Osteoporosis Flashcards
Define osteoporosis (OP)
progressive, systemic disease characterized by low bone density, impaired bone architecture, compromised bone strength. Increased fracture risk. 80 percent are women
What are the 3 categories of OP
postmenopausal
Age-Related
Secondary
Postmenipausal OP
decreased estrogen causes accelerated bone loss. Estrogen deficiency increases bone reabsorption more than formation
Age Related OP
occurs in M and F > 70 yoa
M and F lose bone mass as they age
Occurs due to hormone, Ca, Vit D deficiency
Secondary OP
any age; related to drug therapy and other diseases
Patho of OP
Bone loss occurs when bone reabsorption exceeds bone formation
Skeletal growth peaks around 30 yoa
Risk Factors of OP
low bone mineral density low trauma FX as an adult smoking low body weight or BMI age > 3 ETOH drinks day chronic steroid use family history of 1st degree relative
Female white low Ca intake Secondary OP (RA) low physical activity Frail low sun exposure recent falls cognitive impairment estrogen deficient before 45 yoa
Medical conditions associated with OP
ETOH abuse CKD Cushings CF DM Eating disorders Hyperparathyroidism Hyperthyroidism
hypogonadal states organ transplant Skeletal CA- myeloma GI issues- gastrectomy, malabsorption Hemophilia
Drugs associated with OP
Phenytoin Phenobarbital Methotrexate- cytotoxic thyroid supplements ( over replacement ) TPN Lithium
Corticosteriods 5mg>/ prednisone day for 3mos or >
Gonadatroin releasing analog
Heparin
Immunosuppressants - tacrolimus
Glucocorticoids in OP:
Exogenough admin results in n increase in bone resorption , inhibits bone formation, decreases estrogen and testosterone production
risk > with > dose and long term therapy
Most bone loss occurs in the first 6-12 most of initial therapy and continues to decline
Therapy for OP from glucocorticoids
Start pt on biphosphenate:
- when initiation of steroid therapy- 5mg > d x3mos >
Calcitonin is an alternative to biphosphenates
OP clinical presentation
asymptomatic unless fracture occurs
Most common fx: vertebrae, proximal femur, distal radius
height loss > 1.5cm
postural changes bone pain
Screening of OP
F and M >50yoa women with early menopause older adults with fractures medication use associated with bone loss high risk persons
Diagnosis of OP
GS: dexa scan
- Measure of central (hip and spine) bone mineral density
- t-score: comparison of the pt BMD to that of a healthy younger individual, its the number of standard deviations from the mean
- NORMAL: t-score > 1
- OSTEOPENIA: t-score of -1 to -2.4
- OSTEOPOROSIS: t-score of -2.5 or
Non-Rx therapy for OP
smoking cessation, ETOH use reduction, exercise, limiting caffeine and soda intake
Adequate CA and Vit D intake
Treatment with Ca
Increases BMD, fraction prevention is minimal Do not take with high fiber foods Can cause constipation go by % of elemental Ca Take in small doses of 600mg day or < Adult men 1000-1200mg day PM women 1200-1500mg day
Calcium Pearls
Calcium carbonate should be taken with food
Pt on PPI/H2 or elderly can have absorption issues rt to decreased stomach acidity - calcium citrate is better absorbed and it can be taken with or wo food
Calcium Pearls
Calcium carbonate should be taken with food
Pt on PPI/H2 or elderly can have absorption issues rt to decreased stomach acidity - calcium citrate is better absorbed and it can be taken with or wo food
Calcium intake > 2.5g/d should be avoided, can cause toxicity- hypercalcemia, hypercalciuria
VIT D
Maximizes intestinal Ca absorption
Increases BMD and reduces fractures
800-1000 U day for adults
Goal is a 25 (OH) Vit D serum concentration of 30ng.dL or higher
VIT D
Maximizes intestinal Ca absorption Increases BMD and reduces fractures 800-1000 U day for adults MAX dose is 2000 U Goal is a 25 (OH) Vit D serum concentration of 30ng.dL or higher D2- ergocalciferol D-3 Cholecalciferol OTC or Rx
Rx therapy is recommended when
all M and F over age 50 if they meet any of the following criteria:
hx of hip or vertebral fx
T score
Biphosphonates
1st line therapy proven to prevent hip and vertebral fx
Provides greater BMD and fx reduction
Most common Rx of all for OP
Biphosphonates MOA
mimics pyrophosphate
binds to bone matrix- inhibits osteoclast activity, becomes incorporated into the bone
remain in bone extended periods of time- Half like of 10 years
pyrophosphate
endogenous bone reabsorption inhibitor resulting in decreases osteoclast maturation
AE of Biphosphonates
GI: mild NV to severe esophagitis. Dispepsia, ABD pain, reflux, esophagus ulceration
CI of Biphosphonates
Pt with Hx of esophageal abnormalities, gastritis, PUD
caution with pt on NSAIDS
Not recommended for pt with CKD, (GFR <30-35)
Hypocalcemia
Biphosphate administration
poorly absorbed
decreased absorption when taken with food, Fe, Ca
Take in AM with water, swallow whole
sit upright for 30m post admin
IV Biphosphonates
can cause osteonecrosis of jaw, atypical femoral fx with Cancer, chemo, radiation and steriod use
Lab Monitoring: SrCr Alk Phos phosphate Mag Ca
obtain prior to admin of each dose
Biphosphonate Alendronate dosing
Fosomax, Binosto PO prevention 5mg daily or 35mg weekly PM 10mg daily or 70mg weekly Steroid induced 5mg/d for M, 10mg/d for PM not on estrogen therapy Men 10mg/d or 70mg/week $4 for a 70mg tab
Biphosphonate Ibandronate
Boniva
150mg PO monthly
3mg IV every 3 mos
$92 for a 150mg pill
Biphosphonate Risedronate
Actonel, Ateliva
5mg/d or 35mg/w or 150mg/month
Men 35mg/week
$95 for a weekly tab
Biphosphonate Zoledronic Acid
Reclast, Zometa
treatment and steroid induced 5mg once yearly IV >15min
PM 5mg IV every 2 years
SERM
Indicated for preventing and treating OP
AKA mixed estrogen agonist toward the bones/antagonist toward breast and uterus
decreased breast Ca risk
Increases BMD- not as well as Biphosphonates and once stopped, benefits are lost
SERM treatment
Raloxifene/Evista 60mg a day supplement with Ca and Vit D AE: hot flashes, GI, leg cramps, Arthralgia, DVT CI: nursing, preg,potential pregnancy Do not use with hx of VTE
HRT
Estrogen alone or in combo with progesterone- very effected however high risks with long term use
Only use for ST therapy
risk of VTE and breast Ca with use
Calcitonin
nasal spray 200 U/d- alternate nostrils daily
IM or SC- 100U/d
PO- can’t- inactivated by gastric acid
AE rhinitis, rhino ulcerations, GI, rash
Anabolic Agents Teriparatide
Forteo
Recombinant parathyroid hormone
moderate to severe OP
stimulates osteoblastic activity to form new bone when given daily
t-score < -3.5, hx of fractures, or multiple RF failed Biphosphonate therapy
proven reduction of fracture risk in F, approved for M and steroid use but no proven improvement
Teriparatide Dosing
20u daily SC in thigh/abd up to 2 years, must stay refrigerated
AE: hypotension, transient hyperCa, N, HA,
CI: pt at risk for osteosarcoma- black box
$900 per pen
Combo therapy
> BMD
no reduced Fx
Concern with forming brittle bones dt high turnover
not recommended
Pre-M women
use Biphosphonates with caution dt pregnancy risk
no good date on Rx therapy and fx reduction
MEN
only alodrenonte has clinical evidence reducing fx in men
Teriparatide should be an alternative therapy
