Osteoporosis

Question 1

Men or women are more likely to have osteoporosis?

Answer 1

Women

Question 2

______ deficiency & age are responsible for most postmenopausal osteoporosis

Answer 2

Estrogen deficiency

Bone tissue is lost progressively.

Question 3

Lifetime osteoporotic fracture risk for a women who reaches age 50 is? What about for a man?

Answer 3

50% for women - 20% for men

Question 4

What are three causes of secondary osteoporosis?

Answer 4

Meds (ie steroids, antiepileptics)

Vit D deficiency

Alcohol

Question 5

High or low body weight is related to risk factors for developing osteoporosis?

Answer 5

Low body weight

Question 6

What are all the risk factors for osteoporosis?

Answer 6

Women > 65, Men >70

White or Asian

Low body weight (<127 lbs or BMI <20)

FH of osteoporosis/ fragility fracture

Personal history of fragility fracture

Long-term glucocorticoid use

>2-3 drinks alcohol/day

Estrogen deficiency <45 years

Testosterone deficiency

Low calcium intake

Vit D deficiency

Sedentary lifestyle

Current tobacco use

Question 7

What is the Frax algorithm?

Answer 7

Fracture risk assessment tool -

This calculates a patients 10 year probability for a fracture.

Its used for postmenopausal women and men age 40-90. Only validated for untreated patients.

Question 8

What the gold standard test for bone density?

Answer 8

DXA scan - bone densitometry.

Question 9

Who should be DXA scanned?

Answer 9

Women 65 years older or men 70 years older.

Younger but at risk for osteoporosis or osteomalacia.

People with pathological fractures

Radiographic evidence for diminished bone density.

Question 10

Someone with a T score of -1.0 to -1.5 should get scanned every?

Answer 10

Every 5 years.

Question 11

Someone with a T score of -1.5 to -2.0 should get scanned every how many years?

Answer 11

every 3-5 years.

Question 12

What is a Z score

Answer 12

This is comparing bone density in premenopausal women, younger men and kids. Expresses bone density as a standard deviation from age-matched race matched, and sex matched means Same=same

Question 13

What are the normal ranges for T score?

Answer 13

BMD is within 1 standard deviation of a younger adult. T score is greater than -1

Question 14

What is the T score for osteopenia (low bone density)

Answer 14

BMD is between -1 and -2.5 Score is between 1 and 2.5 standard deviations below a younger normal adult

Question 15

What is the T score for osteoporosis?

Answer 15

BMD is 2.5 SD or more below a younger normal adult T score is less than -2.5

Question 16

What is the T score for severe or established osteoporosis?

Answer 16

BMD is 2.5 SD or more below a younger adult. T score is -2.5 or lower but you already have 1 or more fragility fractures.

Question 17

Is osteoporosis obvious? IE are people symptomatic?

Answer 17

No, typically asymptomatic/silent until a fracture

Question 18

In terms of osteoporosis, people with vertebral fractures usually present how?

Answer 18

Height loss or kyphosis Acute episodes may be associated with pain Often no preceding trauma or minor trauma (speed bump) Acute back pain with sudden lifting, coughing, bending.

Question 19

Where is back pain with someone with vertebral fractures localized to?

Answer 19

Usually localized to the midline spine, variable quality May refer into flank, anterior abdomen, posterior superior iliac spine, radiation into the legs is considered rare. May have pain on palpation/percussion of affected vertebrae

Question 20

What are 3 things you can see on radiograph when someone has osteoporosis?

Answer 20

Radiolucency

Cortical thinning

Occult fractures

Question 21

Bone loss has to be greater than what % to be detected on radiograph?

Answer 21

Greater than 30%

Question 22

What lifestyle modifications should someone take with osteoporosis

Answer 22

Smoking cessation Limit alcohol intake Regular weight bearing and muscle strengthening exercise - At least 30 minutes 3x a week Consume at least 1200mg of calcium/day Adequate calorie intake Take measures in the home to avoid falls Wearing a brace - clam shell brace

Question 23

What are the guidelines for pharmacological intervention in post menopausal women and men over the age of 50 years.

Answer 23

History of a hip or vertebral fracture

T score less than 2.5 on DXA on the femoral neck or spine

T score between -1 and -2.5 at the femoral neck or spine, and a 10 year probability of hip fracture of greater than 3% or a 10 year probability of any major osteoporosis related fracture greater than 20% based on WHO algorithm.

Question 24

Total calcium and vitamin D intake a day should be?

Answer 24

Calcium = 1200mg

Vitamin D = 800 units

Question 25

What are common side effects from calcium supplementation?

Answer 25

Increased risk of nephrolithiasis

May increase CV disease (controversial)

Dyspepsia

Constipation

Interferes with iron and thyroid hormone absorption (take at different times)

Question 26

What are common side effects from vit D supplementation?

Answer 26

Excessive amounts - hypercalcemia, hypercalciuria, nephrolithiasis

Chronically high Vit D levels are linked to increased risk of cancer, mortality, and falls

Question 27

How do you measure Vit D levels?

Answer 27

25(OH)D test

Question 28

Whats is a good first line therapy medication for osteoporosis that has shown to improve BMD and decrease fractures?

ex: alendronate (fosamax), risendronate (actonel)

Answer 28

Bisphosphanates.

Question 29

What levels do you need before you begin treatment with Bisphosphonates?

Answer 29

Calcium, 25-hydroxyvitamin D, creatinine

Correct hypocalcemia and vit D deficiency before starting.

Question 30

What are common contraindications for using bisphosphonates?

Answer 30

Esophageal disorders, after bariatric surgery, or unable to follow dosing requirements.

Question 31

How do you need to take bisphosphonates?

Answer 31

1st thing in the morning on an empty stomach for maximal absorption - take with at least 8oz of water.

Don’t eat or drink, or take any other medication for at least 30 minutes afterwards. Also you need to remain upright for 30 minutes afterwards.

There are IV regimens for those who can’t tolerate oral.

Question 32

When should you d/c bisphosphonates?

Answer 32

If taking alendronate or risendronate for 5 years or zoledronic acid (reclast) yearly x 3 years

AND you have a stable BMD + no previous vertebral fractures + low risk for fracture in the near future.

If you have highest risk for fracture, continue PO therapy for up to 10 years. IV therapy for up to 6 years.

Question 33

What are common side effects of bisphosphonates that you need to be warry about?

Answer 33

Upper GI irritation (reflux, esophagitis, esophageal ulcers)

IV bisphosphonates can cause acute phase reaction (fever, myalgia, arthralgia)

Osteonecrosis of the jaw.

Not recommended in people with CrCl <30

Question 34

Calcitonin may ______ spine bone density, and ________ vertebral fracture risk

Answer 34

Increase, decrease

Question 35

Is calcitonin first line? When is it beneficial?

Answer 35

Not first line therapy due to other more effective drugs available.

Beneficial for short term pain releif in those with acute pain related to vertebral fractures

Question 36

Adverse reactions of calcitonin?

Answer 36

Malignancy risk increases, rhinitis.

Question 37

What oral analgesics are recommended for pain with osteoporosis?

Answer 37

Acetaminophen, Narcotics

NSAIDs - controversial - may impair bone healing.

Question 38

What is a kyphoplasty/vertebroplasty? Who is this for?

Answer 38

Injection of bone cement under image-guidance into fractured vertebra.

Only for those unable to achieve pain control. Showed significant benefit to pain control in trials

Question 39

Adverse events of kyphoplasty/vertebroplasty?

Answer 39

Extravasation of cement, cement PE, infection.