Week 10 Osteoporosis - Older Women's Health Flashcards

1
Q

Definition

Osteoporosis

A

“Porous bone”

Can be asymptomatic until bone fracture

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2
Q

DEXA scan
T-score range interpretation
And who does this apply to only?

A

T-score: -1.0 ≤ x is (normal BMD)

T-score: -1.0 and -2.5 (low BMD or osteopenia)

T-score of -2.5 ≥ x (osteoporosis)

Post-menopausal women and men age 50 and older

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3
Q

Risk Factors for Osteoporotic fractures
Which two are the most predictive?

A
  • Advanced age
  • Previous fracture
  • Long-term glucocorticoid therapy
  • Low body weight (less than 127 lb)
  • Parental history of hip fracture
  • Current cigarette smoking
  • Excess alcohol intake
  • Rheumatoid Arthritis
  • Secondary Osteoporosis – anything causing this
  • Other things to consider: calcium and vitamin D intake, inadequate physical activity, recurrent falls, frailty, dementia, visual impairment

BOLDED - MOST PREDICTIVE

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4
Q

Osteoporotic risk factor assessment:
Do you assess everyone?
Whom especially?

A

YES
Especially these populations
* Postmenopausal women (any age)
* M > 50y/o
* Any individual who experiences a fragility or low-trauma fracture

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5
Q

BMD (DXA) screening recommendations (4 of them) from NOF

A
  • W 65y/o ≤ & M 70y/o ≤, regardless of clinical risk factors
  • Younger postmenopausal W; W in the postmenopausal transition & men 50-59 y/o with clinical RFs for fracture
  • Adults who have a fracture > 50y/o
  • Adults with/condition (eg, rheumatoid arthritis) or taking a medication (eg, glucocorticoids in a daily dose ≥ 5 mg prednisone or equivalent for ≥ 3 months) associated with low bone mass or bone loss
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6
Q

How to interpret DXA scan?
Which sites preferred?

A

2 sites used
LUMBAR AND HIP (BOTH)
- Total hip + femoral neck = 1 site
- Get osteoporosis anywhere = osteoporosis DX

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7
Q

Definition

T-score

A

SD difference between patient’s BMD and that of a young adult reference popualtion (T-score)

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8
Q

Osteoporosis Diagnostic Criteria

A
  • Fragility Fracture OR T score ≤ -2.5 at ANY site on DXA scan
  • One site has this → osteoporosis
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9
Q

What does FRAX calculator calculate?
What are some limitations?

A

10-year probability of fracture w/BMD
* Uses femoral neck BMD to estimate risk-will underestimate risk in patients with low lumbar spine but high femoral neck BMD
* Does not account for all risk factors-fall risk is a notable exclusion
* Does not account for dose or duration of glucocorticoids or variation in alcohol/cigarette use
* Does not account for risk differences in various minority groups (especially outside the US)
* Not as useful in patients whose femoral neck BMD cannot be measured

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10
Q

T-score range AND/OR FRAX score

Who should be treated for osteoporosis?

A

Post-menopausal women and men > 50 with any of the following:
* A hip or vertebral fracture (regardless of T score)
* T score: ≤ -2.5 on DXA scan
* T score: -1.0 to -2.5 at the femoral neck or lumbar spine AND a 10-year probability of hip fracture ≥ 3% OR a 10-year probability of a major fracture ≥ 20% using FRAX calculation

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11
Q

NOF/IOM recommendations for calcium intake

A

M 50-70y/o: 1000mg daily
W 51+ and M 71+y/o: 1200mg daily

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12
Q

Risk of Calcium over-supplementation?
SEs?

A

Increased risk of CVD event (just dose 1200mg)
SEs:
* Nephrolithiasis
* Dyspepsia
* Constipation
* Bind to iron and thyroid hormone

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13
Q

Calcium carbonate vs. Calcium citrate

A
  • Carbonate: cheapest, best absorbed with food (avoid in pts on H2 blockers and PPIs)
  • Citrate: best absorbed fasting, preferred in patients on H2 blockers/PPIs
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14
Q

Optimal Vitamin D dosage intake

A
  • NOF recommendations: 800-1000iu daily for adults 50 and older
  • IOM recommendations: 600iu daily for adults 50 and older; 800iu daily for adults 71 and older
  • UTD recommendations (based on meta-analysis): 800iu daily in post-menopausal women
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15
Q

Labs to check prior to osteoporosis treatment

A
  • CBC
  • CMP
    • Calcium, kidney studies, LFTs/ALK Phos
  • 25-hydroxyvitamin D
  • Phosphorous
  • +/- TSH, PTH, urine calcium
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16
Q

Pharm Treatment options for osteoporosis
What to avoid?

A

Calcium & Vitamin D plus Anti-resorptives
* Bisphosphonates (oral/IV)
* SERMs
* Denosumab
* Estrogen – not used for osteoporosis, more off-label use
* PTH – anabolic agent (Forteo)

AVOID COMBO therapy

17
Q

Nonpharm tx osteoporosis

A

weight bearing exercise

18
Q

Bisphosphonates MOA
1st line?
Med names
what to check before starting??

A

1st line therapy for osteoporosis in post-menopausal women
* Reduce bone turnover increasing in bone density and decreasing fracture risk (antiresorptive → less bone remodeling → stronger bones)
* Must ensure normal calcium & vitamin D and check renal function before starting
* PO: alendronate, risendronate, ibandronate
* IV: zoledronic acid (once yearly infusion)

19
Q

When to consider bisphosphonate “drug holiday?”
What test to use to monitor?

A

After 5 years (po) or 3 years (IV), if fracture risk is
* Low: discontinue BP and recheck BMD after 2-4 years
* High (T score < -3.5 or hx fracture): consider continuing therapy for up to 10 years (6 years IV)

Monitor with DXA scan

20
Q

IV risk of bisphosphonates
Long-term use risk

A

Osteonecrosis of Jaw (ONJ) - LOW RISK for IV use
Atypical femur fracture (AFF) - LOW RISK but increases with long term risk of medication

21
Q

Definition/MOA

SERMs
Meds

A

Selective Estrogen Receptor Modulators
* Estrogenic agonist in the bone = stronger bones
* Estrogen antagonist in breast tissue = decreased risk of breast cancer

Tamoxifen – usually used for breast cancer tx
Raloxifene (Evista) used for osteoporosis

22
Q

SERMs contraindications

A
  • Active or past history of venous thromboembolic events – work on estrogen receptors
  • Lactating women
  • Pregnancy
23
Q

SERMs AEs

A
  • Hot flashes + leg cramps
  • 2- to 3-fold increased risk of venous thromboembolic events
  • No increased risk of stroke, but Black Box Warning for increased risk of death following stroke
24
Q

Prolia (denosumab)

A
  • Rank Ligand inhibitor
  • SQ injection Q 6 months
  • Useful in patients with high fracture risk who cannot tolerate bisphosphonates or have markedly impaired renal function or in patients unresponsive to bisphosphonates
  • Must check serum creatinine, calcium, phosphorus and magnesium within 14 days of injection
25
Q

Forteo (teriparatide)

A
  • Anabolic agent – stimulate new bone formation and activate bone remodeling
  • Daily SQ injection
  • Recommended in severe osteoporosis, those unable to tolerate or have contraindications to bisphosphonates and those who fail other osteoporosis treatments
  • Monitor for hypercalcemia
  • No significant benefit after 2 years
  • Recommend an antiresorptive after teriparatide is discontinues
26
Q

When to repeat DXA screeing?
“” When on antiresorptive meds

A

High risk - Q2yrs
osteopenia - Q3-5yrs

Q1-2yrs after starting therapy
Then increase interval testing once therapeutic effect established