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Primary Care Exam 3 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What is the main theme in regards to osteoporosis care?

A

Prevention!

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2
Q

Define osteoporosis

A
  • Loss of bone mass
  • Loss of bone architecture
  • Susceptibility to fracture
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3
Q

What is the most common bone disease in humans?

A

Osteoporosis

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4
Q

Where are the most common osteoporotic fractures?

A

Hip, vertebrae, and wrist

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5
Q

What is a common reason for loss of height, pain, and kyphosis?

A

Vertebral fracture

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6
Q

What are some of the effects of vertebral fractures?

A
  • Can impact function (bending/reaching)

- Can impact lung/digestive function

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7
Q

What are some psychological sequelae of osteoporosis?

A
  • Anxiety
  • Depression
  • Body image
  • Self-esteem impacts
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8
Q

What are some quality of life sequelae of osteoporosis?

A
  • Chronic pain management

- Disability

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9
Q

What percentage of adult bone mass is acquired in childhood and adolescence?

A

90%

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10
Q

At what age does bone mass peak?

A
  • Age 19 in women

- Age 20.5 in men

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11
Q

At what age does bone mass begin to decline?

A
  • Age 40 in women

- Age 50 in men

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12
Q

When does the most rapid bone loss occur in women?

A

Perimenopause

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13
Q

What causes such a rapid bone loss in women in perimenopause?

A

Drop in estrogen levels

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14
Q

What are some uncontrollable risk factors for osteoporosis?

A
  • Age >50
  • Female
  • Menopause (especially early, before age 45)
  • FH
  • Low body weight/small & thin
  • Caucasian/Asian
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15
Q

What are some controllable risk factors for osteoporosis?

A
  • Lifelong inadequate intake of calcium & vitamin D
  • Not eating enough fruits and veggies
  • Excessive ETOH
  • Smoking
  • Too much protein, Na, and caffeine
  • Lifelong inactive lifestyle
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16
Q

Describe the cortical portion of bones

A
  • Dense, outer covering

- Mechanical strength & protection

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17
Q

Describe the trabecular portion of bones

A
  • “Spongy” bone/mesh-like
  • Inside of long bones (especially at ends), vertebrae, pelvis
  • Offers mechanical support
  • More metabolically active
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18
Q

What are the two continuous processes in bone remodeling?

A

Resorption and formation

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19
Q

How often does the human skeleton regenerate itself?

A

Every 10 years

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20
Q

What is the purpose of bone remodeling?

A
  • Replace worn out or damaged bone

- Ensure oxygen & nutrient supply

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21
Q

What are the 4 phases of bone remodeling and what is involved in each?

A
  1. Resorption (osteoclasts - cells that break down old bone)
  2. Reversal (prepping for deposition of bone - formation of “cement line”)
  3. Formation (osteoblasts - cells that synthesize bone matrix formation)
  4. Mineralization
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22
Q

What is bone reabsorption?

A
  • Resorption of bone tissue by osetoclasts & release of minerals
  • Results in transfer of calcium from bone tissue to the blood
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23
Q

What are osteoclasts?

A

Multi-nucleated cells that contain numerous mitochondria and lysosomes

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24
Q

What are the 3 major players in regulation of bone remodeling?

A
  • PTH
  • Calcitrol (vitamin D)
  • Estrogen
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25
Q

How does PTH maintain serum calcium?

A
  • Stimulating bone resorption
  • Increasing calcium reabsorption in kidneys
  • Increasing calcitrol production in kidneys
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26
Q

How does calcitrol (vitamin D) maintain serum calcium?

A
  • Increases intestinal calcium and phosphorus absorption to provide minerals needed for bones
  • In cases of Ca & Phos deficiency, will stimualte bone resorption to maintain serum levels
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27
Q

How does estrogen maintain serum calcium?

A
  • Inhibits bone resorption
  • Increase in bone resorbing cytokines
  • Can reduce bone formation directly through estrogen receptors on osteoblasts
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28
Q

How does calcitonin play a role in bone remodeling?

A
  • Produced by thyroid gland

- Inhibits osteoclasts/opposes PTH

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29
Q

How does thyroid hormone play a role in bone remodeling?

A

Stimulates both resorption and formation, causing increased turn-over

30
Q

How do glucocorticoids play a role in bone remodeling?

A

Inhibit bone formation

31
Q

What is the primary treatment goal of osteoporosis?

A

Prevention of fractures

32
Q

What does the clinical evaluation for osteoporosis look like?

A
  • PMH: risk factor assessment
  • PE: Height assessment
  • Lab tests as appropriate to look for secondary causes
  • BMD testing with DXA
33
Q

Who should we screen for osteoporosis, according to USPTF?

A
  • Women 65+
  • Women <65 with fracture risk =/> 65+ yo white woman w/o additional risk factors (>9.3%)
  • No recommendation for men w/o previous known fx or secondary causes for osteoporosis
34
Q

Who should we screen for osteoporosis, according to National Osteoporosis Foundation?

A
  • All post-menopausal women 50+ should be evaluated for osteoporotic risk to determine need for BMD testing
  • BMD testing via DXA for women 65+ and men 70+
  • Postmenopausal women & men 50+ who have had an adult age fx to dx & determine degree of osteoporosis
  • Low-trauma fx during adulthood
    & Historical ht loss (current ht is 1.5in+ shorter than peak ht age 20)
    & Prospective ht loss (current ht 0.8in+ shorter previously documented ht)
  • Recent or ongoing long-term glucocorticoid tx - if bone density testing not available, vertebral imaging may be considered based on age alone
  • Check for secondary cause of osteoporosis
35
Q

What are some reasons to screen for bone density before age 65?

A
  • PMH fragility fx
  • Body weight <127lb
  • Medical causes of bone loss, i.e. long-term glucocorticoid use
  • 1st degree relative w/ hx hip fx
  • Current smoker
  • ETOH abuse
  • Rheumatoid arthritis
36
Q

How long does it take for glucocorticoid-induced osteoporosis to cause significant bone loss?

A

3 months

37
Q

How many patients taking >7.5mg/dL of prednisone will fx?

A

50%, regardless of age or gender

38
Q

What is DXA?

A
  • Dual-energy x-ray absorptiometry (DXA)

- Imaging usually done of lumbar spine and hip

39
Q

To what does the T score on a DXA refer?

A

Findings compared to standards for healthy, younger adults of same sex and race

40
Q

To what does the Z score on a DXA refer?

A

of standard deviations from the mean for people of the same sex, age, and race

41
Q

What is the WHO DXA definition of osteoporosis?

A
  • Normal = T score >/= -1
  • Low bone mass = -2.5 to -1
  • Osteoporosis = = -2.5
42
Q

What is FRAX?

A
  • Screening tool developed by WHO
  • Calculates 10-yr probability of hip fx & 10-yr probability of major osteoporotic fx
  • Specific to region & ethnicity
43
Q

What are some uses of FRAX?

A
  • Helpful in decision to tx for those with low bone density but not osteoporosis
  • Helpful in deciding on DXA screen (YES if 10-yr risk >9.3%)
44
Q

When is consideration of Z score helpful?

A

Younger people or when considering secondary osteoporosis

45
Q

In what cohort would you be suspicious of secondary cause?

A

Osteoporotic fx or low Z score in younger post-menopausal women

46
Q

What diagnostic tests would you consider if you are suspicious for secondary cause?

A
  • CBC
  • CMP (including LFTs)
  • 24hr urinary calcium level
  • 25-hydroxyvitamin D level
  • TSH
    Consider: PTH, celiac panel, serum protein electrophoresis, total testosterone/gonadatropin in younger men
47
Q

Who do we treat pharmacologically?

A

Post-menopausal women/men age 50+ with

  • Hip/vertebral fx (clinically or on imaging)
  • T score = -2.5 at femoral neck,hip, or lumbar spine
  • Low bone mass (-1.0 > T > -2.5) and 10-yr probability of hip fx 3% or greater or major osteoporosis-related fx 20% or greater based on US FRAX algorithm
48
Q

How often should we rescreen with DXA?

A

q2yr after intiiation of tx and then not after if stable/improved

For women 65+ who are not tx:

  • 10yr interval if T-score >-1.5
  • 5yr interval if T-score -1.5 to -1.99
  • 1-2yr interval if T-score -2.0 to -2.49
49
Q

Diagnostic classification based on T-score

A
  • Normal: >-1.0
  • Osteopenia (low bone mass): -1.0 to -2.5
  • Osteoporosis:
50
Q

Indications for tx

A
  • Personal hx of hip or vertebral fx
  • T-score 3%)
  • Risk of any major fx of 20% (FRAX)
51
Q

Non-pharmacological interventions for low bone density/osteoporosis

A
  • Adequate calcium & vitamin D
  • Tx vitamin D deficiency
  • Regualr weight-bearing/muscle-strengthening exercise
  • Fall prevention
  • Tobacco cessation
  • Tx ETOH abuse
52
Q

Calcium requirements for women and men

A
  • Women <50: 1,000mg/day
  • Men <70: 50-70mg/day
  • Women 51+/Men 71+: 1,200mg/day
53
Q

Vitamin D requirements

A

800-1,000 IU/day

54
Q

Foods high in dairy

A
  • Calcium
  • Dark, leafy greens
  • Canned sardines and salmon
  • Fortified foods
55
Q

Foods high in vitamin D

A
  • Dairy (if fortified)
  • Salt-water fish: salmon, mackerel, tuna, sardines
  • Liver
  • Fortified foods
56
Q

What is diagnosable vitamin D deficiency & what is the vitamin D goal?

A
  • Deficiency: <20ng/mL

- Goal: >30ng/mL

57
Q

Treatment for vitamin D deficiency

A
  • 50,000 IU D2 or D3 PO weekly (or 6,000 IU daily) for 8-12 weeks
  • 1,500-2,000 IU/day maintenance
58
Q

How do you address fall risk in patients at risk for osteoporotic fx?

A
  • Correct vision, home eval for environmental risks

- Referral for PT/OT for assistive devices (walkers/canes) and balance training/muscle strengthening

59
Q

What are the goals of osteoporosis tx?

A
  • Prevent fx by maintaining bone strength & reducing falls/trauma to bones
  • Stable/increase bone mass
  • Promote wellness
  • Avoid disability
  • Reduce suffering
  • Tolerability of tx
60
Q

What are some FDA-approved pharmacologic options for osteoporosis?

A
  • Bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid), which inhibit osteoclast activity & decrease bone resorption
  • Calcitonin - decrease bone resorption
  • Estrogen agonist/antagonist (raloxifene)
  • Estrogens and/or hormone therapy, tissue-selective estrogen complex (conjugated estrogens/bazedoxifene)
  • Parathyroid hormone 1-34 (teriparatide) - daily injections used with PM women with prior fractures
  • Denosumab - inhibits RANK ligand (modulator of osetoclast activity)
61
Q

What is the class, MOA, dosing, and side effects of Fosomax (alendronate)?

A
  • Class: bisphosphonate
  • MOA: specific inhibitor of osteoclast mediated bone resorption
  • Dosing:
    Therapeutic=10mg/day or 70mg/wk
    Prevention=5mg/day or 35mg/wk
  • Alendronate + cholecalciferol (vit D3):
    70mg + 2,800 or 5,600 IU vit D once/wk
  • Side effects: esophageal sx, MS aches, HA
62
Q

What is the class, MOA, dosing, pt instructions and side effects of Actonel, Atlevia (risedronate)?

A
  • Class: bisphosphonate
  • MOA: specific inhibitor of osteoclast mediated bone resorption
  • Dosing (therapeutic/prevention):
    5mg/day or 35mg/wk or 150mg/mo
  • Actonel + calcium: 35mg (4 tabs) + 500mg calcium carbonate (24 tabs)
  • Can be taken after breakfast *
  • Side effects: esophageal sx, MS aches, HA
63
Q

What is the dosing and pt instructions of Boniva (ibandronate)?

A
  • Daily dose: 2.5 mg
  • Monthly dose: 150mg
  • Wait 60 min before eating, drinking, or lying down *
64
Q

Instructions and side effects for bisphosphonates

A
  • If PO, must be taken 1st thing in AM w/ 8oz water, wait 30min (alendronate/Fosamax and risendronate/Actonal/Atlevia) to 60 min (ibandronate/Boniva) before eating and be upright 30 min (alend/risend) to 60 min (iband) after taking
  • SE: GI & esophageal sx
  • Contraindicated w/ GFR <30-35
  • Rare reports of osteonecrosis of jaw, femur fx
65
Q

What is the MOA, dosing, pt instructions and side effects of Miacalcin or Fortical (calcitonin)?

A
  • Regulates plasma calcium
  • Decreases bone resorption/helps decrease bone pain
  • Dose: 200U/spray once in nostril daily
  • Miacalcin: 200U/mL 100 units SC or IM every other day
  • Adverse rx: rhinitis, GI upset, flushing, rash (inj)
  • Not indicated for prophylactic dosing
66
Q

What is the class, MOA, dosing, and side effects of Evista (raloxifene)?

A
  • SERM - Selective Estrogen Receptor Modulator
  • May reduce risk of breast cancer
  • Less likely than tamoxifen to lead to uterine cancer, hysterectomy, or cataracts
  • Therapeutic/prophylactic dose: 60mg/day
  • Adverse rxn: hot flashes, increased risk blood clots
67
Q

What is the class, MOA, dosing, pt instructions and side effects of Forteo (teriparatide)?

A
  • Human parathyroid hormone
  • Anabolic: increases bone remodeling & increases skeletal mass & bone strength
  • Hx osteoporotic fx/multiple risk factors for fx/failed or intolerant to osteoporosis tx
  • Dosing: 20mcg SC once daily into thigh/abd wall
  • May tx for up to 2 years
  • Adverse rxn: dizziness, leg cramps, hypercalcemia, hyperuricemia, inj site rxn
68
Q

What are other options for bisphosphonates?

A

Boniva (IV):

  • Administered every 3mo
  • 15sec injection w/ butterfly needle
  • Can be obtained at OBGYN/Rheum & Endocrine

Reclast

  • Indicated for elderly
  • Reduces risk of second fracture
  • Given IV 5mg once a month
69
Q

What is Prolia and what does it do?

A
  • RANK ligand inhibitor

- Inhibits formation, function, & survival of osteoclasts

70
Q

What are some less widely used medications?

A
  • Hormone therapy: NOT typically initiated for sole tx of osteoporosis
  • If initiated for perimenopausal sx, does have benefits for bone density*
  • Raloxifene/tamoxifen
71
Q

What are some considerations in regards to tx duration?

A
  • Consider benefits
  • Consider specific tx
  • Evidence of efficacy beyond 5yr limited
  • Risk of ONJ & atypical femur fx increases after 5yr w/ bisphosphonates
  • If modest, tx 3-5yr
  • If still high risk after this duration, consider continuation/change to alternative tx

Primary Care Exam 3 (4 decks)

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