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Women's Health 1 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

How to make bone

A
  • 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
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2
Q

Definition of osteoporosis

A
  • skeletal disorder characterized by compromised bone strength predisposing person to increased risk of fracture
  • *not LESS bone
  • most common type of bone dz
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3
Q

What are two components of bone strength

A
  • bone density

- bone quality

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4
Q

What are the sx of osteoporosis?

A

NONE
until there is a fracture or screening
(advanced cases rarely report bone pain)

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5
Q

How many bones is it ok for an adult to break when falling from standing?

A

NONE

  • Adults should not fracture bone when fall from a standing height
  • called a “fragility fracture”
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6
Q

11 Risk factors for osteoporosis

A
  1. menopause (F) and low T (M)
  2. Stasis (confined to bed, wheelchair, inactive)
  3. Vit D deficiency, low calcium diet
  4. GI surgery (reduced absorption)
  5. Hyperparathyroidism, hypogonadism, other endocrine disorders
  6. Chronic rheumatoid arthritis, chronic kidney disease, eating disorders
  7. Chronic medication use (antiseizer meds, PO >5 mg steroid use >3 months)
  8. Fam hx of osteoporosis
  9. Low BMI
  10. Smoking/etoh
  11. Adults treated for breast or prostate cancer (with hormone suppressing drugs)
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7
Q

How many males and females will suffer an osteoporosis related fx in their life?

A

1/2 F
1/4 M

there are more stats on the slide

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8
Q

What is the harm in osteoporosis ?

A
  • 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
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9
Q

Why is a fracture considered a sentinel event?

A

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
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10
Q

Indications for osteoporosis screening

A
  • 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

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11
Q

Three ways to dx osteoporosis

A
  1. Fragility fx of spine, forearm, hip (and shoulder but she didn’t say this one in class)
  2. Bone densitometry (DXA test)
  3. Direct visualization of bone during sx or bone biopsy
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12
Q 
Bone densitometry (DXA)
- describe
A
  • 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
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13
Q 
Bone densitometry (DXA)
- what three locations are scanned
A
  • hips
  • spine
  • distal radius (usually only if can’t do other two)
  • try to get as many sites as possible
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14
Q 
Bone densitometry (DXA)
- who should be tested
A
  • 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
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15
Q

What should be on the DXA report? (lots)

A
  • 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
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16
Q

DXA T-score

A
  • Score is standard deviations from mean (healthy 30 year old adult)
  • Use the lowest measured score to classify the patient
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17
Q

DXA Z-score

- describe

A
  • 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
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18
Q

DXA z-score

  • what is considered normal score
  • what type of pt more commonly gets a z-score vs. t-score
A
  • > -2.0 is normal

- children, teens, women with a menstrual cycle, younger men

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19
Q

What should always accompany the DXA report

A
  • 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
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20
Q

FRAX

- describe

A
  • 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
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21
Q

Who should get a FRAX score (3)

A
  1. Post-menopausal women or men >50
  2. Pt with low bone density (osteopenia)
  3. People who have NOT taken osteoporosis medication (once take med, invalidates score)
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22
Q

Summary of how to diagnose bone strength

A
  • Bone density: DXA t-score

- Bone quality: ortho surgeon OR hx of fragility fracture

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23
Q

What needs to be ruled out when dx osteoporosis

A

other metabolic bone dz

  1. Hyperparathyroidism - PTH and calcium
  2. Osteomalacia: vit d and alk phos
  3. Paget’s disease: alk phos
  4. Renal osteodystrophy - complication of CKD, adynamic bone
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24
Q

Paget’s disease

A
  • body generates new bone faster than normal
  • bone is softer and weaker than normal
  • bone pain, deformities, fractures
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25
Q

What is future of osteoporosis diagnosis?

A
  • bone turnover markers

- used to dx and monitor tx

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26
Q

MC marker of resorption

A

C-telopeptide (CTx)

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27
Q

markers of formation

A
  1. Bone specific alk phos
  2. osteocalcin
  3. Procollagen type-1-n-terminal propeptide
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28
Q

Who gets treated for reduced bone mass

A

No rules, just guidance

  • clinical judgement call
  • if osteoporosis - yes treat
  • if osteopenia - maybe?
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29
Q

Overview of treatment options

A
  1. vitamin D and calcium
  2. physical activity
  3. lifestyle mods
  4. medications
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30
Q

Vitamin D treatment

A
  • 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
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31
Q

What is a severe vitamin d deficiency called?

A
  • osteomalacia in adults

- rickets in children

32
Q

Vitamin D daily recommendation

A

<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
33
Q

Three sources of vitamin D

A
  1. sunlight
  2. food: fatty fish, fortified milk, dairy, orange juice, soy milk, cereal
  3. supplements: D2 and D3
34
Q

Calcium treatment

  • recommended daily intake
  • some other notes
A
  • 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!!
35
Q

5 general physical activity recommendations

A
  1. weight bearing exercise - walk, run, etc. 30 min a day
  2. Balance and strength training: strong muscles = strong bones
  3. fall prevention
  4. stop smoking/etoh
  5. dont’ be stupid :)
36
Q

7 Risk factors for falls

A
  1. hx of fall
  2. muscle weakness
  3. gait/balance abnl
  4. visual deficits
  5. dehydration
  6. dementia
  7. physical fragility
37
Q

Physical activity recommendations for pt with osteoporosis or elderly (5)

A
  1. avoid excessive forward flexion of spine, bending forward at waist
  2. Avoid twisting/jerking of spine
  3. Keep one foot on floor at all times
  4. Proper posture to limit kyphosis dt vertebral fx
  5. proper body alignment
38
Q

Unsafe movements that affect proper alignment

A
  1. slumped, head-forward posture
  2. Bending forward at waist
  3. twist spine to point of strain
  4. twist trunk and lean forward while cough/lift
  5. Overextend body to reach for something high = lost balance
  6. Exercise that involves waist bending: sit-ups, crunches, toe-touches
39
Q

physical activity

A

there is more but this seems kind of obvious…

40
Q

Moore balance brace

A
  • for weak ankles
  • reduces trips and falls
  • Fits in pts shoes
  • custom
  • bilateral
41
Q

Hip pads

A

sexy addition to undergarment collection (also protects from fractures

42
Q

FDA-approved drugs for osteoporosis

A
  1. Bisphosphonates
  2. Calcitonin
  3. Estrogens
  4. Estrogen agonist/antagonist
  5. PTH
  6. Human monoclonal antibody to RANK-ligand
    OR can be classified:
  7. hormone replacement
  8. anti-resorptive
  9. anabolic
43
Q

Hormone replacement therapy

  • when to use
  • examples
A
  • used sparingly for very specific populations of at risk women
  • Premarin, estradiol, suave, vista, vivelle
44
Q

Hormone replacement therapy

  • MoA
  • How effective
A
  • slows bone turnover, increases BMD in early and late postmenopausal women
  • decreases fragility fx risk by 20-35%
45
Q

Hormone replacement therapy

- what happens when discontinue

A
  • Acceleration fo bone turnover
  • decrease in BMD
  • eventual loss of anti-fracture efficacy
46
Q

Hormone replacement therapy

- overview of precautions, CI, risks

A
  • cardio related issues
  • endometrial cancer
  • vag bleeding
  • ovarian cancer
  • breast tenderness
47
Q

Bishosphonates

  • what category of med
  • MoA
A
  • anti-resorptive
  • potent inhibitor of bone resorption
  • inhibits osteoclast activity leading to reduced bone turnover
  • bind to bone mineral
  • long skeletal retention
48
Q

Bishosphonates

- what is benefit

A
  • reduce vertebral fx risk and increase BMD

- some studies show reduction in non-vertebral and hip fx risk

49
Q

Bishosphonates

- what should be monitored prior to initiation

A
  • serum ca

- Cr/renal function

50
Q

Bishosphonates

- side effects (11)

A
  • 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)
51
Q

Osteonecrosis of the jaw

A
  • 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
52
Q

Bishosphonates

- how often dosed?

A

can be weekly, monthly or yearly

53
Q

Bishosphonates

- flu like sx

A
  • can occur any time after starting med
  • many report relief after stop med but not all
  • unknown risk factors
54
Q

Bishosphonates

- how to take

A
  • 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
55
Q

Calcitonin

  • what pts
  • dose
A
  • osteoporosis in women min 5 years into menopause

- single daily intranasal spray. Subq also avail

56
Q

Calcitonin

- effect

A
  • not stated

- generally safe, might get a nosebleed

57
Q

PTH

- name two types

A
  • Forteo
  • Tymlos

(anabolic)

58
Q

PTH

  • MoA
  • effect
A
  • stimulate osteoblast activity and overall bone remodeling
  • results in new bone formation
  • doubles normal rate of bone formation in osteoporosis pts
59
Q

PTH

- indications

A
  1. W/M with glucocorticoid-induced osteoporosis at high risk of fx
  2. postmenopausal w with osteoporosis and high risk of fx
  3. Men with primary or hypogonadal osteoporosis and high risk of fx
60
Q

What is considered high risk of fx (4)

A
  • previous osteoporotic fx
  • multiple risk factors
  • low BMD (Score
61
Q

PTH

  • how well tolerated
  • time frame
  • effect
A
  • 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
62
Q

PTH

- main ADR mentioned in class

A
  • HA
  • N
  • transient hypercalcemia at initiation of med
63
Q

Monoclonal antibody med

  • name
  • MoA
A
  • Denosumab (Prolia)
  • blocks binding of RANKL which inhibits development of osteoclasts
  • decreases bone resorption
  • increase bone density
64
Q

Monoclonal antibody

- effect

A

(when given subq twice yearly for 36 months)

- reduction in vertebral, non vertebral, hip fx in F with osteoporosis

65
Q

What classification of drug is Prolia (Monoclonal antibody )

A

antiresorptive but NOT a bisphosphonate

66
Q

Monoclonal antibody

- indication

A
  • postmenopausal women with osteoporosis at high risk for fracture
67
Q

Monoclonal antibody

- how given

A

by health professional

68
Q

Monoclonal antibody

- CI

A

hypocalcemia

69
Q

Monoclonal antibody

- ADR, CI

A 
CI
- hypocalcemia
- weak immune system
ADR
- rash
- osteonecrosis of jaw
- usual broken bones/delayed bone healing
70
Q

What are two combo therapies

A
  1. Two anti-resorptive meds (slight improvement

2. one anti-resorptive and one anabolic (best option)

71
Q

Treatment monitoring therapy

A
  • 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
72
Q

Max duration of bisphoshonates

A

3-5 years

73
Q

When to repeat bone density in one year (3)

A
  1. monitor anabolic medication
  2. new fx suggests worsening bone health
  3. High risk requires close f/u
74
Q

When to repeat bone density in two years (2)

A
  1. stable on meds

2. osteopenia with low FRAX score, counseled on lifestyle changes

75
Q

When to repeat bone density in three years or more (1)

A
  • multiple stable DXA scan over 5-10 yr period and low risk

Women's Health 1 (17 decks)

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