Osteoporosis Management

Question 1

Define Osteoporosis

Answer 1

Bone Porosity and Fragility

Low Bone Density

Microarchitecture disruption due to impaired mineralization

Question 2

Pathophysiology of Osteoporosis

Answer 2

Reduced Osteoblast Bone Formation
Excessive Osteoclast Bone Resorption

Question 3

What causes reduced bone mass?

Answer 3

Age, menopause, low serum calcium, alcohol consumption, smoking

Question 4

What are secondary causes of osteoporosis?

Answer 4

Glucocorticoids
Immunosuppressants (Cyclosporine)
Anti Seizure medications (Phenytoin, PHB)
Chemotherapy
Heparin
GnRH agonists and antagonists
Aromatase inhibitors

Question 5

Criteria for Pharmacological Treatment

Answer 5

Osteoporosis with BMD T-score ≤ -2.5 SD

Osteopenia with BMD T-score - 1 to - 2.5 SD
- High FRAX Risk Score 10-year probability
(1) Hip > 3%
(2) Major osteoporosis > 20%

History of fragility fractures
- Hip, Spine (height loss), Wrist, Humerus, Pelvis

Question 6

Goals of osteoporosis therapy

Answer 6

Preventing fractures

Improve QOL

Reduce economic burden

Question 7

Risk factors for osteoporosis

Answer 7

Post-menopausal women

Men ≥ 65 y.o.

Question 8

What BMD score indicates coexisting problems?

Answer 8

z-score values ≥ -2 SD (Glucocorticoid therapy, alcoholism)

Question 9

What medications are commonly used for osteoporosis? Give the dosing, duration of Tx, contraindications and side effects.

Answer 9

Tx Duration: Low risk or high risk
- PO Bisphosphonates 5 or 10 years
- IV Bisphosphonates 3 or 6 years

Alendronate 70 mg/week
Risedronate 35 mg/week
- CI: Unable to sit upright 30 min, hypocalcemia, CrCL < 30 mL/min, Aspiration risk, oesophageal / gastric abnormalities
- ADR: Atypical femoral fractures, osteonecrosis of the jaw (More in IV & cancer pt)

Zoledronic acid 5 mg IV infusion for 30 min
- CI: Renal and hypocalcemia

Question 10

Denosumab dosing, contraindications, ADR

Answer 10

SQ q 6-monthly
CI: Hypocalcemia, Pregnancy
ADR: Muscle, back, bone or joint pain, N/V/C/D, slight tiredness, increased cholesterol levels

Question 11

Why should you not discontinue denosumab?

Answer 11

It may cause increased risk of spinal column fractures

Question 12

Teriparatide dosing, CI, ADR, duration of Tx

Answer 12

20µg QD

CI: CrCL<30, postural hypotension, hypercalcemia, skeletal malignancies, bone metastases, unexplained ALP rise, previous implants or external beam radiation therapy to the skeleton, hereditary disorders predisposing to osteosarcoma, pregnancy

Duration < 2 years
ADR: Serious calciphylaxis, worsening of previous stable cutaneous calcification, transient orthostatic hypotension, transient and minimal elevations of serum Ca or hypercalcemia

Question 13

Calcitonin MOA, ADR, CI

Answer 13

Reduce blood calcium & inhibit osteoclastic bone resorption

ADR: Red streaks on skin, injection site reaction, warmth, red face, neck, arm, upper chest

CI: Hypersensitivity, hypocalcemia

Question 14

Raloxifene dosing, CI, ADR

Answer 14

60 mg QD
CI: CrCL < 30
ADR: VTE (hot flashes) / Stroke risk (blood clots)
Reduced risk of breast cancer

Question 15

Romosozumab dosing, duration, CI, ADR

Answer 15

SQ once monthly for 12 months
CI: CV death, stroke
ADR: Hypersensitivity, hypocalcemia, MI, stroke in the preceding year

Question 16

Where to monitor for atypical femoral fractures?

Answer 16

Thigh, hip, groin pain

Question 17

ONJ Risk Factors

Answer 17

Tooth extraction
Invasive dental procedure
Cancer and radiotherapy
Oral hygiene is poor

Question 18

Counsel patients about ONJ

Answer 18

Smoking cessation
Avoid invasive dental procedures
Maintain oral hygiene

Question 19

Serum 25(OH) Vitamin D levels

Answer 19

≥ 20-30 ng/mL but < 50-100 ng/mL

Question 20

Calcium supplementation quantity per day? When to give supplementation?

Answer 20

1000 mg elemental calcium/day (> 51 y.o.)
800 mg/day (19-50 y.o.)

When dietary intake < 700 mg/day

Question 21

Vitamin D supplementation quantity per day

Answer 21

Cholecalciferol 800 IU/day