Osteoporosis

Question 1

Osteoporosis

-defn & primary vs secondary

Answer 1

microarchitectural deterioration of bone tissue leading to decreased bone mass
Leads to…
–>bone fragility & susceptibility to fracture

Primary = unrelated to chronic illness; due to normal aging process & decreased gonadal function

Secondary = secondary to chronic illness/meds that cause accelerated bone loss
i.e. glucocorticoids, hyperthyroidism

Question 2

Causes/Etiologies of Osteoporosis

Answer 2

Genetics (Huge!)
Low Ca or Vitamin D intake/stores
Tobacco and/or alcohol use
prior history of fracture
medications
malabsorption
excessive urinary excretion of Ca
Overactive thyroid gland
other medical conditions

Question 3

Assessment of Osteoporosis

Answer 3

Gold Standard = DEXA

FRAX - WHO fracture risk assessment tool; calculates 10 yr fracture risk
-used as a treatment decision making tool in previously untreated patients

Secondary assessments must be performed for FRAX and DEXA scores… such as
- physical assessments (TUG), tinneti, Berg

Question 4

How often do you repeat bone density scans if you are on treatment for osteoporosis?

Answer 4

1-2 years

Question 5

How often do you repeat bone density scans if you are NOT on treatment for osteoporosis?

Answer 5

every 2 years if not on treatment AND at risk for fractures

Question 6

DEXA

• what does it stand for?
• Interpreting the scores (T & Z)

Answer 6

Dual Energy X-ray Absortiometry
-difference in absorption between high & low energy x-rays that are directed from two different sources

Measures bone density at spine, prox. femur, forearm, & total body)

T Score: standard deviation from a young healthy adult
-2.5 or less BELOW the mean = osteoporosis
1-2.5 BELOW the mean = osteopenia

Z score: standard deviations from an age matched density
-applies to pre-men females & males <50

Question 7

Nonpharmacological Treatment for Osteoporosis

Answer 7

1. Nutrition - adequate Ca intake (1200mg/day) & optimal Vitamin D levels (24OHD > 32ng/mL)

Why Vitamin D? it increases Ca absorption & stores

2. Exercise - Weight bearing exercise above that provided by ADL’s for 30 min, most days
3. Avoid tobacco & alcohol use

Question 8

Pharmacologic Treatments for Osteoporosis

-list them (6)

Answer 8

1. Ca Supplements
2. Vitamin D Supplements
3. Biphosphonates (most common)
4. Teriparatide
5. Denosumab
6. Selective estrogen receptor modulators

Question 9

Ca Supplements

Answer 9

Calcium Carbonate
- taken w/ meals b/c needs stomach acid for absorption (poorly absorbed in ppl w/ PPI’s)

Calcium Citrate
- can be taken w/ or w/o food

LIMIT to 500mg/day

Can lead to constipation

Question 10

Vitamin D Supplements

Answer 10

D2 & D3 (D3 from the sun)

Can be taken w/ or w/o food

Safe upper limit = 2,000 IU
-likely much higher D3 of 10,000 IUs/day up to 5 months

Question 11

Biphosphonates

• common medications
• what do they target
• side effects

Answer 11

Most common pharmacologic agent taken for osteoporosis

Targets osteoclasts & inactivates them; meaning more osteoblasts & new bone formation

Side Effects: upper GI irritation (pt must be able to be upright), osteonecrosis of jaw, severe musculoskeletal pain, hypocalcemia

Common medications - "-ronate"
Alendronate (Fosamax)
Risedronate (Actenel)
Ibandronate (Boniva)
Zolendronic acid (Reclast)

Question 12

What is Teriparatide?

Answer 12

anabolic bone building agent used to treat osteoporosis

Question 13

What is Denosumab?

Answer 13

inhibits osteoclast formation which is used to treat osteoporosis
–> consider in patients w/ kidney dysfunction

Question 14

Who should receive treatment?

Answer 14

1. those w/ osteoporosis
2. those w/ low bone mass (high risk medications)
3. FRAX risk calculation
   >3% hip fracture over next 10 years
   >20% any osteoporotic fracture over next 10 years