Osteoporosis

Question 1

what is osteoporosis

Answer 1

• breakdown in bone structure due to decreased bone mineral density
• decreased bone mass
• increased bone fragility
• increased fracture risk

Question 2

what are fragility fractures

Answer 2

• attributable to osteoporotic bone shock
• all fractures that result from a low energy traumatic event
• associated with increased morbidity and morality

Question 3

decreased bmd leads to __

Answer 3

decreased bmd -> brittle bones + low energy force -> easily broken

Question 4

areas prone to fragility fractures

Answer 4

• distal radius

- vertebral fractures

Question 5

patients with previous fragility fracture have __ risk of another fragility fracture

Answer 5

2x increased risk

low bmd = inc risk for 2ndary frcature

Question 6

most devastating consequence of osteoporosis

Answer 6

hip fractures

- mortality rate 25% in first year

Question 7

other implications of fragility fractures

Answer 7

• increase in financial cost
• ## treatment reduces mortality by 30%

Question 8

biggest risk factor for future fracture

Answer 8

previous fragility fracture

Question 9

all low energy fractures should be considered in fragility fractures EXCEPT

Answer 9

• facial bones
• skull
• feet
• hands
• digits
• patella

Question 10

work-up for patients with decreased bmd

Answer 10

• dxa
• serum vit d level
• risk factor assessment
• younger than 50 = further evaluation for secondary osteoporosis

Question 11

modifiable risk factors

Answer 11

• smoking
• alcohol (>3 drinks/day)
• overall nutrition

Question 12

nonmodifiable risk factors

Answer 12

• age, gender
• fhx
• rheumatoid arthritis
• glucocorticoid use
• secondary osteoporosis

Question 13

moa for bisphosphonates

Answer 13

• causes osteoclast cell death -> decreases bone resorption

bind calcium -> resorbed by osteoclasts -> causes osteoclast cell death -> decreased resorption of bone

Question 14

initial therapy with bisphosphonates is recommended in ___

Answer 14

postmenopausal women

Question 15

moa of calcitonin

Answer 15

• causes decreased bone resorption by osteoclasts
• does not reduce risk for non-vertebral fractures
• can control bone pain

Question 16

calcitonin is indicated for ___

Answer 16

• women with osteoporosis at least 5 years post menopause

- nasal spray: only in high fracture risk women with osteoporosis who cannot tolerate other treatment options

Question 17

what is raloxifene

Answer 17

• estrogen agonist in bone
• causes decreased bone resorption by osteoclasts
• reduced risk for vertebral fractures

Question 18

raloxifene is indicated for ___

Answer 18

post menopausal women with

• low risk for dvt
• bisphosphonates or denosumab inappropriate
• high risk of breast ca

Question 19

moa of teriparatide

Answer 19

• recombinant human pth

- greater ca absorption and stimulating osteoblastic activity -> increased bone mineral density

Question 20

teriparatide is indicated for ___

Answer 20

• men and postmenopausal women with osteoporosis and high fracture risk
• teriparatide or abaloparatide for upto 2 years to reduce vertebral and non vertebral fractures

Question 21

moa of denosumab

Answer 21

• receptor activator of rank ligand inhibitor
• rankl = increases osteoclast activity
• denosumab binds to rankl = decreased osteoclast aactivity

Question 22

denosumab is indicated for ___

Answer 22

men and post menopausal women (alternative initial treatment) with osteoporosis and high fracture risk

90 mg sc every 6 mos

Question 23

risk fracture reduction of denosumab

Answer 23

• vertebra 68%
• hip 40%
• non vertebral 20%

Question 24

t/f drug holidays are recommended for denosumab

Answer 24

false, effects are reveresed after 6 mos if not taken on schedule

Question 25

monitoring of treatment

Answer 25

- dexa every 1-3 years in postmenopausal - bone turnover markers as an alternative - ctx = anti-resorptive therapy - p1np = bone anabolic therapy

Question 26

guideline for postmenopausal women with osteoporosis taking bisphosphonates

Answer 26

- assess fracture risk after 3-5 years - bisphosphonate holiday for upto 5 years - reinitiate therapy earlier if significant bmd decline, intervening fractures, other factors

Question 27

guideline for postmenopausal women with osteoporosis taking denosumab

Answer 27

reassessment after 5-10 years

Question 28

adverse effects of oral bisphosphonates

Answer 28

- upper gi irritation (minimized by adherence to dosing procedures) - atypical femoral fractures - nonunion of atypical fractures

Question 29

adjunct therapy for oral bisphosphonates

Answer 29

- daily calciuma and vit d - especially if with low bmd and high risk of fractures - to prevent hip fractures

Question 30

factors in frax calculation tool

Answer 30

- oral glucocorticoids - rheumatoid arthritis - secondary osteoporosis - t score of femoral neck - alcohol

Question 31

t/f prior clinical vertebral and hip fractures are stronger risk factors

Answer 31

true

Question 32

t/f rheumatoid arthritis is protective

Answer 32

false

Question 33

other interventions

Answer 33

- adequate calcium and vit d intake - decrease alcohol, caffeine, and tobacco - encourage regular physical activity - fall prevention and home safety evaluation

Question 34

daily ca intake

Answer 34

men 50-70 1000 mg men >71 1200 mg women >50 1200 mg

Question 35

daily vit d intake

Answer 35

normal serum level 30-80 ng/ml recommended 800-1000 iu supplementation (<30 ng/ml) 50,000 iu/week for 8-12 weeks

Question 36

t/f a patient who suffered a fracture from a low energy mechanism that would not cause a fracture in a normal person should be osteoporotic until proven otherwise

Answer 36

true