Osteoporosis Flashcards
Women lose up to __% of bone mass in the 5-7 years postmenopause
20
*~ 50% of women will experience an osteoporotic fracture in their lifetime
~50% of these women did not have osteoporosis defined by BMD
Describe the burden of hip fractures
- 24% mortality within first year
- 50% of hip fracture sufferers unable to walk without assistance
- 25% will require long term care
T/F?
A clinical diagnosis of osteoporosis can be made based upon a fragility fracture regardless of BMD status
True
*If they have a hx of a fragility fracture (fall from a regular height) then they can be dx with osteoporosis
What are factors contribute to bone strength
- Bone mass
- Bone turnover
- Bone quality
*-If you have an imbalance of one of these, then your bone strength is off
describe the pathophysiology of postmenopausal osteoporosis
With the onset of menopause (mid-forties or fifties), diminishing estrogen levels lead to excessive bone resorption that is not fully compensated by an increase in bone formation
**Theory: estrogen blocks cytokine secretion, resulting in decreased bone resorption
At menopause, estrogen goes down and OC activity increases and OB activity decreases= get more bone resorption
What are bone mass measurement devices
- central- qCT (not recommended for screening)
2. Dual-energy X-ray absorptiometry (DEXA)***
Who should BMD testing be performed on?
- Women 65+ years and men age 70* regardless of risk factors
Younger postmenopausal women and men aged 50-69 years with a risk factor: - Prior fragility fracture (before age 50)
- Use of a high risk meds
- FHX of osteoporosis
- RA or condition associated with increased bone loss
- Glucocorticoids 5mg+ daily for 3 or more months
- Current smoker
- Low body weight (<127 lbs)
- Initiating therapy for osteoporosis, on therapy for osteoporosis or discontinuing hormone replacement therapy
What are other risk factors for osteoporotic fx
- Small stature (<127 lbs)
- Personal history of fracture
- Premature Menopause
- History of amenorrhea
- Caucasian
- Advanced age
- Dementia
- Immobilization
- diet
- cig smoking/alcohol intake
- inactivity
- disease
what disease and meds can cause osteoporosis
disease: GI and anorexia
Meds: steroids, anticonvulsants, Depo-Provera
Describe te DXA process/ areas imaged
- Lumbar spine: L1-L4 (average)
- Hips: Femoral neck and total hip
Non-dominate forearm if:
- Spine instrumentation
- Spine fracture
- Severe degenerative disc disease
- Severe hip arthritis
- Hyperparathyroidism
How do you interpret T scores from DXA
WHO classification to determine normal, osteopenia, osteoporosis
Normal: -1.0 and above
Osteopenia: -2.5
Osteoporosis: -2.5 and below
Severe Osteoporosis: -2.5 and below w/ fracture
Describe what T and Z scores are
- T: Standard deviation difference between the patient’s BMD and a young-adult reference population
- Z: Standard deviation difference between the patient’s BMD and an aged-matched population
How do you interpret Z scores
Used to determine if further evaluation for secondary causes of osteoporosis is warranted
Steroids, Alcohol
Z-Score
What labs do you order for routine assessment of excluding secondary causes of osteoporosis
- CBC
- TSH
- 25-Hydroxyvitamin D
- 24-hour urinary calcium and creatinine clearance
- CMP: serum chemistries:
- calcium
- phosphorus
- creatinine
- alkaline phosphatase
- albumin
- liver enzymes
What are second level tests (nonroutine tests) for excluding secondary causes of osteoporosis?
- Markers of bone remodeling (Urine NTx, Bone specific alkaline phosphatase)
- Urine free cortisol
- ESR
- Intact parathyroid hormone (PTH)
- Anti-transglutaminase antibodies
- Serum and urine protein electrophoresis
- Bone biopsy
What is the FRAX (fracture risk assessment tool)
Introduced by WHO in 2008 in collaboration with the NOF
Goal: To identify patients at high risk of osteoporotic fracture
Estimates the 10-year probability of hip fracture or major osteoporotic fractures combined (hip, proximal humerus, distal forearm, spine)
What are the goals of osteoporsis prevention
- Maximize peak bone mass (usually reached by 30y/o)
2. Minimize rate of bone loss
What determines peak bone mass
60-70% due to genetic predisposition
30-40% due to diet, exercise, disease, medications
Non-pharmacologic therapies for osteoporosis prevention
- Calcium – elemental
- Vitamin D
- Weight-bearing exercise
- Habit Alteration (quit smoking and limit alcohol intake)
- Fall-prevention techniques
What is the optimal daily Ca2+ intake for women
> 50 years old (postmenopausal):
On estrogen: 1000-1200 mg
Not on estrogen: 1200-1500 mg
> 65 years old: 1200-1500 mg
*Calcium Supplements should contain Vitamin D– Some people take Tums for Ca2+ but there is no Vit. D so they are not absorbing it
Average adult needs ___ Vit. D units daily to maintain a 25-hydroxyvitamin D level at __ ng/ml.
800-1000
30
What is the managment recommendation for someone with 25-hydroxyvitamin D3 (total) <20 ng/ml
- Vitamin D 50,000 units
- Once weekly for 6-8 weeks–> 800-1000 units thereafter
- Recheck 25-hydroxyvitamin D in 3 months to access level
What is the managment recommendation for someone with 25-hydroxyvitamin D3 (20-30 ng/ml
- Vitamin D3 OTC- 800-1000 units daily
2. Recheck 25-hydroxyvitamin D in 3 months to access level
What is the recommendation of exercise for the prevention of osteoporosis
- 30 minutes of weight bearing exercise, at least 3 times weekly
- Normal growth, maintenance and remodeling of the skeleton depend on physical loading
- May aid in fall prevention by strengthening muscles which provide flexibility, balance and agility
Describe the NOF guides for tx threshold for osteoporosis
- Postmenopausal women and men age 50+ (ethnicity not specified)
- previous hip or vertebral fx
- T-score -2.5 or less at the femoral neck, total hip or spine
- low bone mass and risk factors
- T-score between -1.0 and -2.5 at the femoral neck , total hip or spine, and ten-year fracture risk as assessed by FRAX of 3% or more at the hip, 20% or more for major osteoporosis-related fracture (humerus, forearm, hip or clinical vertebral fracture)
Describe the 2 type of therapy agents used to tx osteoporosis
- Anti-resorptives: Decrease bone remodeling by inhibiting osteoclastic bone resorption
Increase bone mass - Anabolics: Increase bone mass
Increase the number of trabecular elements in cancellous bone
Stimulate osteoclastic bone formation
Examples of Anti-resorptive and anabolic meds
Anti-resorptive: Estrogen, Bisphophonates, SERM calcitonin
Anabolic: PTH (terapuratide/ Forteo)
FDA Approved for the prevention of postmenopausal osteoporosis
Not FDA approved for the treatment of postmenopausal osteoporosis
Estrogen replacement therapy
FDA approved for the prevention and treatment of osteoporosis.
SERMS
SE: hot flashes
FDA approved for the treatment of osteoporosis
FDA approved for the prevention and treatment of glucocorticoid-induced osteoporosis
Bisphophonates
-(Fosamax and Actonel)
only med that causes bone formation
Teriparatide (Forteo)
SC daily for 24 months only
Describe the black box warning of Teriparatide (Forteo)
Should not be used in the following patients:
- Paget’s disease;
- primary bone cancer;
- increased bone-specific alkaline phosphatase;
- metastatic bone cancer;
- treatment with radiation to the bone;
- hypercalciuria;
- elevated PTH
Describe what Denosumab (Prolia) is and how it is administered
Humanized monoclonal antibody against RANKL
Given as an injection every 6 months
Must check serum calcium levels prior to injection (can lower serum calcium)
When is Denosumab (Prolia) recommended
For women at high risk of fracture or breaking a bone. High Risk is defined as:
- Already broken a bone from osteoporosis
- Several risk factors for breaking a bone
- Not able to take other osteoporosis medicines due to side effects
- Have not received enough benefit from other osteoporosis medicines
