4 - Osteoporosis Flashcards Preview

Year 3 - Clinical (Winter) > 4 - Osteoporosis > Flashcards

Flashcards in 4 - Osteoporosis Deck (20)
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1
Q

Describe osteoporosis. Define bone strength and fragility fracture

A
  • Generalized skeletal disease characterized by compromised bone strength predisposing a person to increased risk of fracture
  • Bone strength = bone mineral content (often measured by BMD) + bone quality (reflecting microarchitectural structure)
  • Fragility fracture – occurs spontaneously or from minor trauma (falling from a standing height or less)
2
Q

Goals of therapy for osteoporosis

A
  1. Reduce future risk of fractures
    - - Major = hip and vertebral fractures
    - - Hairline fractures don’t really affect people enough to go to the Dr. but could be seen on an X-ray
    - - Clinical vertebral = causes pain and seen on an X-ray
    - - Major osteoporotic = spine, forearm, shoulder, hip
  2. Prevent negative outcomes as a result of fractures (disability, loss of independence, chronic pain, hospitalizations, death)
3
Q

Describe the clinical assessment for osteoporosis

A
  1. Identify risk factors prompting assessment for osteoporosis (BMD testing)
  2. Physical exam – measure height annually (> 6 cm loss since peak height or > 2 cm w/in past year)
  3. Fall risk assessment
4
Q

What are some risk factors for older adults (50 years and older) prompting assessment for osteoporosis?

A
  • Fragility fracture after age 40
  • Prolonged use of glucocorticoids
  • Parental hip fracture
  • Vertebral fracture or osteopenia identified on radiography
5
Q

What are some risk factors for younger adults (< 50 y/o) prompting assessment for osteoporosis?

A
  • Fragility fracture
  • Prolonged use of glucocorticoids (prednisone 7.5 mg/day or more for 3 months or more in past year)
  • Hypogonadism or premature menopause (age < 45 y/o)
  • Malabsorption syndrome
  • Primary hyperparathyroidism
6
Q

Drugs associated w/ osteoporosis

A
  • Immunosuppressants
  • PPIs
  • EtOH
  • Antacid (aluminum)
  • Canagliflozin
  • Heparin > 30 d
  • Lithium
  • SSRIs
  • Thiazolidinediones
  • Vitamin A
7
Q

Fall risk factors

A
  • Muscle weakness
  • Previous falls
  • Impaired visual acuity
  • Poor balance/ gait
  • Disability
  • Advanced age
  • Postural hypotension
  • Fear of falling
  • Medications (diuretics, CNS depressants)
  • Environmental factors
  • Chronic conditions (arthritis, stroke, incontinence, DM, PD, dementia)
8
Q

When to treat osteoporosis

A

Depends on:

  • Px risk of fracture (low < 10% = pharmacotherapy no likely benefit; moderate 10-20% = pharmacotherapy considered; high > 20% or hx of fragility fracture = pharmacotherapy recommended)
  • Efficacy, safety, cost considerations of therapy
  • Px goals
9
Q

Pharmacotherapy options for osteoporosis

A
  • Bisphosphonates (alendronate, risedronate) – 1st line for established osteoporosis & corticosteroid-induced osteoporosis
  • Denosumab SQ q6months – 1st line for established osteoporosis
  • Raloxifene – decreases vertebral #s in menopausal women
  • Estrogen +/- progesterone – consider for osteoporosis prevention in early post-menopause if sx of estrogen deficiency
  • Teriparatide – consider for high-risk osteoporosis & corticosteroid-induced osteoporosis w/ prior fragility & low BMD
  • Calcitonin – not recommended; useful for pain from acute vertebral compression
  • Efficacy similar for bisphosphonates, denosumab, & estrogen (effective for vertebral, hip, & non-vertebral fractures)
10
Q

Adverse effects of bisphosphonates

A
  • “Common” = GI (abdominal pain, dyspepsia, reflux, diarrhea)
  • “Rare” = ONJ
  • Pt should be able to swallow the capsule & stay upright for at least 30 min; should be taken 30 min before breakfast
11
Q

Adverse effects of denosumab

A

Rash, MSK pain, decreased calcium

12
Q

Adverse effects of raloxifene

A
  • 5-15% flushing
  • Leg cramps
  • Flu-like sx
13
Q

Adverse effects of teriparatide

A

Nausea, dizziness, leg cramps

14
Q

Describe ONJ

A
  • Area of exposed alveolar bone (mandible or maxilla) that doesn’t heal after 8 weeks
  • Risk is higher in high-dose bisphosphonates for bone metastases, glucocorticoid use, diabetes, poor dental hygiene
15
Q

Describe atypical fractures

A
  • Appear to develop as femur stress fractures
  • May present as new thigh pain
  • Most commonly associated w/ increased duration of use, especially > 5 years
16
Q

Monitoring for osteoporosis

A
  • Recommendation was every 1-3 years, but no evidence for that claim
  • Goal is to prevent fractures; studying BMD frequently is costly & yearly is unnecessary
  • BMD not correlated to response of therapy/ risk, so don’t reassess BMD for at least 5 years
17
Q

Duration of therapy for osteoporosis

A
  • For alendronate & zoledronic acid, continuing therapy for 5 years vs. 10 years increases risk of vertebral fractures; no difference in non-vertebral (5.3% at 5 years vs. 2.4% at 10 years for alendronate)
  • Should discuss duration of therapy w/ px at baseline & at 5 years
  • Drug holidays allowed as bisphosphonates stay in the bone for extended periods of time; reassess risk in 1 year
18
Q

Tips for good bone care/ hygiene

A
  • Lifestyle (regular exercise, weight-bearing)
  • Vitamin D
  • Calcium
  • Fall prevention (minimize hazards for falling in the home; assess drugs; improve strength & balance)
  • Smoking cessation
  • Dietary measures (encourage adequate protein, calcium & vit D intake, avoid excess alcohol & caffeine)
19
Q

Supplementation for osteoporosis. What are the harms?

A
  • Calcium 1200 mg/day and vitamin D 800 IU/day
  • Decreases risk of non-vertebral (5/1000 decrease/year) & high-risk hip fractures (9/1000 decrease/year)
  • Harm:
    • Vitamin D –> negligible up to ~4000 IU/day
    • Calcium –> GI sx (nausea, constipation, bloating), hypercalcemia
  • Dietary Ca preferred (300 mg each = 1 cup milk, ¾ cup yogurt)
20
Q

Is exercise recommended for osteoporosis? If so, what kind?

A
  • Weight-bearing and stability
  • Reduced rate/risk of falls (RRR ~ 30%)
  • Small increase in BMD (up to 1%) over ~ 12 months
  • Individualize for adherence and safety