Osteoporosis Flashcards
What is the most common bone disorder in the US?
Osteoporosis
- 8 million women
- 2 million men
How is osteoporosis defined?
A reduction in bone strength that leads to increased fracture risk
Why is osteoporosis considered a silent disease?
Patients are often asymptomatic until a fracture occurs
What are signs and symptoms of osteoporosis if they do occur?
Fracture related -pain -lack of mobility -depressed mood due to physical limitations -decreased height —greater than 1.5 inch loss -rounding of the spine
What does osteoporosis result from?
Imbalance in bone remodeling
-osteoclast activity (bone resorption) exceeds osteoblast activity (bone formation)
—causes decreased bone mineral density (BMD)
When does the imbalance in bone modeling occur?
A normal age related process
- begins around age 30
- for women: becomes more apparent after menopause
What are important ways to develop and maintain adequate BMD?
- physical activity
- adequate vitamin D and calcium intake
What are other factors that can contribute to low BMD or osteoporotic fracture?
-low body weight
-premature menopause
-chronic disease
-smoking
-alcohol use
—3 or more drinks per day
-medications
—corticosteroids
How is osteoporosis diagnosed clinically?
Presence of a fracture without major trauma
-known as a fragility fracture
What scan is used to diagnose osteoporosis based on BMD?
-DXA
—dual energy x-ray absorptiometry
—measures bone density at the hip and spine
What does the DXA report include?
- actual bone density
- T score
- Z score
What is the T score?
- used for diagnosis
- compares the patient’s bone density to the peak bone density of a healthy 20-29 year old adult
- is the number of standard deviations from the mean reference population
What is the Z score?
Compares the patient’s bone density to that of an individual of the same:
- age
- sex
- ethnic background
When are Z scores used?
To help diagnose osteoporosis in:
- men younger than age 50
- children
- premenopausal women
What organization has defined bone density levels?
The World Health Organization (WHO)
What tool calculates the estimated risk of fracture based on BMD and individual patient factors, developed by the WHO?
The Fracture Risk Assessment Tool (FRAX)
How can the incidence of osteoporosis be reduced?
- by optimizing skeletal development and peak bone mass early in life
- prevention of age related and secondary causes of bone loss
What are the goals once osteoporosis develops?
- prevent fractures
- stabilize the skeletal system
- improve strength and bone mass
What organizations provide recommendations for the prevention and management of osteoporosis using both lifestyle modifications and pharmacologic therapies?
- American Academy of Clinical Endocrinologists (AACE)
- American College of Rheumatology (ACR)
- National Osteoporosis Foundation (NOF)
What organizations provide additional guidelines that focus on the pharmacologic treatment of osteoporosis?
- Endocrine Society
- American Society for Bone and Mineral Research (ASBMR)
- American College of Physicians
What can reduce the risk of fractures?
-maintenance of a bone healthy lifestyle
What is adequate calcium intake essential for?
- development of bone mass during childhood
- maintenance of bone mass throughout life
How should calcium be primarily obtained?
Through a patient’s diet
When is calcium supplementation recommended?
When dietary intake is inadequate?
What are calcium intake recommendations based on?
Amount of elemental calcium in each product?
How much elemental calcium is in calcium carbonate?
40% elemental calcium
-1250mg contains 500mg of elemental calcium
When is pharmacologic treatment recommended for osteoporosis?
-postmenopausal women or men who are at least 50 years of age with:
—T scores less than 2.5 in the:
—
What determines the choice of pharmacologic therapy for osteoporosis?
Based on anti-fracture benefits demonstrated in clinical studies
What are first line agents recommended by the AACE for osteoporosis?
- alendronate
- risedronate
- zoledronic acid
- denosumab
What agents are recommended for patients at low or moderate risk of fractures?
Oral agents
For which patients are injectable medications preferred as initial therapy for osteoporosis?
- very high fracture risk
- GI concerns
- difficulty remembering or adhering to a medication schedule
What do the 2019 guidelines from the Endocrine society recommend as first line therapy in postmenopausal women at high risk of fractures?
Bisphosphonates
Which bisphosphonate is not recommended by the Endocrine Society and for which patients?
Ibandronate
-not recommended to reduce:
—nonvertebral fractures
—hip fractures
When is denosumab recommended?
Alternative initial treatment
When are parathyroid hormone analogs (teriparatide and abaloparatide) recommended?
Reserved for postmenopausal women at very high risk of fracture?
When are the selective estrogen receptor modulators (raloxifene and bazedoxifene) recommended?
Can be used in patients who have a low risk of thromboembolism
—when bisphosphonates or denosumab are inappropriate
-reduce the risk of vertebral fractures
When is calcitonin recommended?
Last line agent
-recommended only in patients who do not tolerate any other therapy
When is romosozumab recommended?
Not yet addressed in clinical practice guidelines
What is one of the most significant adverse effects of glucocorticoid therapy?
Osteoporosis
Who published guidelines in 2017 for the prevention and treatment of osteoporosis in patients who are treated with glucocorticoids?
ACR
Describe the 2017 ACR guidelines for osteoporosis related to glucocorticoids.
-all patients practice a bone healthy lifestyle
-optimize calcium and vitamin D
-specific pharmacologic agents recommended based on age and risk factors
-oral bisphosphonate recommended for patients:
—at least 40 years of age with:
—
What is an important consideration with bisphosphonate therapy?
Duration of therapy to:
- maximize benefits
- minimize adverse effects
How long is bisphosphonate therapy recommended to be continued in patients at high risk of fractures?
- oral therapy for up to 10 years
- IV therapy for up to 6 years
How long is bisphosphonate therapy recommended to be continued in patients at lower risk of fractures?
Initially, 3 to 5 years
-then drug holiday for 2 or 3 years
How is oral bisphosphonate therapy administered?
NOT at the same time as food or other medications
What are the dosing instructions for the administration of bisphosphonates?
-first thing in the morning
-on an empty stomach
-with 6 to 8 ounces of plain (not mineral) water
-do NOT eat or drink (except water) and remain upright for at least 30 minutes
—60 minutes with ibandronate
Coadministration with what drugs may increase the risk of GI effects with bisphosphonates?
- aspirin
- NSAIDs
Which osteoporosis medication is highly protein bound?
Raloxifene
-caution when coadministering with other highly protein bound drugs
What drug interaction with Raloxifene must be closely monitored?
Warfarin
-can decrease the prothrombin time by 10%
Describe the drug interaction potential of denosumab.
Minimal drug interactions
-may enhance the adverse effects of immunosuppressant medications
—
Describe the drug interaction potential of teriparatide.
Digoxin
-risk of hypercalcemia due to teriparatide may cause toxicity in patients taking Digoxin
Describe the drug interaction potential of abaloparatide or romosozumab.
No known drug interactions
What are the Focus Points for MTM in osteoporosis?
-goals of treatment are to:
—prevent loss of BMD
—
