Osteoporosis - Exam 1 Flashcards
What is osteoporosis defined as? What does it result in?
low bone mass, microarchitectural disruption, and skeletal fragility, resulting in decreased bone strength and an increased risk of fracture.
What is bone strength defined as? What is osteoporosis?
Bone Strength = Bone quality + Bone quantity
Osteoporosis: Low bone quality or Low bone quantity
osteoporosis: loss of BOTH bone mineral and matrix
The majority of osteoporosis patients are ______. ___% of men and ____% of women
women
4.2% are men and 18.8% are women
____ women and ____ men will suffer a fragility fracture in their lifetime
1:2
1:5
What are the 3 primary bone cells? Give a brief description of what each one does
osteocytes: primary bone cells
osteoBlasts: Build Bones
osteoClasts: Cut Calcium
______ secretes a matrix to form new bone known as bone remodeling. Activated with bone usage to conserve energy.
OsteoBlasts
______ Multinucleated cell which absorbs bone through use of acids recycling Calcium back into the bloodstream
osteoclasts
What is the pathopsy pathway when there is high blood calcium level detected?
high blood calcium level -> thyroid secretes calcitonin -> results in a buildup of bone by osteoblasts-> blood Ca level decreases and goes back to normal
What is the pathopsy pathway when there is low blood calcium level detected?
low blood calcium is detected -> PTH from the thyroid gland is secreted -> causes breakdown of bone by osteoclasts -> blood calcium level starts to increase -> normal blood calcium level
____ inhibits osteoclasts activity and a low ____ can cause an imbalance
estrogen
estrogen
aka estrogen keeps the osteoclast from breaking down bone
What is trabeculae?
a small, often microscopic, tissue element in the form of a small beam, strut or rod that supports or anchors a framework of parts within a body or organ
bone quantity
Where are the 4 highest quantity of trabeculae found? **What 2 places are osteoporosis the most likely to be problematic?
- End of long bones*
- Vertebrae*
- Pelvis
- Skull
What are the 3 components of bone matrix?
collagen
ground substance
inorganic salts (mainly hydroxyapatite)
maybe go watch this youtube video??
https://www.youtube.com/watch?v=78RBpWSOl08&t=3s
What is considered primary osteoporosis? What are the 4 risk factors?
old age
- Caucasian / Asian - smaller bone structure
- Smoking
- Malnutrition (Vitamin D / Calcium)
- Decreased physical activity
What is secondary osteoporosis?
bone disease usually from a medication side effect or other disease (think hyperPTH, hyperthyroid, CKD, liver dz, hypogonadism, Cushings, DM, Cancer, anything that causes immobility)
What medications can cause secondary osteoporosis? **Which one is the important one to remember?
Steroids
Valproic Acid
Heparin
Depo-Provera
Aromatase Inhibitors
Cyclosporine
Antacids
Lithium
Methotrexate
What dose of steroids is concerning for osteoporosis?
>5mg Prednisone QD or equivalent for > 3 months
What are the s/s of osteoporosis?
nothing!!!!
s/s will manifest as pathologic fx, loss of vertebral height > 1.5cm, can present as back pain
Where are 3 common sites for pathologic fracture due to osteoporosis?
Compression fractures of vertebrae
Hip fracture
Distal radius fracture (Colle’s)
What is the USPSTF screening recommendation for osteoporosis?
women aged 65 years old and older
or women younger than 65 who have an increased risk of osteoporosis
If you are going to screen men for osteoporosis, what is the recommended starting age?
70 and older
What are the 4 early screening considerations for osteoporosis?
Parental Hx of hip fx
Smoking
Excessive ETOH usage
Low body weight (<135 lbs)
When a pt gets a DEXA scan, what are they looking at?
L1-4 and BOTH hips
measures DENSITY of bones
a DEXA T-score compares what? Z-scores? **What T score is considered osteoporosis? osteopenia? normal? **(draw the graph)
Bone density T-scores compared the patient to a 30 year old subject
Z-scores compare the patient to a peer of equal age & gender
Therefore, a T-Score of <-2.5 separates the ____ from the population. What score do you use to dx?
lowest 1%
Always use the lowest (worst) score to diagnose
The T-Score ___ diagnoses Osteoporosis. Dx can also be made with ______
≤ -2.5
fragility fx
if the pt is dx with a fragility fx, what does their T score need to be to dx osteoporosis?
The diagnosis stands without confirmation of a low T-score or even with a normal T-score.
There is no way to measure Bone Quality, but the fracture shows it is poor.
What might an xray show of pt with osteoporosis?
May show demineralization but this would likely be an incidental finding; X-rays are not a primary diagnostic tool for osteoporosis.
How can you differentiate between primary and secondary osteoporosis?
can order labs and they are often NORMAL
but ordering them to rule out secondary osteoporosis
What labs would you consider ordering while working up a pt for osteoporosis?
Calcium, Phosphate, Vitamin D
25-OH Vitamin D
PTH levels
A1c
TSH
Kidney / Liver Function
Celiac Disease (TTG, IGA Endomysial Antibodies)
Often all Normal - Differentiates between primary and secondary osteoporosis.
order labs based on the pt’s presenting s/s
**What is the FRAX score? When should you consider treatment?
Gives a 10 year likelihood of osteoporotic or hip fracture based off significant patient data.
Consider treatment with 10 year Osteoporotic fx risk ≥20% or Hip ≥3%
What should you do next if your pt has a T score between -2.5 < T < -1.0?
FRAX score
Consider treatment with 10 year Osteoporotic fx risk ≥20% or Hip ≥3%
What if the patient has a good T-score but has multiple risk factors? (DEXA has no accounting for these)?
FRAX score
What is the 3 step overview of treatment options for osteoporosis?
What are the 5 lifestyle modifications for osteoprosis?
- exercise: walking is super good for bones!!
- weight loss
- smoking cessation
- ETOH moderation
- reduce fall risks
read the fall risk prevention slide again
What are the 2 supplementations for osteoporosis and osteopenia?
Vit D and Calcium
What is the recommendation for Vit D for postmenopausal women? Which form?
800 IU of Vit. D daily
D3 preferred over D2
What is the Vit D recommendation is the labs are less than 20? What is a safe vit D level? What level is toxic?
High dose 50,000 IU weekly for 3-6 months, then switch to daily supplementation
Vitamin D level safe up to 100
Toxicity >150
_____ needs to be determined and managed as necessary before bisphosphonates are initiated
Vit D
What are the different options of calcium supplementation? What are the pt education points for each?
Calcium Citrate: can be taken with or without food and with a PPI
Calcium Carbonate: should be taken with food, if PPI used, less uptake will occur
What is the goal intake for calcium? How much in each serving of dairy?
1200mg Ca total intake / day is sufficient usually
Roughly 300mg of Ca is in every dairy serving and 50% should be from diet
When should you start calcium supplementation in a pt with osteoporosis? High calcium increases risk of _____
Only supplement if serum Calcium is low or diet is insufficient
cardiac arrhythmias
When should you start pharmacotherapy in osteoporosis? What are the 4 different options?
osteoporosis and osteopenia with +FRAX
Alendronate (Fosamax)
Risedronate (Actonel)
ibandronate (Boniva)
Zoledronic Acid (Reclast)
How does bisphosphonates work?
osteoclasts lose resorptive function upon bisphonsphate uptake. This allows for bone building but there is a trade off with bone flexibility diminishing.
aka bones cannot cut calcium out of the bones anymore
What are the 3 pt education points for Bisphosphonate?
Due to poor absorption, patient should take with 8oz of water first thing in the morning with no other foods or medications for 30 minutes. (60 minutes with Ibandronate)
Do not recline for 30 minutes after taking medication to minimize risk of reflux
Discontinue if any reflux symptoms appear
**What is the important possible SE of bisphosphonates?
Osteonecrosis of the Jaw - Loss or Breakdown of the jaw - infection, pain, swelling - generally associated with tooth extraction and/or local infection with delayed healing
GI related SE are to be expected!
What pt populations are bisphosphonates not a good choice for?
eGFR < 30-35
significant esophageal or GI disorders, specifically Roux-en-Y gastric bypass surgery
Avoid in those who are unable to sit up for 30-60 minutes post ingestion
on pharmacotherapy and low risk of fx, how long should the pt stay on bishosphonates before taking a drug holiday? mild risk? moderate risk? high risk? How long should the drug holiday be?
low risk: 2-3 years
mild: 2-5 years
moderate: 3-5 years
high: up to 10 years
Drug Holiday = generally a year or longer
_____ is a good option for those who cannot tolerate Bisphosphonates or those with CKD. Do you need a drug holiday?
Denosumab (Prolia, Xgeva)
No drug holiday - bone regression occurs with stopping
______ is a usually only chosen when there is a need for significant Breast Cancer Reduction along with osteoporosis
Raloxifene (Evista)
What are the pros of using Raloxifene? Cons?
Pros: Inhibits bone resorption; reduces risk of vertebral fracture; Reduces Breast Cancer risk
Cons: Increased incidences of thromboembolic events / hot flashes
What are the anabolic medication tx option for osteoporosis? What needs to be corrected before the pt starts?
Romosozumab (Evenity)
Correct Calcium and Vitamin D beforehand
_____ is a good treatment options for pt with CKD but effect wanes after 12 months and need to d/c usage
Romosozumab (Evenity)
What is the monitoring requirements for osteoporosis therapy? Should you use different classes of therapy together?
new DEXA scan after 2 years
NO!!! combo therapy is NOT recommended
What are the 5 indications for referral to endo for osteoporosis?
Osteoporosis in premenopausal women or men <50
Hx of fragility fx + normal DEXA
Failed tx or continual fractures with tx
Conditions which make normal therapy difficult
Considerations of advanced therapies
go review the 2 case studies from lecture
DO IT!!
What is Osteogenesis Imperfecta? Most often affects _____
An inherited connective tissue disorder causing “brittle bones.” Anywhere from early osteoporosis to fractures without trauma
Collagen 1
**What is the hallmark PE finding of Osteogenesis Imperfecta? What are 4 additional ones?
**Eye Sclera - Bluish/Greyish Color
hearing loss
weak joints
soft bones
Dentinogenesis imperfecta - teeth are discolored and soft
What are the 4 different types of Osteogenesis Imperfecta?
How do you dx Osteogenesis Imperfecta? What will the xray show?
Often clinical - Blue Sclera, dentinogenesis imperfecta, multiple fractures with little trauma and often have a family hx
Imaging: Plain films may show bowing and low bone density.
In children with multiple fractures, need to rule out _____ and some pts may ______
abuse
some with OI bruise easily.
What is the tx for Osteogenesis Imperfecta?
physical therapy / exercise/ mobility improvments/ sx to place steel rods in legs
IV Bisphosphonate therapy -> helps to turn off osteoclast activity
