Osteoporosis Management Flashcards by Fouad Alkoum

What is the recommended calcium intake for premenopausal women and men?

1000–1200 mg/day

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What is the recommended calcium intake for postmenopausal women and men aged 65 and older?

1200–1500 mg/day

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What is the recommended vitamin D intake?

800–1200 IU/day

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What types of exercise are recommended for osteoporosis management?

Aerobic and resistance training

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What lifestyle modifications are suggested for osteoporosis management?

Limit alcohol to ≤2 drinks/day
Limit caffeine to ≤2 servings/day
Smoking cessation
Fall prevention

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What caution should be taken regarding calcium and vitamin D intake?

Excessive calcium/vitamin D may increase kidney stones and vascular calcifications

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What are the calcium content estimates for dairy products?

Milk/Yogurt: 300 mg/cup
Cheese: 300 mg/oz
Calcium-fortified fruit juice: 300 mg/cup

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What should be added to estimate total calcium intake from nondairy sources?

Add 300 mg

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What is the best source of calcium?

Low-fat dairy

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What is the difference between calcium carbonate and calcium citrate?

Calcium carbonate: Requires gastric acid; less effective with PPIs
Calcium citrate: Better for PPI users and kidney stone formers

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What are the dietary sources of vitamin D?

Fatty fish (salmon, tuna, mackerel): D3 (400 IU/3.5 oz)
Fortified milk: 400 IU/quart
Sunlight: 10,000 IU in 10 minutes for fair-skinned individuals

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What is the goal serum 25-OH vitamin D level for deficiency treatment?

30–100 ng/mL

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What is the dosing for vitamin D based on serum levels?

20–30 ng/mL: 2000 IU D3 daily
10–20 ng/mL: 50,000 IU D2 weekly for 3 months, then 2000 IU D3 daily
<10 ng/mL: 50,000 IU D2 twice weekly for 3 months, then 2000 IU D3 daily

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What may require higher doses of vitamin D?

Malabsorption, liver disease, obesity

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Is there an increased risk of coronary artery disease or vascular calcification with recommended doses of calcium and vitamin D?

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What are the indications for initiating pharmacologic therapy for osteoporosis?

History of fragility fracture
T-score ≤-2.5 at any site
FRAX 10-year risk: ≥3% hip fracture or ≥20% major osteoporotic fracture

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What are the key processes involved in bone remodeling?

Osteoclasts resorb old bone
Osteoblasts form new bone (osteoid)
Osteocytes regulate remodeling via sclerostin

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What is the role of RANK-L and OPG in bone metabolism?

RANK-L: Stimulates osteoclasts via RANK
OPG: Decoy receptor that inhibits RANK-L, reducing bone resorption

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What are examples of antiresorptive agents?

Bisphosphonates
Denosumab
Estrogens
Raloxifene
Calcitonin

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What are examples of anabolic agents?

Teriparatide
Abaloparatide

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What are the FDA-approved bisphosphonates?

Alendronate
Risedronate
Ibandronate
Zoledronic acid

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What is the dosing schedule for Denosumab (Prolia)?

60 mg SQ every 6 months

What is the dosing for Teriparatide?

20 mcg SQ daily

What is the dosing for Abaloparatide?

80 mcg SQ daily

What is the mechanism of action of bisphosphonates?

Inhibit osteoclast activity by blocking farnesyl diphosphate synthase (FPPS)

What is the increase in bone mass due to bisphosphonates?

* Spine: 4–8% * Hip: 3–6%

What is the reduction in fracture risk with bisphosphonates?

* Vertebral fractures: 33–68% * Hip fractures: 40–50%

What are the administration requirements for oral bisphosphonates?

Take on empty stomach with water; remain upright for 30–60 minutes

What is the administration schedule for IV bisphosphonates?

Zoledronic acid: Yearly infusion

What are common side effects of bisphosphonates?

* Esophageal/GI pain * Osteonecrosis of the jaw (ONJ)

What is the mechanism of action of Denosumab?

Monoclonal antibody against RANK-L

What is the increase in BMD with Denosumab?

* Spine: 6.5% * Hip: 3.5%

What is the reduction in fracture risk with Denosumab?

* Vertebral fractures: 68% * Hip fractures: 40%

What occurs upon discontinuing Denosumab?

Rapid bone loss and vertebral fractures may occur

What are the risk factors for osteonecrosis of the jaw (ONJ)?

* Antiresorptive agents (bisphosphonates, denosumab)

What preventive measures should be taken for ONJ?

* Oral exam before starting therapy * Delay invasive dental work if possible

What are the risk factors for atypical femoral fractures (AFFs)?

Long-term antiresorptive therapy (>5 years)

What management strategy can reduce the risk of AFFs?

Drug holidays for bisphosphonates reduce risk by 70%

What is the duration limit for hormone replacement therapy (HRT)?

Limited to ≤3 years for postmenopausal symptoms

What are the risks associated with hormone replacement therapy (HRT)?

* Increased breast cancer * Cardiovascular events

What are the effects of Raloxifene as a selective estrogen receptor modulator (SERM)?

* Increases BMD by 2–3% * Reduces vertebral fractures by 31–49% * Reduces breast cancer risk by 76%

What are the effects of Teriparatide as an anabolic agent?

* Increases spine BMD by 9–13% * Increases hip BMD by 2.5–5% * Reduces vertebral fractures by 65% * Reduces nonvertebral fractures by 50%

What are the effects of Abaloparatide as an anabolic agent?

* Increases spine BMD by 10.4% * Increases hip BMD by 4% * Reduces vertebral fractures by 86% * Reduces nonvertebral fractures by 43%

What are the indications for testosterone therapy?

Men with osteoporosis and hypogonadism (testosterone <150 ng/dL)

What are the risks associated with testosterone therapy?

* Exacerbates prostate cancer * Sleep apnea * Cardiovascular risks

Is combination therapy of antiresorptive agents recommended?

Not recommended

What is the recommended sequence for therapy?

Anabolic agent first, followed by antiresorptive agent

How often should BMD testing be repeated?

Every 2 years

What indicates compliance and predicts bone mass increase in monitoring therapy?

30% reduction in bone turnover markers

What are the criteria for treatment failure?

* ≥2 fragility fractures * BMD decrease > LSC * Bone turnover markers increase by 30%

What is the treatment for glucocorticoid-induced osteoporosis (GIOP)?

* Bisphosphonates (alendronate, risedronate, zoledronic acid) * Teriparatide for high-risk patients

What are the risk stratification categories for GIOP?

* Low risk: FRAX <10% * Medium risk: FRAX 10–20% * High risk: FRAX >20%, T-score ≤-2.5, or fragility fracture

What are the key points in osteoporosis management?

* Nonpharmacologic measures are essential * Pharmacologic therapy for high-risk patients * Antiresorptive and anabolic agents are effective * Monitor for ONJ and AFFs with antiresorptive agents * Sequential therapy (anabolic → antiresorptive) is beneficial