Osteoporosis Flashcards

1
Q

What is osteoporosis

A

low bone density (weak bones) leading to increased fracture risk

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2
Q

Why do men and women start losing bone density in 3-4 decade

A

Women: Menopause= estrogen deficiency= increased osteoclast activity= bone resorption>formation
Men: aging and secondary causes; occurs later 2/2 larger bone size and mass

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3
Q

What can all individuals do to reduce risk of osteoporosis

A

Incorporate healthy bone lifestyle from birth
Regular exercise, nutritious diet, avoid tobacco, minimize alcohol consumption
Fall prevention

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4
Q

RF of osteoporosis are

A

age, Hx of fracture, glucocorticoids, parent Hx of hip Fx, low body weight, cigarette smoking, excess alcohol, RA

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5
Q

Secondary osteoporosis RF are

A
hypogonadism
premature menopause 
malabsorption 
chronic liver disease 
IBD
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6
Q

Age related osteoporosis results from

A

hormone, calcium, and vitamin D deficiency

leads to accelerated bone turnover and reduced osteoblast formation

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7
Q

Drug induced osteoporosis results from

A

systemis corticosteroids, thyroid hormone replacement, AED (phenytoin, phenobarbitol), depot medroxyprogesterone acetate

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8
Q

What is the FRAX tool

A

WHO created tool to assess probability of Fx in the next 10 years
-age, race, sex, Hx of fragile fx, BMI, glucocorticoids, current smoking, alcohol (3+/day), RA, femoral neck or total hip bone mineral density

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9
Q

What is the Garvan calculator

A

Uses 4 RF (age sex low trauma Fx and falls) +/- BMD to calculate 5 and 10 year risk estimates
Better than FRAX bc it includes falls and # of previous Fx instead of a bunch of other random RF

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10
Q

What is the standard diagnostic test fro BMD

A

DXA (dual energy x-ray absorptiometry)

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11
Q

Diagnosis of osteoporosis is based on

A

low trauma Fx OR
central hip/spine DXA using WHO T-score threshold
*For kids, pre-menopause women, and men <50, Dx based on Z score

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12
Q

What are T scores indicative of

A

Osteopenia (low bone mass): -1 to -2.5
Osteoporosis: Less than -2.5
(T scores applied to perimenopausal women, men 50+, and other races)

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13
Q

Absorptive therapies (keep it in the bone) include

A

*Calcium
*Vitamin D
**Bisphosphanates
calcitonin
Estrogen agonists
Estrogen
Testosterone
Teriparatide
Denosumab

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14
Q

What age group needs the most calcium and vitamin D

A

9-18 years old

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15
Q

What are the tow forms of calcium

A
  • Calcium carbonate (can cause bloating, gas, constipation, hypercalcemia, hypophosphatemia; rarely, stones)
  • Calcium citrate (hypercalcemia, hypophosphatemia)
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16
Q

What are the forms of vitamin D

A

D3: Cholecalciferol (not active, natural form)
D2: Ergocalciferol (plant derived)
D: Calcitriol, AKA 1,25 OH vitamin D (active)

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17
Q

When would you need to increase the dose of D3 (cholecalciferol)

A

In malabsorption

If taking anticonvulsants (carbamazepine, phenobarb, phenytoin)

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18
Q

What are the ADE of D3 (cholecalciferol)

A

Hypercalcemia (HA, weakness, cardiac disturbance)

Hypercalcuria

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19
Q

When would you Rx Ergocalciferol (D2)

A

if Vitamin D deficient

20
Q

How is Calcitriol formed

A

D3 is hydroxylated in the liver and other tissues to make calcifediol (25 OH-D)
That is then metabolized in the kidneys to make calcitriol

21
Q

Indications for using exogenous Calcitrol

A

renal osteodystrophy
hypoparathyroid
refractory rickets

22
Q

What are the bisphosphanates (first line for osteoporosis)

A

Alendronate
Risedronate
IV Zoledronic acid (Reclast) (IV infusion q2 years)
(first line for post-menopause women, man and glucocorticoid induced osteoporosis)
-IV and oral Ibandronate only for post-menopausal women

23
Q

What is the MOA of bisphosphonates

A
Mimic pyrophosphate (endogenous bone resorption inhibitor)= decrease osteoclast maturation, #, recruitment, and life span 
Half life is up to 10 years (becomes incorporated into bone)
24
Q

Important notes for each bisphosphonate

A

Alendronate: Take in AM on empty stomach w/ 6=8 oz water. Dont eat and Stay upright for 30 min. Dont take w/ any other supplements
Ibandronate: same as Alendronate, but stay upright for 60 min
Risendronate: Same as Alendronate, but ER tab (Atelvia) is taken right AFTER breakfast
Zoledronic acid: DO NOT take if CrCl <35

25
Q

How do you monitor bisphosphonates

A

Generally 1-2 years s/p initiation (determine efficacy)

Then q2 years with bone turnover markers

26
Q

What are ADE of bisphosphonates

A

oral: Nausea, Dyspepsia
IV: Flu-like illness
rare: perforation, ulceration, GI bleeding, MSK pain, atypical Fx, sub-trochanteric femoral fracture
BBW: ONJ

27
Q

What are the bone turnover markers of resorption

A

Type 1 collagen degradation (PYD, DPD, C and N nucleopeptides)
TRACP 5b, Cathepsin K, Matrix metalloproteinases

28
Q

What are the bone turnover markers of formation

A

Procollagen type 1 propeptides (PICP, PINP, osteocalcin)

BALP

29
Q

DO NOT USE bisphosphonates if

A

CrCl <30-35
Serious GI conditions (barrett’s esophagus, achalasia, esophageal varicies)
Pregnant

30
Q

What is ONJ

A

osteonecrosis of jaw; more common in those w/ cancer, chemo, radiation, and glucocorticoid therapy on higher dose IV bisphosphonate

31
Q

What is a “drug holiday”

A

Patients taken of bisphosphanates and followed w/ bone turnover markers and central DXA BMD
AKA, 5 years after being taken off Alendronate therapy, post-menopause women showed prolonged suppression of bone turnover and maintenance of BMD

32
Q

Who meets criteria for a drug holiday

A

Women w/o evidence of low rtauma Fx who repsonded well to bisphosphanates who’s T score is in “osteopenic” range (> -2)
*Best results if women are low risk (T score > -2.5). NOT for high risk women w/ T score < -3.5

33
Q

What is calcitonin

A

third line med; for women 5 years post-menopause
Tx for pain relief w/ acute vertebral Fx
refrigerate and prime nasal spray

34
Q

What is endogenous calcitonin

A

hormone released from thyroid when calcium is high

promotes deposition of calcium into bone (inhibits osteoclasts, stimulates osteoblasts)

35
Q

What are the second gen estrogen agonist/antagonist

A

Raloxifen, Bazedoxifene (selective estrogen receptor modulators)
decrease bone resorption= increased BMD and decreased fractures
*Bazedoxifen is for post-menopausal women w/ a uterus, no progesterone needed!!

36
Q

What hormone therapy can you give for osteoporosis

A
Estrogen therapy (short term for women who need to manage menopause Sx) 
Testosterone (or methyltestosterone for women) increase BMD
37
Q

What is Teriparatide (anabolic Tx)

A

Recombinant product that acts like first 34 AA in PTH

Good for post-meno women, men, and pt on glucocorticoids at high risk (T score < -3.5)

38
Q

What is the MOA of teriparatide

A

increases bone formation, bone remodeling rate, and osteoblast number and activity
leads to improved bone mass and architecture

39
Q

How do you take teriparatide

A

It is a pre-filled pen (subQ injection into thigh or abdomen w/ site rotation- 20mcg daily up to 2 years)
1st dose pt should sit or lie down (orthostatic hypo)
Refrigerate before and after use
Use new needle w/ each dose
Throw away after 28 days

40
Q

What is Abaloparatide

A

Synthetic analog of human PTH that stimulates bone formation
FDA approved for high risk postmenopausal osteoporosis
-consider antiresorptive Tx to protect against bone loss after d/c abaloparatide

41
Q

What is Denosumab

A

binds to and inhibits RANKL os surface of osteoclast precursor cells and mature osteoclasts
Inhibits osteoclastogenesis
Good for postmenopausal women and chemo induced osteoporosis
Dissipates when d/c
**Give 60 mcg subQ q6 months

42
Q

ADE of Denosumab are

A

back, extremity, and MSK pain

increased cholesterol, cystitis, low serum calcium, skin problems

43
Q

What should be used FIRST vs LAST when treating osteoporosis

A

First line: Alendronate, Risedronate, Zoledronic acid, and Denosumab (decrease vertebral, hip, and other Fx)- second are Ibandronate, raloxifen, and teriparatide
Last resort: Calcitonin

44
Q

What is Vertebroplasty and Kyphoplasty

A

bone cement is injected into fractured vertebral space to alleviate debilitating pain 6-52 weeks s/p vertebral Fx
ADE: cement leakage= nerve damage, Fx around cement

45
Q

What is osteomalacia

A

soft bones; undermineralized adult bones
(same as rickets in kids)
Caused by severe, prolonged VD deficiency (MC), d/o causing hypophosphatemia, and long term anticonvulsants

46
Q

What do osteomalacia patients present with

A

pathologic Fx and/or deep bone pain, proximal muscle weakness; BMD and no other Sx
Extremely low 25 (OH) vitamin D (calcifediol)

47
Q

How do you treat osteomalacia

A
high dose (50,000 units q1 wk for 8 wks) Ergocalciferol (D2) 
When you reach Calcifediol level >30, change to chronic VD maintenance therapy (D2 50,000 q 1-2x month OR OTC D3 1000-2000 units qd)