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825 > Prevention/Treatment of Osteoporosis > Flashcards

Prevention/Treatment of Osteoporosis Flashcards

1
Q

Goals of Care

A
  1. Optimize bone mineral density - prevention and treatment
  2. Optimize calcium and vitamin D levels
  3. Reduce osteoporosis risk factors when possible
  4. Prevent fractures - huge consequences on quality of life and costs, especially the older patients
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2
Q

Osteoporosis

A

BMD at least 2.5 SDs below mean for young adults

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3
Q

Osteopenia

A

BMD between 1-2.5 SDs below mean for young adults

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4
Q

Normal BMD

A

Between +/- 1 SD

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5
Q

BMD

A

-Dual x-ray absorptiometry
-Hip/lumbar are recommended sites
Two scores:
-Z-score: age matched
-T-score: expected for young, normal adults

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6
Q

Endogenous Risk Factors

A
  • Age
  • Female
  • White/Asian
  • Hereditary
  • Small stature
  • Low weight (<128 lbs)
  • Early menopause or oophorectomy
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7
Q

Exogenous Risk Factors

A
  • Sedentary lifestyle
  • Low mobility
  • Low calcium intake
  • Excessive alcohol
  • Cigarette smoking
  • High caffeine intake
  • Minimal sun exposure
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8
Q

Medical Problems + Osteoporosis

A
  • Hyperthyroiddism
  • Hypogonadism
  • Cushing’s Syndrome
  • Rheumatoid arthritis
  • High fall risk increases risk of fractures
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9
Q

Drugs + Osteoporosis

A
  • Glucocorticoids
  • Long-term heparin
  • Lithium
  • Anticonvulsants
  • Thiazolidinedione
  • Proton pump inhibitors
  • Drugs altering calcium absorption/elimination
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10
Q

Patient-Related Falling Risk Assesment

A
  • Medications
  • Cognitive impairment
  • Balance/gait disorders
  • H/O stroke
  • LE arthritis
  • Advanced age
  • Orthostatic HTN
  • Visual deficiencies
  • Weakness
  • Impaired ADLs
  • Depression
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11
Q

Environmental Factors for Fall Risk Assessment

A
  • Obstacles/clutter
  • Walking surface
  • Bumps from others
  • Poor lighting
  • Stairs
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12
Q

Indications for BMD Testing

A
  • Women >= 65 y.o.
  • Men >= 70 y.o.
  • Postmenopausal women and men 50-69 y.o. based on risk profile
  • Postmenopausal women and men >50 y.o. who fracture
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13
Q

Indications for Vertebral Imaging

A
  • All women >= 70 y.o. and men >= 80 y.o. if T-score < -1.0 SD at spine, hip , or femoral neck
  • Women 65-69 y.o., men 70-79 y.o. if BMD T-score =< -1.5 SD at spine, hip , or femoral neck

Postmenopausal women and men >= 50 y.o. if they have one of the following:

  • Low trauma fracture
  • Historical height loss of +1.5 inches
  • Prospective height loss of +0.8 inches
  • Recent/ongoing long term glucocorticoid treatment
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14
Q

Osteoporosis Prevention

A
  • Avoid vitamin deficiency states
  • Weight bearing exercise
  • Modify exogenous risk factors if possible to reduce the likelihood of falling
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15
Q

Calcium/Vitamin D in Diet

A
  • Calcium: milk, yogurt, broccoli, cheddar, spinach

- Vitamin D: salmon, tuna, egg yolk, milk, cereal, cod

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16
Q

Vitamin D Deficiency

A

-25-OH vitamin D levels: Goal > 30 ng/dL

Supplementation:

  • 50,000 IU every week for 8 weeks OR
  • 6,000 IU daily then 1,500-2,000 IU daily
17
Q

Preventing Falls

A
  • Strategies for 65+ y.o. who have increased risk of falls in community dwelling:
    1. Exercise or physical therapy
    2. Screening for osteoporosis
    3. Vitamin D Supplementation - benefit by 12 months, 600 IU for 50-70 y.o., 800 IU for +70 y.o.
18
Q

Who to Treat?

A

Postmenopausal women and men >= 50 y.o. who

  • Hip/vertebral fractures
  • T score =< -2.5 SD at femoral neck, total hip, or lumbar spine by DXA
  • Low bone mass (T-score between -1 and -2.5 SD at femoral neck, total hip, or lumbar) + 10 year risk of hip fracture >= 3% OR 10 year major osteoporosis fracture >= 20%
19
Q

Osteoporosis Guidelines

A
  1. Women with known osteoporosis should be offered pharmacologic treatment to reduce hip/vertebral fracture (Alendronate, risedronate, zoledonic acid, prolia) for 5 years
  2. Men with osteoporosis should use BPs to reduce risk of vertebral fractures
  3. Recommend AGAINST BDM monitoring during 5-year treatment in women with osteoporosis, women using menopausal estrogen, or women using raloxifene
  4. Clinician should decide whether to treat osteopenic women 65 y.o.+ on patient preferences, fracture risk profile, benefit v.s. harms, and cost of medications
20
Q

Type of Therapeutic Regimens

A
  • Bisphosphonates (BP)
  • Denosumab
  • Teriparatide and Abaloparatide
  • Calcitonin
  • Estrogens and SERMs (Raloxifene)
21
Q

Estrogen + Osteoporosis

A
  • Indication: treat/prevent osteoporosis
  • Slows bone loss and increase BMD in some studies
  • Increases risk of MI, breast cancer, stroke, and emboli
  • Don’t use for osteoporosis alone
22
Q

SERMs + Osteoporosis

A
  • Raloxifene
  • MoA: selective estrogen receptor modulator
  • Approved to treat/prevent osteoporosis
  • Increases BMD in spine and femoral neck and reduces vertebral fracture
  • Indication: 1st line in postmenopausal women who are contraindicated for BP/denosumab
  • *Consider SEs**
23
Q

SERM AEs

A
  • Chest pain
  • Peripheral edema
  • Venous and pulmonary thromboebolism
  • Hot flashes
  • Weight gain
24
Q

Duavee

A
  • Basedoxifene/conjugated estrogen
  • Tissue-selective estrogen complex
  • Indication: women with intact uterus with menopause and to prevent postmenopausal osteoporosis
25
Q

BP

A
  • Structural analog of pyrophosphonate
  • Binds to resportive surfaces, integrates into bone matrix
  • Taken up by osteoclasts and inhibits binding proteins for their function
  • Increases BMD
  • Decreases vertebral and nonvertebral fractures
  • Oral ones approved for osteoporosis (others for cancer) like Alendronate, Ibandronate, and Risedronate
26
Q

BP SE

A
  • GI
  • Osteonecrosis of jaw (rare)
  • Atypical fracture (rare)
  • CI: CrCl < 30-35 mL/min due to renal excretion
27
Q

Osteonecrosis of Jaw

A
  • Requires dental appointment before treatment is started

- Higher risk with injectable BP in cancer patients

28
Q

Atypical Fractures

A
  • Uncommon
  • Usually connected to long term BP use
  • Ongoing safety review
29
Q

Atypical Fracture Provider Advice

A
  • Be aware of the possible risk of atypical subtrochanteric & diaphyseal femur fractures
  • Follow drug label recommendations
  • Discuss known benefits & potential risks of using BPs w/ pts
  • Evaluate any patient who presents with new thigh or groin pain to rule out a femoral fracture
  • D/C potent antiresorptive meds in pts who have evidence of a femoral shaft fracture
  • Consider periodic reevaluation of the need for continued BP therapy, particularly in patients who have been treated for over 5 years
  • Report any adverse events with the use of BPs to the FDA’s MedWatch program
30
Q

Denosumab

A
  • Prolia
  • Fill-length human monoclonal IgG2
  • RANKL inhibitor
  • Treats postmenopausal women with osteoporosis with high risk of fractures
  • SQ every 6 months
31
Q

Teriparatide

A
  • Forteo
  • Recombinant PTH
  • Stimulates osteoblasts and transiently increases plasma Ca+
  • EXPENSIVE
  • Only for specific patients
32
Q

Teriparatide Patients

A
  • Post-menopausal women
  • Primary or hypogonadal osteoporosis in men
  • Glucocorticoid-induced osteoporosis
  • Failed/intolerant to other therapies
33
Q

Teriparatide SE/CI/Warnings

A
  • SE: Dizziness, leg cramps
  • CI: Paget’s disease, increased alkaline phosphatase, h/o radiation treatment
  • Black Box Warning: osteosarcoma, don’t use for more than 2 years
34
Q

Abaloparatide

A
  • Thymlos
  • PTHrR analog
  • Indication: Postmenopausal women with osteoporosis at high risk for fracture defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy
  • Self-administered with pre-filled pen
35
Q

Abaloparatide AE

A
  • Most common: hypercalcemia, dizziness, nausea, headache, palpitations, fatigue, stomach pain, vertigo
  • Orthostatic hypertension within 4 hours of dose
  • Warning: Osteosarcoma, don’t use for more than 2 years
36
Q

Calcitonin

A
  • MoA: hypocalcemic hormones secreted by follicular cells of thyroid gland
  • Increase mineral stores in bones and decrease the number/activity of osteoclasts
  • Increases spine BMD by 1-3%
  • Cancer risks have been shown to outweight the benefits in many cases, taken off certain markets
  • *May treat pain from acute vertebral compression fractures**
37
Q

Osteoporosis Conclusions

A
  • Prevention is of the utmost importance
  • BMD screening is recommended in all women >= 65
    years and men >= 70 years
  • Treatment-Refer to NOF/ACP guidelines
  • Consider side effects and length of therapy (reassess after 3-5 years of treatment)
  • Bisphosphonates and denosumab are typically 1st-line
    therapies for osteoporosis/high risk osteopenia (based on FRAX)
  • Hormone therapy reduces fracture risk, however the risks generally outweigh the benefits.
  • Teriparatide, abaloparatide, romosozumab are approved for specific patients with severe osteoporosis at high risk for fractures
38
Q

Romosozumab-aqqg

A
  • Evenity
  • Monoclonal antibody binds to sclerostin, an osteocyte-derived inhibitor of osteoblast activity
  • Use: postmenopausal women at high risk of fracture
  • SE: ONJ, atypical fractures
  • Injection, 12 mo max duration
  • Possible risk of MI, stroke, and CV death
  • Brand new possible therapy, had a hard time making it to market do to side effects/risks

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