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Endocrinology > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Non modifiable risk factors for Osteoporosis

A

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

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2
Q

Modifiable risk factors for osteoporosis

A

smoking,

excessive alcohol intake,

sedentary lifestyle

medications (steroids, anticonvulsants),

vitamin D deficiency or low Ca intake,

estrogen deficiency (premature menopause, hysterectomy/oophorectomy)

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3
Q

When to start screening women?

A

>65 years <65 yrs if +1 or more risk factors

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4
Q

When to start screening men?

A

>70 years

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5
Q

how often to repeat testing?

A

q2 yrs

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6
Q

What medications cause osteoporosis?

A

steroids,

phenytoin, carbamazepine,

PPI,

anastrazole and leuprolide

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7
Q

What other misc diseases or conditions cause osteoporosis?

A

RA and other inflammatory dx

Multiple myeloma

alcoholism

immobilization,

CKD and RTA

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8
Q

What GI disorders cause osteoporosis?

A

Celiac dx and Crohn’s dx,

chronic liver dx

eating disorders

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9
Q

What endocrine disorders cause secondary osteoporosis?

A

hyperthyroidism,

hyperparathyroidism

hypercortisolism

hypo- gonadism -low estrogen or low testosterone

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10
Q

When to screen in pts younger than 65 yrs?

A

fracture after low impact trauma,

long term glucocorticoid (>7.5 mg for >3 months)

low body weight.

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11
Q

What T score shows osteoporosis?

A

< -2.5 at any location is osteoporosis

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12
Q

When to order a 24 hr urinary calcium excretion test?

A

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

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13
Q

When to order spiral imaging (lateral spine XR) to look for possible vertebral fracture

A

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

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14
Q

when diagnosed with osteoporosis you need to:

A

Check for secondary causes

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15
Q

if after two years of osteoporosis and repeat DEXA shows BMD <5% what do you do

A

Continue oral bisophosphonate and repeat DEXA in 2 yrs

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16
Q

if after two years of osteoporosis and repeat DEXA shows BMD>5% what do you do?

A

consider IV bisophosphonate or teriparatide, or denosumab

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17
Q

If pt has a fragility fracture while on treatment for osteoporosis?

A

Consider treatment of teriparatide or denosumab

must make sure you rule out secondary causes for osteoporosis.

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18
Q

Severe osteoporosis is defined as:

A

T score

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19
Q

How to treat severe osteoporosis

A

consider teriparatide for 3 years then bisphosphonate can’t keep on teriparatide (PTH analog) due to increased risk for osteosarcoma)

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20
Q

when do you start to see a benefit with bisphosphonates?

A

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.

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21
Q

Do we ever use raloxifene for osteoporosis treatment?

A

No. it’s less effective than bisphosphonates and has not been proven to reduce fractures with combo with bisphosphonates

22
Q

how long to keep someone on a bisphosphonate treatment for osteoporosis?

A

5 years.

Greater than 5 yrs is associated with increased risk for atypical femoral fractures and so need to have a periodic break

23
Q

What level of renal impairment are bisphosphonates are contraindicated ?

A

if renal GFR < 30-35

24
Q

secondary causes of premenopausal osteoporosis:

A

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

25
Q

Role of calcitonin in acute osteoporotic vertebral fractures

A

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

26
Q

what is discordance in DEXA results?

A

this can be due to underlying disease or how the machine picks up bone density.

27
Q

causes for focal increase in bone density on DEXA scan despite also having osteoporosis?

A

osteophytes (OA) or syndesmophytes (spondylarhtritis) osteoblastic metastasis Compression fracture Paget’s dx

28
Q

causes for focal decrease in bone density in DEXA scan

A

osteolytic lesions fibrous dysplasia

29
Q

systemic causes for discordant decreased DEXA

A

glucocorticoid incuded osteoporosis (bone loss in spine >hip) hyperparathyroid (bone loss in hip>spine)

30
Q

non skeletal factors for discordant changes on DEXA scan

A

aortic calcification calcium tablets in GI tract

31
Q

treatment decisions for osteoporosis are based on

A

lowest bone density measurement because bone density at any location correlates to fracture risk at that location.

32
Q

can hyperparathyroidism cause osteoporosis?

A

yes, it can cause greater loss of cortical (forearm or hip) than trabecular (vertebrae) bone loss and associated with hypercalcemia.

33
Q

what lab abnormality is associated with Paget’s dx

A

elevated serum alkaline phosphatase level.

34
Q

osteoporosis risk factors in men

A

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)

35
Q

best known risk factor for osteoporosis in men:

A

congenital hypogonadism: Klinefelter syndrome or crytoorchidism

acquired hypogonadism - mumps, cirrhosis, chronic renal failure and HIV

localized radiation

androgen deprivation therapy (leuprolide) or surgical orgectomy

36
Q

when does luprolide start to have an effect on bone mineral density?

A

6-9 months after starting the drug

37
Q

when can you start to see osteoporotic skeletal fractures while on luprolide?

A

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

38
Q

if started on denosumab for osteoporosis what should you know about it?

A

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

39
Q

can denosumab be used in CKD pts?

A

Can be used safely in CKD and CKD4.

40
Q

in which pts is teriparatide and ablaoparatide contraindicated?

A

it is not for anyone who has a history of radiation therapy increased risk for osteosarcoma with use

41
Q

how do you prevent steroid induced osteoporosis?

A

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

42
Q

how long can someone remain on teriparatide for osteoporosis?

A

2 years b/c it can increase risk for osteosarcoma

43
Q

what dose of steroid increases their risk?

A

>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

44
Q

baseline osteopenia T score is

A

-1.0 to -2.5

45
Q

Osteoporosis T score is

A

-2.5 or less OR history of fragility fracture

46
Q

if DEXA score doesn’t show osteoporosis when do you start treatment?

A

when FRAX 10 year risk score shows >3% risk for hip or >20% major osteoporotic bone fracture

47
Q

when to start treatment for osteoporosis if on steroids?

A

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

48
Q

Normal T score is

A

-1 or greater

49
Q

what are Z scores used for?

A

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

50
Q

antiresorptive therapy is needed when

A

osteoporosis DEXA T score 3% or major osteoporotic fracture >20%

51
Q

if patient has CKD and osteoporosis and needs antiresportive therapy which medication do you start?

A

denosumab

52
Q

Treatment options for osteoporosis

A

Endocrinology (26 decks)

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