Osteoporosis Flashcards
Non modifiable risk factors for Osteoporosis
advanced age
post menopausal
low body weight
white or asian ethnicity
malabsorption dx
hypercortisolism or hyperthyroidism or hyperparathyroidism
inflammatory disorders (RA)
chronic liver
renal dx
Modifiable risk factors for osteoporosis
smoking,
excessive alcohol intake,
sedentary lifestyle
medications (steroids, anticonvulsants),
vitamin D deficiency or low Ca intake,
estrogen deficiency (premature menopause, hysterectomy/oophorectomy)
When to start screening women?
>65 years <65 yrs if +1 or more risk factors
When to start screening men?
>70 years
how often to repeat testing?
q2 yrs
What medications cause osteoporosis?
steroids,
phenytoin, carbamazepine,
PPI,
anastrazole and leuprolide
What other misc diseases or conditions cause osteoporosis?
RA and other inflammatory dx
Multiple myeloma
alcoholism
immobilization,
CKD and RTA
What GI disorders cause osteoporosis?
Celiac dx and Crohn’s dx,
chronic liver dx
eating disorders
What endocrine disorders cause secondary osteoporosis?
hyperthyroidism,
hyperparathyroidism
hypercortisolism
hypo- gonadism -low estrogen or low testosterone
When to screen in pts younger than 65 yrs?
fracture after low impact trauma,
long term glucocorticoid (>7.5 mg for >3 months)
low body weight.
What T score shows osteoporosis?
< -2.5 at any location is osteoporosis
When to order a 24 hr urinary calcium excretion test?
only after correction of vitamin D deficiency and have adequate Ca (1000-2000 mg/day) for 2 weeks prior to test.
Order if suspecting inadequate absorption of Ca and has hx of malabsorption disorders
When to order spiral imaging (lateral spine XR) to look for possible vertebral fracture
pts with low bone density who are likely to have a vertebral fx
(F>70 or M>80),
loss of height >4 cm,
self reported vertebral fx
systemic steroids >3 months
when diagnosed with osteoporosis you need to:
Check for secondary causes
if after two years of osteoporosis and repeat DEXA shows BMD <5% what do you do
Continue oral bisophosphonate and repeat DEXA in 2 yrs
if after two years of osteoporosis and repeat DEXA shows BMD>5% what do you do?
consider IV bisophosphonate or teriparatide, or denosumab
If pt has a fragility fracture while on treatment for osteoporosis?
Consider treatment of teriparatide or denosumab
must make sure you rule out secondary causes for osteoporosis.
Severe osteoporosis is defined as:
T score
How to treat severe osteoporosis
consider teriparatide for 3 years then bisphosphonate can’t keep on teriparatide (PTH analog) due to increased risk for osteosarcoma)
when do you start to see a benefit with bisphosphonates?
see benefit in about 6-12 months so fractures in that time do not require change in management. But if there’s progression after being on bisphosphonate then consider different treatment.
Do we ever use raloxifene for osteoporosis treatment?
No. it’s less effective than bisphosphonates and has not been proven to reduce fractures with combo with bisphosphonates
how long to keep someone on a bisphosphonate treatment for osteoporosis?
5 years.
Greater than 5 yrs is associated with increased risk for atypical femoral fractures and so need to have a periodic break
What level of renal impairment are bisphosphonates are contraindicated ?
if renal GFR < 30-35
secondary causes of premenopausal osteoporosis:
hyperthyroidism,
hyperparathyroidism
vitamin d or calcium deficiency
GI malabsorption (celiac sprue, IBD)
Cushing’s dx
estrogen deficiency (premature ovarian failure)
RA medications (phenytoin, chronic heparin or steroids)
CKD or liver dx
hypercalciuria
alcoholism
Role of calcitonin in acute osteoporotic vertebral fractures
this SECOND LINE is used to relieve pain from acute osteoporotic vertebral fractures. Prefer NSAIDS for pain relief Not helpful for increasing bone density or fracture prevention
what is discordance in DEXA results?
this can be due to underlying disease or how the machine picks up bone density.
causes for focal increase in bone density on DEXA scan despite also having osteoporosis?
osteophytes (OA) or syndesmophytes (spondylarhtritis) osteoblastic metastasis Compression fracture Paget’s dx
causes for focal decrease in bone density in DEXA scan
osteolytic lesions fibrous dysplasia
systemic causes for discordant decreased DEXA
glucocorticoid incuded osteoporosis (bone loss in spine >hip) hyperparathyroid (bone loss in hip>spine)
non skeletal factors for discordant changes on DEXA scan
aortic calcification calcium tablets in GI tract
treatment decisions for osteoporosis are based on
lowest bone density measurement because bone density at any location correlates to fracture risk at that location.
can hyperparathyroidism cause osteoporosis?
yes, it can cause greater loss of cortical (forearm or hip) than trabecular (vertebrae) bone loss and associated with hypercalcemia.
what lab abnormality is associated with Paget’s dx
elevated serum alkaline phosphatase level.
osteoporosis risk factors in men
hypogonadism or androgen depivation therapy (leuprolide therapy) hyperthyroidism hyperparathyroiidsm medications (steroids anticonvulsants) vitamin D deficiency smoking EOTH use history of fractures GI (subtotal or total gastrectomy, celiac’s dx or IBS)
best known risk factor for osteoporosis in men:
congenital hypogonadism: Klinefelter syndrome or crytoorchidism
acquired hypogonadism - mumps, cirrhosis, chronic renal failure and HIV
localized radiation
androgen deprivation therapy (leuprolide) or surgical orgectomy
when does luprolide start to have an effect on bone mineral density?
6-9 months after starting the drug
when can you start to see osteoporotic skeletal fractures while on luprolide?
seen up to 20% after being on it for 5 years need to get daily calcium 1200 mg daily and oral vitamin D replacement for osteoporosis prevention
if started on denosumab for osteoporosis what should you know about it?
once started, must be continued indefinitely. it helps prevent vertebral fracture in post menopausal women If you stop this, it results in loss of bone mineral density and see increased risk of vertebral fracture.
watch for hypocalcemia too
ok to use in CKD pts
can denosumab be used in CKD pts?
Can be used safely in CKD and CKD4.
in which pts is teriparatide and ablaoparatide contraindicated?
it is not for anyone who has a history of radiation therapy increased risk for osteosarcoma with use
how do you prevent steroid induced osteoporosis?
general measures: - use lowest dose of steroid for shortest duration - topical steroids over oral or enteral steroids - daily weight bearing exercises - stop tobacco and excessive ETOH use - fall prevention Calcium vitamin D supplement - bisphosphonates -parathyroid hormone (teriparatide as second line agent) for severe osteoporosis
how long can someone remain on teriparatide for osteoporosis?
2 years b/c it can increase risk for osteosarcoma
what dose of steroid increases their risk?
>7.5 mg /day for >3 months and has increased risk for steroid induced osteoporosis and fragility fractures has baseline osteopenia or has greater than age 50
baseline osteopenia T score is
-1.0 to -2.5
Osteoporosis T score is
-2.5 or less OR history of fragility fracture
if DEXA score doesn’t show osteoporosis when do you start treatment?
when FRAX 10 year risk score shows >3% risk for hip or >20% major osteoporotic bone fracture
when to start treatment for osteoporosis if on steroids?
guidelines recommend: -men>50 yrs -post menopausal women taking >7.5 mg/day of prednisone for >3 months should be started on bisphosphonates (alendronate or risedronate) and if can’t tolerate then use teriparatide
Normal T score is
-1 or greater
what are Z scores used for?
NOT for diagnosis of osteoporosis used to compare individuals bone density with others of same age - useful for fraction risk estimation in YOUNG PREMENOPAUSAL WOMEN OR CHILDREN
antiresorptive therapy is needed when
osteoporosis DEXA T score 3% or major osteoporotic fracture >20%
if patient has CKD and osteoporosis and needs antiresportive therapy which medication do you start?
denosumab
Treatment options for osteoporosis
