fragility
susceptibility to fracture
a problem of decreased peak bone mass and accelerated bone loss
affects 10 million in the US

Question 2

When does it get harder to add bone mass?

Answer 2

Reach full genetic potential around 18-20. After that you hold steady until menopause. Inadequate lifestyle factors (smoking, poor diet, etc) will affect your potential.

Question 3

What is a central DXA measurement?

Answer 3

gold standard for measuring bone mass
measures multiple skeletal sites: spine, proximal femur, forearm, total body
office based
considered clinical standard

Question 4

What is a T-score?

Answer 4

number of standard deviations from the young adult mean density
osteoporosis= T score -2.5 or less
osteopenia= T score -1 to -2.5

Question 5

For every standard deviation below the norm….

Answer 5

fracture risk doubles

Question 6

What is a Z-score?

Answer 6

number of standard deviations from age matched mean density
accounts for age
apply to pre-menopausal females and males <50

Question 7

What is the FRAX?

Answer 7

WHO fracture risk assessment tool
treatment decision making tool in previously untreated patients
calculates 10 year fracture risk: hip fracture, major osteoporotic fracture (spine, forearm, hip, shoulder)

Question 8

What is primary osteoporosis?

Answer 8

unrelated to chronic illness

related to aging and decreased gonadal function

Question 9

What is secondary osteoporosis?

Answer 9

secondary to chronic illnesses/meds that cause accelerated bone loss
examples- glucocorticoid use, hyperthyroidism

Question 10

What are osteoporosis risk factors?

Answer 10

genetics, low calcium intake, low vitamin D stores, tobacco and alcohol use, prior history of fracture, medications, malabsorption, excessive urinary calcium, overactive thyroid, other medical conditions

Question 11

What are options for secondary evaluation of osteoporosis?

Answer 11

comprehensive metabolic panel
CBC
24 hour urine for calcium, creatinine, sodium
25-hydroxy vitamin D
TSH
SPEP/UPEP if anemic
PTH

Question 12

How can you assess fall risk?

Answer 12

Timed Get Up and Go Test (stand from seated, walk ~10 feet, turn around, return to seated position in chair)
normal time <10 seconds
good objective measure to have documented

Question 13

How can your lifestyle affect bone health?

Answer 13

adequate calcium intake (diet + supplement ~1200 mg/day)
optimal vitamin D levels (25OHD>32ng/mL)
weight bearing exercise
avoid tobacco use
avoid excessive alcohol use

Question 14

What are some dietary sources of calcium?

Answer 14

milk-300mg, yogurt-250mg, orange juice-300 mg, cheese-195-335mg, cottage cheese-130 mg, soy milk-100 mg, dark green leafy vegetables-50-135 mg

Question 15

What are two sources of calcium?

Answer 15

Calcium carbonate: needs stomach acid for absorption (poorly absorbed if on PPI), taken with meals
Calcium citrate: can be taken with or without food, limit to 500 mg in dose, constipation

Question 16

What are some vitamin D supplements?

Answer 16

vitamin D2: ergocalciferol
vitamin D3: cholecalciferol
25OHD lab value helps to guide supplement
can be taken with or without food
safe upper limit defined at 2000 IU
likely much higher: vitamin D3 10,000 IU/day up to 5 months

Question 17

Natural ways to get Vitamin D?

Answer 17

Sunlight
sunscreen however inhibits formation of vitamin D
recommended to have 30-60 minutes of sun exposure

Question 18

What are exercise recommendations for people with OA?

Answer 18

thirty minutes most days of the week
weight bearing exercise: running, walking, elliptical
muscle strengthening exercises
balance

Question 19

What are examples of weight bearing exercises?

Answer 19

aerobics, circuit training, jogging, jumping, volleyball, walking

Question 20

What are the effects of exercise on BMD in kids?

Answer 20

weight bearing increases BMD
gains over 6 months at hip and spine
range 1-6% before puberty
range of 0.3-2% during adolescence

Question 21

What are effects of exercise on BMD in premenopausal women?

Answer 21

resistance training
high impact weight bearing exercise: produce 1-2% gains in BMD at spine and hip (resistance training>spine, high impact training>hip)
menstrual status effects these gains

Question 22

What are the effects of exercise on BMD in older adults?

Answer 22

post-menopause: lumbar spine BMD can be increased by 1-2%, hip data somewhat contradictory
older men: 12 month trial of moderate weight bearing exercises 3xweek vs no exercise (2% net gain in femoral neck BMD)

Question 23

Who gets referred to physical therapy

Answer 23

those at increased risk of fall
those with unstable gait
those with noted weakness: safe walking program, gait evaluation, lower extremity strengthening program
people with osteoporosis to get set up on a exercise program

Question 24

What are the pharmacological treatments of Low bone mass?

Answer 24

bisphosphonates
teriparatide
denosumab
selective estrogen receptor modulators

Question 25

What are the types of bisphosphonates?

Answer 25

alendronate (Fosamax): weekly
risedronate (Actonel): weekely, monthly
ibadronate (Boniva): monthly, IV every 3 months
zolendronic acid (reclast): IV annually

Question 26

What is mechanism of action for bisphosphonates?

Answer 26

osteoclasts are targets

1) bisphosphonate attaches to exposed bone mineral surfaces
2) osteoclast takes up bisphosphonate which leads to loss of ruffled border, inactivation, detachment
3) new bone formation by osteoblasts renders bisphosphonate inert, inaccessible

Question 27

What are side effects of bisphosphonates?

Answer 27

upper GI irritation, osteonecrosis of jaw, severe musculoskeletal pain, hypocalcemia, uveitis/scleritis, atypical femur fractures

Question 28

What is teriparatide, and when should it be avoided as a treatment?

Answer 28

anabolic (bone building agent), SQ injection given daily
black box warning: osteosarcoma
Avoid if: Paget’s disease, elevation of bone alkaline phosphatase, open epiphyses, prior external beam radiation, prior implant radiation

Question 29

What is denosumab and its MOA?

Answer 29

new agent, approved summer 2010: post menopausal osteoporosis
humanized monoclonal antibody against RANKL
inhibits osteoclast function
decreases bone resorption
consider in patients with kidney dysfunction

Question 30

What are 3 other possible pharmacologic agents that are used for osteoporosis?

Answer 30

calcitonin: nasal spray or injection, decreased vertebral fractures, no hip fracture data
raloxifen: SERM, decreased vertebral fractures
estrogen replacement

Question 31

Who should receive treatment?

Answer 31

those with osteoporosis
those with low bone mass: high risk medications (steroids, aromatase inhibitors, androgen deprivation therapy)
FRAX risk calculation: >3% hip fracture of next 10 years, >20% any osteoporotic fracture over next 10 years

Question 32

How can you monitor bone health?

Answer 32

repeat bone density: every one to two years if on treatment, every two years if not on treatment but at risk for further bone loss
continuous re-evaluation of treatment needs