Osteoporosis Flashcards
How to make bone
- team of cells work in concert: BRU (bone remodeling unit)
- skeleton regenerated Q10 years
- Osteoclast breaks down bone (esp fatigued, older)
- Osteoblast forms new bone
Definition of osteoporosis
- skeletal disorder characterized by compromised bone strength predisposing person to increased risk of fracture
- *not LESS bone
- most common type of bone dz
What are two components of bone strength
- bone density
- bone quality
What are the sx of osteoporosis?
NONE
until there is a fracture or screening
(advanced cases rarely report bone pain)
How many bones is it ok for an adult to break when falling from standing?
NONE
- Adults should not fracture bone when fall from a standing height
- called a “fragility fracture”
11 Risk factors for osteoporosis
- menopause (F) and low T (M)
- Stasis (confined to bed, wheelchair, inactive)
- Vit D deficiency, low calcium diet
- GI surgery (reduced absorption)
- Hyperparathyroidism, hypogonadism, other endocrine disorders
- Chronic rheumatoid arthritis, chronic kidney disease, eating disorders
- Chronic medication use (antiseizer meds, PO >5 mg steroid use >3 months)
- Fam hx of osteoporosis
- Low BMI
- Smoking/etoh
- Adults treated for breast or prostate cancer (with hormone suppressing drugs)
How many males and females will suffer an osteoporosis related fx in their life?
1/2 F
1/4 M
there are more stats on the slide
What is the harm in osteoporosis ?
- leading cause of morbidity** and mortality in adults
- 25% have to move out of home
- 50% never regain previous function
- 25% die w/in first year after breaking hip
Why is a fracture considered a sentinel event?
Can be the first sign of osteoporosis
- fracture begets fracture (sleep begets sleep in children, FYI)
- Americans who hav ea fx today are 2X more likely to fx again than people who haven’t had a fx
Indications for osteoporosis screening
- Estrogen deficient women at clinical risk for osteoporosis (menopausal, >50)
- Men with risk factors or >70
- To monitor therapy
- M&F >50 with fracture
**anyone >50 with a fx needs to be screened
Three ways to dx osteoporosis
- Fragility fx of spine, forearm, hip (and shoulder but she didn’t say this one in class)
- Bone densitometry (DXA test)
- Direct visualization of bone during sx or bone biopsy
Bone densitometry (DXA) - describe
- non invasive test that can dx osteoporosis or low bone mass
- helps estimate bone density
- stands for dual energy x-ray absoptiometry
- very low radiation exposure
- can also calc total body composition and do orthopedic hip and peds scanning
Bone densitometry (DXA) - what three locations are scanned
- hips
- spine
- distal radius (usually only if can’t do other two)
- try to get as many sites as possible
Bone densitometry (DXA) - who should be tested
- Clinical judgment call… all four expert groups disagree
- Base on fracture risk and skeletal health assessment
- only perform if results will influence patient treatment decisions
- NOF says F >65 M>70
- not usually indicated in children/adolescents or healthy young men or premenopausal women
What should be on the DXA report? (lots)
- demographics
- indications for the test (ex. E deficient, hypogonadal, etc.)
- Manufacturer and model of equipment used (for later test comparisons)
- Quality of study, why region of interest was excluded
- BMD for each site
- T-score and Z-score when appropriate
- WHO criteria for dx
- Fx risk factors
- FRAX
- Recommendations for next study
DXA T-score
- Score is standard deviations from mean (healthy 30 year old adult)
- Use the lowest measured score to classify the patient
DXA Z-score
- describe
- like T-score is reported in units of standard deviation
- “age-matched”: compares BMD to someone similar age and body size
- may be misleading since low BMD can be common in older adults
DXA z-score
- what is considered normal score
- what type of pt more commonly gets a z-score vs. t-score
- > -2.0 is normal
- children, teens, women with a menstrual cycle, younger men
What should always accompany the DXA report
- pictures!
- make sure the regions are aligned, the boxes are in the right places, the outline of bone is around the bone
- make sure spine score is not from a sclerotic or hypertrophic spine or scoliosis
FRAX
- describe
- WHO fracture risk assessment tool
- Uses info about bone density and other risk factors to estimate 10 year fracture risk
- Est risk of breaking hip and risk of overall major bone fx
Who should get a FRAX score (3)
- Post-menopausal women or men >50
- Pt with low bone density (osteopenia)
- People who have NOT taken osteoporosis medication (once take med, invalidates score)
Summary of how to diagnose bone strength
- Bone density: DXA t-score
- Bone quality: ortho surgeon OR hx of fragility fracture
What needs to be ruled out when dx osteoporosis
other metabolic bone dz
- Hyperparathyroidism - PTH and calcium
- Osteomalacia: vit d and alk phos
- Paget’s disease: alk phos
- Renal osteodystrophy - complication of CKD, adynamic bone
Paget’s disease
- body generates new bone faster than normal
- bone is softer and weaker than normal
- bone pain, deformities, fractures
What is future of osteoporosis diagnosis?
- bone turnover markers
- used to dx and monitor tx
MC marker of resorption
C-telopeptide (CTx)
markers of formation
- Bone specific alk phos
- osteocalcin
- Procollagen type-1-n-terminal propeptide
Who gets treated for reduced bone mass
No rules, just guidance
- clinical judgement call
- if osteoporosis - yes treat
- if osteopenia - maybe?
Overview of treatment options
- vitamin D and calcium
- physical activity
- lifestyle mods
- medications
Vitamin D treatment
- required to absorb calcium
- children need to build bones, adults need ti to maintain healthy bones
- Lose VD, lose bone
- Lower VD, lower bone density/mass, more likely to fx
What is a severe vitamin d deficiency called?
- osteomalacia in adults
- rickets in children
Vitamin D daily recommendation
<50: 400-800 IU daily
>50: 800-1000 IU daily
- safe upper limit 4000 IU daily
- sometimes rx higher to quickly boost levels
- rare to have problem associated with too much vitamin D
Three sources of vitamin D
- sunlight
- food: fatty fish, fortified milk, dairy, orange juice, soy milk, cereal
- supplements: D2 and D3
Calcium treatment
- recommended daily intake
- some other notes
- 1000-1500 mg
- not everyone needs a supplement!!
- no benefit but some risks to extra intake
- use a ca calculator
- lack of ca is not the cause of osteoporosis!!
5 general physical activity recommendations
- weight bearing exercise - walk, run, etc. 30 min a day
- Balance and strength training: strong muscles = strong bones
- fall prevention
- stop smoking/etoh
- dont’ be stupid :)
7 Risk factors for falls
- hx of fall
- muscle weakness
- gait/balance abnl
- visual deficits
- dehydration
- dementia
- physical fragility
Physical activity recommendations for pt with osteoporosis or elderly (5)
- avoid excessive forward flexion of spine, bending forward at waist
- Avoid twisting/jerking of spine
- Keep one foot on floor at all times
- Proper posture to limit kyphosis dt vertebral fx
- proper body alignment
Unsafe movements that affect proper alignment
- slumped, head-forward posture
- Bending forward at waist
- twist spine to point of strain
- twist trunk and lean forward while cough/lift
- Overextend body to reach for something high = lost balance
- Exercise that involves waist bending: sit-ups, crunches, toe-touches
physical activity
there is more but this seems kind of obvious…
Moore balance brace
- for weak ankles
- reduces trips and falls
- Fits in pts shoes
- custom
- bilateral
Hip pads
sexy addition to undergarment collection (also protects from fractures
FDA-approved drugs for osteoporosis
- Bisphosphonates
- Calcitonin
- Estrogens
- Estrogen agonist/antagonist
- PTH
- Human monoclonal antibody to RANK-ligand
OR can be classified: - hormone replacement
- anti-resorptive
- anabolic
Hormone replacement therapy
- when to use
- examples
- used sparingly for very specific populations of at risk women
- Premarin, estradiol, suave, vista, vivelle
Hormone replacement therapy
- MoA
- How effective
- slows bone turnover, increases BMD in early and late postmenopausal women
- decreases fragility fx risk by 20-35%
Hormone replacement therapy
- what happens when discontinue
- Acceleration fo bone turnover
- decrease in BMD
- eventual loss of anti-fracture efficacy
Hormone replacement therapy
- overview of precautions, CI, risks
- cardio related issues
- endometrial cancer
- vag bleeding
- ovarian cancer
- breast tenderness
Bishosphonates
- what category of med
- MoA
- anti-resorptive
- potent inhibitor of bone resorption
- inhibits osteoclast activity leading to reduced bone turnover
- bind to bone mineral
- long skeletal retention
Bishosphonates
- what is benefit
- reduce vertebral fx risk and increase BMD
- some studies show reduction in non-vertebral and hip fx risk
Bishosphonates
- what should be monitored prior to initiation
- serum ca
- Cr/renal function
Bishosphonates
- side effects (11)
- hypocalcemia
- abd pain
- bone, joint, muscle pain
- uveitis
- rash
- renal dysfunction
- Afib
- Osteonecrosis of jaw
- Atypical subtrochanteric / femoral shaft fx
- GI issues
- flu-like sx (bone, joint, and/or muscle pain)
Osteonecrosis of the jaw
- bone of lower jaw (sometimes upper jaw) becomes exposed, usually after dental work or jaw trauma
- wound fails to heal in usual time frame
- plan a “drug holiday” prior to dental work and until local healing is complete after procedure
Bishosphonates
- how often dosed?
can be weekly, monthly or yearly
Bishosphonates
- flu like sx
- can occur any time after starting med
- many report relief after stop med but not all
- unknown risk factors
Bishosphonates
- how to take
- empty stomach
- first thing am
- with 8 oz water
- 30 min before eat or drink
- Stay upright during 30 minutes after
- any activity that increases intra-and pressure can cause reflux
Calcitonin
- what pts
- dose
- osteoporosis in women min 5 years into menopause
- single daily intranasal spray. Subq also avail
Calcitonin
- effect
- not stated
- generally safe, might get a nosebleed
PTH
- name two types
- Forteo
- Tymlos
(anabolic)
PTH
- MoA
- effect
- stimulate osteoblast activity and overall bone remodeling
- results in new bone formation
- doubles normal rate of bone formation in osteoporosis pts
PTH
- indications
- W/M with glucocorticoid-induced osteoporosis at high risk of fx
- postmenopausal w with osteoporosis and high risk of fx
- Men with primary or hypogonadal osteoporosis and high risk of fx
What is considered high risk of fx (4)
- previous osteoporotic fx
- multiple risk factors
- low BMD (Score
PTH
- how well tolerated
- time frame
- effect
- Generally well tolerated (osteosarcoma but only in rats)
- Used for max 2 years (often followed with antiresorptive agent)
- Reduced risk vertebral and non vertebral fx
- Increases vertebral, femoral, total body BMD
PTH
- main ADR mentioned in class
- HA
- N
- transient hypercalcemia at initiation of med
Monoclonal antibody med
- name
- MoA
- Denosumab (Prolia)
- blocks binding of RANKL which inhibits development of osteoclasts
- decreases bone resorption
- increase bone density
Monoclonal antibody
- effect
(when given subq twice yearly for 36 months)
- reduction in vertebral, non vertebral, hip fx in F with osteoporosis
What classification of drug is Prolia (Monoclonal antibody )
antiresorptive but NOT a bisphosphonate
Monoclonal antibody
- indication
- postmenopausal women with osteoporosis at high risk for fracture
Monoclonal antibody
- how given
by health professional
Monoclonal antibody
- CI
hypocalcemia
Monoclonal antibody
- ADR, CI
CI - hypocalcemia - weak immune system ADR - rash - osteonecrosis of jaw - usual broken bones/delayed bone healing
What are two combo therapies
- Two anti-resorptive meds (slight improvement
2. one anti-resorptive and one anabolic (best option)
Treatment monitoring therapy
- no medical therapy: re-evaulated for fx risk annually
- no meds: DXA every 1-5 years based on initial risk
- Meds used: re-evaluated for med need annually
- Meds used: DXA every 1-2 years
Max duration of bisphoshonates
3-5 years
When to repeat bone density in one year (3)
- monitor anabolic medication
- new fx suggests worsening bone health
- High risk requires close f/u
When to repeat bone density in two years (2)
- stable on meds
2. osteopenia with low FRAX score, counseled on lifestyle changes
When to repeat bone density in three years or more (1)
- multiple stable DXA scan over 5-10 yr period and low risk
