Osteoporosis Flashcards by Nayla Mansoor

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)

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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

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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

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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

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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

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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

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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

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What labs can you get to support osteoporosis Dx

Chem panel (liver, calcium, phosphorous, albumin, AlkPhos)
25 hydroxyvitamin D
CBC

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How do you non-pharm manage osteoporosis

diet 
avoid corticosteroids 
tobacco cessation
avoid excess alcohol intake 
exercise 
fall prevention

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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)

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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

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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)

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Indications for bisphosphanates

pathologic spine Fx
low impact hip Fx
FRAX hip Fx risk >3% or major Fx risk >10%

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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

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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

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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

1. Alendronate, Risendronate, Zoledronic acid, or Denosumab to reduce risk of hip of vertebral Fx in women w/ osteoporosis 2. Treat osteoporotic women w/ Rx x 5 years 3. Offer bisphosphanates to reduce vertebral Fx risk in men w/ clinically recognized osteoporosis 4. No bone density monitoring during 5 yr Rx period in women 5. No HRT or Raloxifen in osteoporotic women 6. 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!!!*