Week 10 Osteoporosis - Older Women's Health Flashcards
Definition
Osteoporosis
“Porous bone”
Can be asymptomatic until bone fracture
DEXA scan
T-score range interpretation
And who does this apply to only?
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
Risk Factors for Osteoporotic fractures
Which two are the most predictive?
- 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
Osteoporotic risk factor assessment:
Do you assess everyone?
Whom especially?
YES
Especially these populations
* Postmenopausal women (any age)
* M > 50y/o
* Any individual who experiences a fragility or low-trauma fracture
BMD (DXA) screening recommendations (4 of them) from NOF
- 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
How to interpret DXA scan?
Which sites preferred?
2 sites used
LUMBAR AND HIP (BOTH)
- Total hip + femoral neck = 1 site
- Get osteoporosis anywhere = osteoporosis DX
Definition
T-score
SD difference between patient’s BMD and that of a young adult reference popualtion (T-score)
Osteoporosis Diagnostic Criteria
- Fragility Fracture OR T score ≤ -2.5 at ANY site on DXA scan
- One site has this → osteoporosis
What does FRAX calculator calculate?
What are some limitations?
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
T-score range AND/OR FRAX score
Who should be treated for osteoporosis?
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
NOF/IOM recommendations for calcium intake
M 50-70y/o: 1000mg daily
W 51+ and M 71+y/o: 1200mg daily
Risk of Calcium over-supplementation?
SEs?
Increased risk of CVD event (just dose 1200mg)
SEs:
* Nephrolithiasis
* Dyspepsia
* Constipation
* Bind to iron and thyroid hormone
Calcium carbonate vs. Calcium citrate
- 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
Optimal Vitamin D dosage intake
- 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
Labs to check prior to osteoporosis treatment
- CBC
- CMP
- Calcium, kidney studies, LFTs/ALK Phos
- 25-hydroxyvitamin D
- Phosphorous
- +/- TSH, PTH, urine calcium
Pharm Treatment options for osteoporosis
What to avoid?
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
Nonpharm tx osteoporosis
weight bearing exercise
Bisphosphonates MOA
1st line?
Med names
what to check before starting??
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)
When to consider bisphosphonate “drug holiday?”
What test to use to monitor?
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
IV risk of bisphosphonates
Long-term use risk
Osteonecrosis of Jaw (ONJ) - LOW RISK for IV use
Atypical femur fracture (AFF) - LOW RISK but increases with long term risk of medication
Definition/MOA
SERMs
Meds
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
SERMs contraindications
- Active or past history of venous thromboembolic events – work on estrogen receptors
- Lactating women
- Pregnancy
SERMs AEs
- 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
Prolia (denosumab)
- 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
Forteo (teriparatide)
- 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
When to repeat DXA screeing?
“” When on antiresorptive meds
High risk - Q2yrs
osteopenia - Q3-5yrs
Q1-2yrs after starting therapy
Then increase interval testing once therapeutic effect established
