Osteoporosis/Osteopenia Flashcards
Distinguish primary vs secondary osteoporosis
- Primary: Bone loss occurs with aging
* Secondary: Results from medications or diseases that affect skeletal health
What type of bone is more sensitive to estrogen loss?
Trabecular bone (Significant losses in perimenopausal and early postmenopausal women)
NAMS Recommendations for osteoporosis screening
- ALL women >65 (regardless of risk factors)
- Postmenopausal women with medical causes of bone loss (regardless of age)
- Postmenopausal women >50 with additional risk factors*
- Postmenopausal women with fragility fracture (falling from standing height)
What are the bone mineral density, T-score, and Z-score measurements on a DEXA (dual energy X-ray absorptiometry )?
BMD: grams of mineral per area or volume; it is only one parameter in determining fracture risk
T-score: compares current BMD to peak BMD
* Used when evaluating BMD in postmenopausal women (reference database Caucasian)
Z-score: compares BMD to mean BMD of peers
* Used in evaluation of premenopausal women
Lab evaluation of osteoporosis
CBC: anemia (r/o multiple myeloma)
Serum Ca++:
*high – hyperparathyroidism
*low – Vit. D deficiency, malabsorption
Serum phosphate:
* high – renal failure * low – hyperparathyroidism
25-hydroxyvitamin D:
* low – poor intake, malabsorption, celiac disease
Alk. Phos.:
* high – Vit. D deficiency, malabsorption, hyperparathyroidism, Paget’s disease, Urinary Ca++, TSH
Creatinine: high – renal osteodystrophy
When do you treat?
- Postmenopausal women and men w/ hx of hip/vertebral fracture
- T-score of −2.5 or less
- Combination of low bone mass (T-score between −1 and −2.5) and a 10-year probability of hip fracture of at least 3% or any major fracture of at least 20% by FRAX
What is the FRAX?
Fracture Risk Assessment Tool (FRAX)
- Developed by the World Health Organization using data from several international cohorts
- Predicts individual 10-year risk of hip or major osteoporotic fracture by incorporating established risk factors and BMD at the femoral neck
- Endorsed by several professional organizations
Pharm rx for osteoporosis?
Bisphosphonates are first line treatment for osteoporosis
* Alendronate (Fosamax): 35 or 70mg once weekly or
5 - 10mg daily empty stomach
* Ibandronate (Boniva): 2.5mg daily or 150mg monthly
* Risendronate (Actonel): 5mg daily, 35mg weekly, or
150mg monthly
Other options
* Raloxifene (Evista), estrogen bone agonist/ breast
and endometrium antagonist (SERM), 60mg PO daily
* Teriparatide (Forteo), recombinant human parathyroid
hormone, 20mcg SQ daily
* Denosumab (Prolia), human IgG monoclonal
antibody, 60mg SQ q.6 months
What are SERMS
Estrogen receptor agonist/antagonist
Different SERM’s have different effects on different tissues
* Tamoxifen: antagonist in breast tissue, agonist in
endometrium
* Raloxifene: agonist in bone, antagonist in breast and
endometrium
* Ospemifene: agonist in vagina and endometrium
No need for progestin but must evaluate abnormal bleeding
Rare adverse events of bisphosphinates
Atypical leg fractures (when administered with denosumab?)
Osteonecrosis of the jaw
Recommendations for patients with osteoporosis
Increased physical activity
Avoidance of smoking and excess alcohol intake,
Total calcium intake of 1000 to 1500 mg per day and a total Vitamin D intake of 600 to 800 IU per day
Antiresorptive agent
* Bisphosphonate as first- line therapy if there are no contraindications → discuss with the patient the rare potential risks of atypical femur fracture or osteonecrosis of the jaw but also the much greater anticipated benefits in terms of overall reduction in the risk of fractures.
Depending on the results of follow-up BMD measurement, discuss the possibility of temporarily discontinuing the bisphosphonate after 5 years of treatment
