Osteoporosis Flashcards
How does osteoporosis usually present
Asymptomatic!
or fracture (vertebral is MC, then hip and pelvic)
Can present as loss of height (1.5 inch loss is significant)
Per USPSTF, who should be screened for osteoporosis
B: women 65+
B: women <65 if Fx risk is >65 y/o white woman w/ no additional RF
I: men, insufficient
How is fracture risk determined
FRAX tool
calculates 10 year risk for osteoporotic fractures in women <65
uses 65 y/o woman w/ no RF as baseline
FRAX tool includes
age, sex, weight, height, Hx fracture, Parent hip Fx, current smoking, glucocorticoids, RA, secondary osteoporosis, alcohol 3+x day, Femoral neck bmd
Gold standard for diagnosing osteoporosis is
DEXA scan
determines bone density of lumbar spine and hips
T scores are SD of BMD compared to mean BMD in normal, healthy young people
Severe osteoporosis: < -2.5 with fracture
Osteoporosis: -1
What is the difference between T and Z scores
T: better for diagnosing, and for younger women
Z: compare patients of the same age, esp women >65
What other tests can you get to diagnose osteoporosis
Fragility Fx of spine, hip, wrist, humerus, rib, or pelvis- Fx caused by a height fall
Quantitive US to calcaneus
What labs can you get to support osteoporosis Dx
Chem panel (liver, calcium, phosphorous, albumin, AlkPhos)
25 hydroxyvitamin D
CBC
How do you non-pharm manage osteoporosis
diet avoid corticosteroids tobacco cessation avoid excess alcohol intake exercise fall prevention
How do you pharm manage osteoporosis
vitamin D, calcium bisphosphanates MAB bone modifier- Denosumab PTH analog- Teriparatide SERM- Raloxifene Sex hormone replacement (not is solely for osteoporosis Tx)
How much calcium and vitamin D should you take
D: 600-800 IU/day
D3: 800-2000 U/day to achieve 25-OH D level >20
Calcium: 100mg/day, 1200mg is postmenopausal or M>70
What is the MOA of bisphosphanates
inhibit osteoclast induced bone resorption (bone to blood)
have a long half life so consider drug holiday (10 years)
Indications for bisphosphanates
pathologic spine Fx
low impact hip Fx
FRAX hip Fx risk >3% or major Fx risk >10%
Who should NOT take bisphosphanates
CKD= contraindicated
Oral NOT for pt w/ esophageal d/o, inability to follow dosing instructions, or s/p gastric bypass
Complications of bisphosphanates are
rare: osteonecrosis of jaw, low impact fractures of femoral shaft
Oral ADE: nausea, CP, hoarseness, erosive esophagitis
IV: acute phase response
What are the oral bisphosphanates
Alendronate (fosamax): 1x wk (vertebral and non)
Risendronate: 1x month (vertebral and non)
Ibandronate sodium (boniva): 1x month (vertebral
What are the IV bisphosphanates
Zolendronate (Reclast): IV over 15-30 min 1x yr
What is Denosumab
MAB that inhibits proliferation and maturation of pre-osteoclasts into mature osteoclasts (bone resorpters)
*NOT first line
Admin: subQ q6 months
Indications for Denosumab are
osteoporosis
major fragility Fx
osteopenia w/ high FRAX (m&w)
Pt with high fracture risk on sex hormone suppression therapy
What is Teriparatide
PTH analog that stimulates production of new collagen bone matrix that must be mineralized
Admin: subQ daily x 2 years
*NOT first line
Contraindications and ADE to Teriparatide are
CI: increased risk of osteosarcoma (dont want to build new cancer bone)
ADE: injection rxn, orthostatic hypotension, arthralgia, muscle cramp, depression, PNA, hypercalcemia
SERM’s reduce the risk of
Vertebral fractures
invasive breast cancer
SERM may cause
increased risk of thromboembolisms and hot flashes
What therapies are not recommended to treat osteoporosis
sex hormone replacement (estrogen, testosterone)
Calcitonin: less effective, studies only on vertebral Fx
How often should you repeat a DEXA scan
T -1 to -1.5: every 5 years
T -1.5 to -2: every 3-5 years
T < -2: every 1-2 years (less if pt responds to therapy)
What are bone turnover markers
molecules released from osteoclasts and osteoblasts during bone resorption and formation
Predict rate of bone loss
Helpful only in a few circumstances
What are complications of osteoporosis
Vertebral fractures- MC and usually ASx (if Sx, height loss)
hip Fx
distal radius Fx (Colles)
Osteoporosis related fractures expose you to
premature mortality loss of function and independence reduce QoL chronic pain disability high Tx costs
What are the 6 ACP guidelines as of May 2017
- Alendronate, Risendronate, Zoledronic acid, or Denosumab to reduce risk of hip of vertebral Fx in women w/ osteoporosis
- Treat osteoporotic women w/ Rx x 5 years
- Offer bisphosphanates to reduce vertebral Fx risk in men w/ clinically recognized osteoporosis
- No bone density monitoring during 5 yr Rx period in women
- No HRT or Raloxifen in osteoporotic women
- Decide whether to Tx W 65+ w/ high Fx risk based on pt pref, Fx risk profile, benefits, harms, and costs of medicine
How do you diagnose fibromyalgia
*VERY good H&P! there is no great diagnostic test or biologic factors
So many things are classified with pain, fatigue, and sleep disturbances (thyroid, cancer, stress) so it is hard to Dx, and a diagnosis of exclusion
What is fibromyalgia
soft tissue pain syndrome more common in W 20-50
Chronic Sx
Potential etiologies of fibromyalgia are
stress induced
genetics
altered pain and sensory processing
sleep abnormalities/mood disturbances
History of fibromyalgia will likely show
wide spread MSK pain (neck, shoulders, low back, hips) out of proportion to exertion fatigue cognitive disturbance psych multiple somatic Sx
What will PE of fibromyalgia show
Mainly non-contributory!
Trigger points of pain
RED flags in fibromyalgia are*****
FHx of myopathy Hx cancer unexplained weight loss or fevers joint inflammation (should not be there in fibromyalgia) neurologic abnormalities
Explain how to diagnose fibromyalgia by exclusion (H&P)
Chronic widespread pain in all 4 quadrants of body and axial skeleton
-assess sleep and mood
11 out of 18 tender points (enough pressure to turn finger tip white)
-Must do joint exam
Labs: CBC, ESR, CRP, TSH, CK
OR… can use Widespread pain index or Symptom Severity Scale
Fibromyalgia overlaps with
chronic fatigue syndrome IBS pelvic and bladder pain disorders migraines and tension HA TMJ pain Psych d/o sleep d/o inflammatory rheumatic disease
Non-pharm ways to treat fibromyalgia are
Patient education sleep hygiene CBT Trigger point injection massage therapy chronic manipulation acupuncture/pressure ***EXERCISE***
Pharm way to treat fibromyalgia is
TCA (amitriptyline)
SSRI/SNRI
Anticonvulsants
NO OPIOIDS!!!
