71. Osteoporosis Flashcards
(28 cards)
In menopausal or peri-menopausal women, provide advice about fracture prevention what ? (5)
- improving their physical fitness
- reducing alcohol
- smoking cessation
- risks of physical abuse
- and environmental factors that may contribute to falls (e.g., don’t stop at suggesting calcium and vitamin D).
You conduct a baseline bone mineral density which reveals she has a moderate risk for fracture. After reviewing her bone density results and making lifestyle suggestions, you discuss drug therapy with her. She has always refused to take hormone replacement therapy. She is already taking a calcium and vitamin D supplement. At this time, what first line medications other than bisphosphonates could you suggest to her for osteoporosis prevention?
- Teriparatide / Forteo / recombinant parathyroid hormone
- Raloxifene / SERM / Evista
- Denosumab / Prolia / Rank ligand inhibitor
Describe investigation osteoporosis (3)
- Screen with FRAX +/- BMD T-score to determine 10-year risk of fracture
- Consider lateral T4-L4 spine X-ray if vertebral fracture suspected
- Consider labs for secondary causes of osteoporosis
Who to screen osteoporosis ? (3)
- All men and women ≥ 65yo
- ≥ 50yo if risk factor
- <50 yo if disorder associated with rapid bone loss
How to screen osteoporosis in all men and women ≥ 65yo ? (3)
- Consider simplified Osteoporosis Self-Assessment Tool (OST) = Weight (kg) - Age (years)
- > 10, reassess OST in 5y
- <10, do FRAX
Screen osteoporosis in ≥ 50yo when? (8)
if risk factor:
- Fragility fracture after age 40 (low trauma fractures) and risk of future fractures
- Vertebral compression fracture or osteopenia on X-ray
- Parental hip fracture
- Prolonged use of glucocorticoids (3mo of >7.5 mg prednisone daily in past year)
- Rheumatoid arthritis, malabsorption syndrome
- Current smoker
- High alcohol intake (>3 units/day)
- Major weight loss (10% below body weight at age 25)
Screen osteoporosis in < 50yo when? (8)
<50 yo if disorder associated with rapid bone loss
- Fragility fractures
- High-risk medications
- Malabsorption
- Inflammatory
- Primary hyperparathyroidism
Name labs for secondary causes of osteoporosis (7)
- Calcium, Albumin
- CBC
- Creatinine
- Alk phos
- TSH
- SPEP (if vertebral fractures on X-ray)
- 25-OH Vitamin D checked once after 3 month of supplementation in impaired instesinal absorption, or osteoporosis requiring pharmacotherapy
Describe prevention : Osteoporosis (5)
- Smoking cessation, alcohol reduction <3 drinks/day
- Vitamin D
- Calcium intake
- Sufficient protein intake (1g/kg/day)
- Exercise Multicomponent program
- Fall awareness and prevention
Describe Vit D intake for osteoporosis prevention (2)
- Vitamin D 1000-2000 IU PO daily
- Consider 10,000 IU PO weekly or 50,000 IU monthly
Describe calcium intake for osteoporosis prevention (2)
- intake 1200mg/day from diet (three servings of low fat milk products)
- Can consider Calcium supplement ≤500mg PO daily in those who cannot meet recommended dietary allowance at high risk of fractures
Exercise Multicomponent program includes what ?
Resistance training ≥ twice weekly, including exercises targeting abdominal and back extensor muscles.
* Back extensor muscles daily
Balance and functional training ≥ twice weekly to reduce the risk of falls.
- Shifting body weight to the limits of stability
- Reacting to things that upset one’s balance (e.g., catching and throwing a ball)
- Maintaining balance while moving (e.g., Tai chi, heel raises, agility training)
- Reducing base of support (e.g., standing on one foot)
Aerobic physical activity 150 mins/week of moderate intensity
Describe : Fall awareness and prevention (5)
- Assistive devices
- Medication review (fall risk)
- Environmental hazards
- Hip protectors
- Urinary incontinence
Offer medication for osteoporosis when ? (2)
- if high risk (>20% 10-year fracture risk)
- or moderate but high risk feature
Name 1st-line tx for osteoporosis
Oral bisphosphonate: Alendronate 70mg PO weekly or Risedronate 35mg PO weekly or 150mg PO monthly
Describe method of taking biphosphonate (2)
- Take 1 hour before breakfast with 250mL water, upright 30 mins, avoid any calcium for 2-3h
- Duration of therapy: 3-6 years
Name risks : Biphosphonate (4)
- Ostéonécrose de la mâchoire
- fractures atypiques du fémur
- œsophagite
- ulcères œsophagiens
6 years of therapy is appropriate for who?
for individuals with a history of
* hip, vertebral or multiple nonvertebral fractures,
* or new or ongoing risk factor(s) for accelerated bone loss or fracture
What’s an inadequate response to biphosphonate ?
> 1 fracture or substantial bone density decline (e.g., ≥ 5%) occurs despite adherence to an adequate course of treatment (typically > 1 yr))
If inadequate response occurs despite adherence to an adequate course of treatment (typically > 1 yr)) or ongoing concern for fracture after 3-6 years, consider what? (3)
- Extending or switching therapy
- Reassessing for secondary causes
- Consult endocrinology
Name other tx of osteoporosis (5)
- IV bisphosphonate: Zoledronic acid 5mg IV once yearly
- Monoclonal Ab (RANKL inhibitor): Denosumab (Prolia) 60mg sc twice yearly
- PTH Analog: Teriparatide (Forteo) 20mcg sc daily
- SERM: Raloxifene
- Other: Calcitonin intranasal, Hormone therapy (in menopausal symptoms)
When to use IV bisphosphonate?
Zoledronic acid 5mg IV once yearly
* if GI/esophageal disorders,
* or inability to tolerate (eg. sit upright for 30-60 mins)
Consider Drug Holiday after 3y (6y in high risk)
When to use Denosumab? (2)
- Denosumab (Prolia) 60mg sc twice yearly if impaired renal function
- No drug holiday on Denosumab
Name adverse effects : Denosumab (2)
- Joint/muscle pai
- osteonecrosis of jaw
- contraindicated in pregnancy
