Osteoporosis & Fragility Fractures Flashcards
What is Osteoporosis?
Chronic disease characterized by bone microarchitecture deterioration due to reduced bone mineral density - decreased bone strength, bone fragility and increased fracture.
What are the etiologies of osteoporosis?
Primary = menopausal and aging
Secondary - due to diseases such as endocrine disorders, malabsorption, treatment (glucocorticoids) and idiopathic
How is osteoporosis being diagnosed?
Based on Bone Mineral Density (BMD) in relation to reference standard
T score of less dow or equal to -2.5 T score
What is the normal T score
greater than or equal to -1 T score
What is the score for osteopenia?
Low bone mass or osteopenia which is between -1 and -2.5 T score
Among the adult populatin, who should be screened for osteoporosis?
All postmenopausal women
Men aged 50 and above
Adults with clinical risk factors (personal hx of fracture, low BMI, inflammatory arthritis, medications , alcoholisms, current smokers)
Among the adult population, what factors increase the risk of osteoporosis?
Advanced age (>70)
Fagility fracture hx
menopause or untreated early menopause
Parental hx of osteoporosis/ fracture
excessive alcohol (>3.5 units per day)
Smoking
Frailty or low level of physical activity
What comorbidities increase the risk of osteoporosis?
Diabetes
Hyperparathyroidism or other endocrine disease
RA
SLE
IBD
Malabsorption
Chronic Liver Disease
Neurological disease (Alzheimer’s, Parkinson’s, MS, Stroke)
Mod to Sev Kidney disease
Bronchial Asthma
HIV
Institutionalized patients with epilepsy
What medications increase osteoporosis?
Glucoroticoids
Antidepressants,
Anti-epileptic agens
Aromatase inhibitors
GnRH agonists for prostate cancer
PPIs
Thiazolidinediones
Anticoagulatns
Methotrexate
Thyroid Hormones
What tool should be used for osteoporosis screening?
FRAX (fracture risk assessment tool)
OSTA (osteoporosis self-assessment tool) as an alternative
Among adult population, what is the clinical presentation of osteoporosis?
may include any of the following:
acute onset back pain
height loss
thoracic kyphosis
previous fability fracture
menopause or untreated early menopause,
parental hx of osteoporosis and/or fracture
alcohol consumption >3.5 units per day
smoking
low weight of BMI of < 18.5
4cm or more height loss or thoracic kyphosis
Among at risk of PMW, should BMD measurement using dual energy xray absorptionmetry (DEXA) be used to diagnose osteoporosis?
YES.
Criteria:
history of fragility fracture/s
BMD T-score of 2.5 or less
Low bone mass (BMD <1.0 and <2.5) with fragility fracture
high fracture risk accdg to FRAX
IF at risk of vertebral fracutre, VFA (vertebral fracture assessment using DXA or lateral spine radiograph
or
FRAX w/o BMD if latter is unavailable. Fracture intervention threshold of 3.75% for major osteoporotic fracutres and/or 1.25% for hip fractures
Is FRAX can be used in male in the Philippines?
NO. only in PMW
Among PMW with osteoporosis, are the anti-resorptive agensts, i.e. alendronate, ibandronate, zoledronate, denosumab, raloxifene, effective in reducing vertebral, non-vertebral, hip fractures compared to placebo?
YES as an initial therapy (alendronate, denosumab, risedronate and zoledronate)
Alternatives: ibandronate, raloxifene
Among PMW with severe osteoporosis, is teriparatide, abaloparatide and romosozumab effective in reducing, vertebral, non-vertebral and hip fractures compared to placebo? How long should treatment duratin be?
YES. Abaloparatide and romosozumab prevent vertebral, non-vertebral and hip fracture
Teriparatide reduces the risk of further vertebral and non vertebral fracture
Teriparatide x 24 months
romosozumab x 12 months
Among PMW with osteoporosis, should calcium and vitamin D supplementatin be given to reduce fragility fracture risk?
Calcium at 700-1200 mg/day and vitamin D at least 800 IU per day are recommended along with anti-osteoporosis medication
Higher doses for homeboud, institutionalized Chron’s , achlorhydria, post bariatric, use of PPI
Among post-menopausal women diagnosed with osteoporosis, should serumc alcium and vitamin D levels be normalized prior to initiating anti-resorptive therapy?
YES for both calcium and vitamin D
What is fragility fracture?
Any fracture in an older person, though not all geriatric fracture.
among patient swith previous fragility fractures, what is the effect of pharmacologic intervetion ont he risk of having a subsequent or second fracture?
biphosphonates and teriparatide are recommended to reduce risk of subsequent fractures
Among patients with acute displaced fragility fractures of the distal radius, is early surgical intervention superior to conservative management for improving functionality?
NOT recommended especially among 65 years old and above
Among patients who sustained fragility fracturs of the hip, is earlyintervetin superior to delayed surgical intervention in improving overall survival, morbidity, mortality and functionality of patients?
Suggested early within 24 to 48 hrs be done
In patients with a previous osteoporotic fragility fracture, will enrollment in a secondary fracture prevention program or fracture liaison service (FLS) improve treatment adherence and prevent re-fractures?
it is recommended that they be managed within a formal integrated system of care that incorporates a fracture liaison service (FLS) to prevent re-fractures and improve adherence to osteoporosis treatment.
Among adults receiving osteoporosis treatment, what is the appropriate interval between central DXA scans in monitoring treatment response?
it is recommended that central DXA test should be done every 1-2 years especially in patients at high risk of fracture, then at longer intervals thereafter once definite satisfactory treatment response is achieved.
Among patients with recent fragility fracture/s, should an immediate referral to bone specialist be done for better evaluation and management?
patients with the following risk factors/conditions be referred to an osteoporosis specialist:
• patients with fragility fracture and/or subsequent fragility fractures
• BMD T-score ≤ − 3.5
• Tx with high dose glucocorticoids (≥7.5 mg/day of prednisolone or equivalent over 3 months) patients with co-morbidities such as CKD, endocrine and rheumatic diseases
Should at-risk PMW and older men receive calcium supplementation and/or Vitamin D supplementation for prevention of osteoporosis and fragility fractures?
Among at-risk adults with normal FRAX and BMD scores, calcium and vitamin D supplementation is recommended for those who cannot meet country-specific reference standards.
What is the recommended dose of calcium?
calcium (minimum 700 mg daily) is preferably achieved through dietary intake or otherwise by supplementation
other studies shows that Calcium of 1000-1200 mg/day and Vitamin D of 800 IU/day reduce risk of any fracture and hip fracture
Among PMW and older men, what doses of calcium and Vitamin D are associated with reduced fragility fracture risk?
Among PMW and older men, supplementation with Vitamin D at 400 to 600IU/day and Calcium at 700 to 800 mg/day is recommended.
Among PMW and older men, what is the benefit of physical activity in the prevention of osteoporosis and fragility fractures?
Among PMW and older men, regular physical activities using a combination of exercise types (such as weight bearing, balance training, flexibility or stretching exercises, endurance and progressive strengthening exercises) are recommended to increase BMD and reduce the risk of fragility fractures.
Among PMW and older men, does smoking cessation prevent osteoporosis and fragility fractures?
Among postmenopausal women and older men, smoking cessation is recommended to reduce risk of osteoporotic fractures.
Among PMW and older men, what diet is effective in the prevention of osteoporosis?
Among PMW and older men, a balanced diet or nutrient-dense diet is recommended to prevent osteoporosis and fragility fractures.
Should at-risk postmenopausal women receive (MHT) for the prevention of fragility fractures? What is the duration of use for MHT?
Among at risk peri and postmenopausal women with climacteric symptoms but without contraindications to MHT, it is recommended that MHT be given for a minimum duration of 2 years but not longer than 3 years to reduce fracture risk.
Among at-risk peri and post-menopausal women with climacteric symptoms but with contraindications to MHT, MHT is not recommended.
Ia HRT recommended for osteoporosis prevention?
YES
What is the duration of MHT use?
5-7 years significantly decrease the incidence of spine, hip and nonvertebral fractures
When should Menopausal Hormone Therapy be initiated to reduce fracture risk?
Among women younger than 60 years of age, initiation of MHT may be of greater benefit in fracture risk reduction.
Up to when should menopausal hormone therapy be given?
It is ideally started during the perimenopausal stage and continued until age 60
In the absence of contraindications, women younger than 60 or within 10 years of menopause onset, systemic hormone therapy is recommended to decreased bone loss
Which hormone preparation should be used for fracture risk reduction?
Among hysterectomized PMW, it is recommended to give estrogen only replacement therapy for fracture risk reduction. Addition of progestins is recommended for women with intact uterus to prevent endometrial pathology.
What are the risk of MHT?
Continuous estrogen + progesterone hormone therapy increases risk of coronary events, stroke, venous thromboembolism, breast cancer, death from lung ca and gallbladder disease
Estrogen only increases risk of coronary events, stroke, VTE, breast Cancer and gallbladder disease
All MHT increases risk of breast Ca except vaginal estrogens. more from estrogen+ progesterone therapy than estrogen alone therapy
Among at-risk postmenopausal women, should SERMS be considered an alternative to MHT for prevention of osteoporosis?
SERMS - selective estrogen receptor modulators (SERMS)
Raloxifene is used to treat and prevent ostoporosis and prevent breast Ca.
use of raloxifene after 2-3 years increases bone density of the lumbar spine
How are adverse events monitored in women receiving MHT for osteoporosis prevention?
- Among women on MHT who are at risk of breast cancer, it is recommended for them to undergo annual mammograms.
- Among women with postmenopausal bleeding on MHT, it is recommended for them to undergo transvaginal ultrasound.
- Among women on MHT, it is recommended that they be monitored for signs and symptoms of venous thromboembolism, cardiovascular and cerebrovascular diseases.
What is AMH
Anti-mullerian hormone is a good predictor of early bone loss as correlated with bone mineral density measurement in the early perimenopausal period
Women should be evaluated for osteoporosis using?
Bone DXA after at least 2 years of therapy
If MHT is discontinued, benefits quickly disappears.
Markers of bone turnover returned to pretereatment after a few months, whereas BMD decreased within 1 to 2 years of stopping medication
