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Summer FDTN Exam 4 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

How does osteoporosis usually present

A

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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2
Q

Per USPSTF, who should be screened for osteoporosis

A

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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3
Q

How is fracture risk determined

A

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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4
Q

FRAX tool includes

A

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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5
Q

Gold standard for diagnosing osteoporosis is

A

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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6
Q

What is the difference between T and Z scores

A

T: better for diagnosing, and for younger women
Z: compare patients of the same age, esp women >65

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7
Q

What other tests can you get to diagnose osteoporosis

A

Fragility Fx of spine, hip, wrist, humerus, rib, or pelvis- Fx caused by a height fall
Quantitive US to calcaneus

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8
Q

What labs can you get to support osteoporosis Dx

A

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

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9
Q

How do you non-pharm manage osteoporosis

A 
diet 
avoid corticosteroids 
tobacco cessation
avoid excess alcohol intake 
exercise 
fall prevention
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10
Q

How do you pharm manage osteoporosis

A 
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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11
Q

How much calcium and vitamin D should you take

A

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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12
Q

What is the MOA of bisphosphanates

A

inhibit osteoclast induced bone resorption (bone to blood)

have a long half life so consider drug holiday (10 years)

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13
Q

Indications for bisphosphanates

A

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

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14
Q

Who should NOT take bisphosphanates

A

CKD= contraindicated

Oral NOT for pt w/ esophageal d/o, inability to follow dosing instructions, or s/p gastric bypass

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15
Q

Complications of bisphosphanates are

A

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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16
Q

What are the oral bisphosphanates

A

Alendronate (fosamax): 1x wk (vertebral and non)
Risendronate: 1x month (vertebral and non)
Ibandronate sodium (boniva): 1x month (vertebral

17
Q

What are the IV bisphosphanates

A

Zolendronate (Reclast): IV over 15-30 min 1x yr

18
Q

What is Denosumab

A

MAB that inhibits proliferation and maturation of pre-osteoclasts into mature osteoclasts (bone resorpters)
*NOT first line
Admin: subQ q6 months

19
Q

Indications for Denosumab are

A

osteoporosis
major fragility Fx
osteopenia w/ high FRAX (m&w)
Pt with high fracture risk on sex hormone suppression therapy

20
Q

What is Teriparatide

A

PTH analog that stimulates production of new collagen bone matrix that must be mineralized
Admin: subQ daily x 2 years
*NOT first line

21
Q

Contraindications and ADE to Teriparatide are

A

CI: increased risk of osteosarcoma (dont want to build new cancer bone)
ADE: injection rxn, orthostatic hypotension, arthralgia, muscle cramp, depression, PNA, hypercalcemia

22
Q

SERM’s reduce the risk of

A

Vertebral fractures

invasive breast cancer

23
Q

SERM may cause

A

increased risk of thromboembolisms and hot flashes

24
Q

What therapies are not recommended to treat osteoporosis

A

sex hormone replacement (estrogen, testosterone)

Calcitonin: less effective, studies only on vertebral Fx

25
Q

How often should you repeat a DEXA scan

A

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)

26
Q

What are bone turnover markers

A

molecules released from osteoclasts and osteoblasts during bone resorption and formation
Predict rate of bone loss
Helpful only in a few circumstances

27
Q

What are complications of osteoporosis

A

Vertebral fractures- MC and usually ASx (if Sx, height loss)
hip Fx
distal radius Fx (Colles)

28
Q

Osteoporosis related fractures expose you to

A 
premature mortality 
loss of function and independence 
reduce QoL 
chronic pain 
disability 
high Tx costs
29
Q

What are the 6 ACP guidelines as of May 2017

A
  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
30
Q

How do you diagnose fibromyalgia

A

*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

31
Q

What is fibromyalgia

A

soft tissue pain syndrome more common in W 20-50

Chronic Sx

32
Q

Potential etiologies of fibromyalgia are

A

stress induced
genetics
altered pain and sensory processing
sleep abnormalities/mood disturbances

33
Q

History of fibromyalgia will likely show

A 
wide spread MSK pain (neck, shoulders, low back, hips) out of proportion to exertion 
fatigue 
cognitive disturbance 
psych 
multiple somatic Sx
34
Q

What will PE of fibromyalgia show

A

Mainly non-contributory!

Trigger points of pain

35
Q

RED flags in fibromyalgia are*****

A 
FHx of myopathy 
Hx cancer 
unexplained weight loss or fevers 
joint inflammation (should not be there in fibromyalgia) 
neurologic abnormalities
36
Q

Explain how to diagnose fibromyalgia by exclusion (H&P)

A

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

37
Q

Fibromyalgia overlaps with

A 
chronic fatigue syndrome 
IBS
pelvic and bladder pain disorders 
migraines and tension HA 
TMJ pain 
Psych d/o 
sleep d/o
inflammatory rheumatic disease
38
Q

Non-pharm ways to treat fibromyalgia are

A 
Patient education 
sleep hygiene 
CBT
Trigger point injection 
massage therapy 
chronic manipulation 
acupuncture/pressure 
***EXERCISE***
39
Q

Pharm way to treat fibromyalgia is

A

TCA (amitriptyline)
SSRI/SNRI
Anticonvulsants
NO OPIOIDS!!!

Summer FDTN Exam 4 (14 decks)

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