Clinical Approach To Disorders Of Bone Metabolsim

Question 1

Risk factors for osteoporosis

Answer 1

Excessive alcohol intake

• > 4 drinks for men a day
• > 2 drinks for women a day

Family history of osteoportic fractures

Gonadal hormone deficiency

Immobilization and inadequate activity

Low body weight

Increasing age

Smoking

Being white or Asian

Question 2

what is the FRAX tool?

Answer 2

Fracture Risk Assessment Tool
- used to screen for osteoporosis risk

Used to screen:

• all women over 65 yrs
• women under 65 yrs if the estimated 10-yr fracture risk exceeds a 65 yr oils white women with no other risk factors

**currently insufficiency evidence to screen men with this tool though((

Question 3

What is a DEXA scan?

Answer 3

Duel Energy X-ray Absorptiometry
- measures bone density in spin and hip

Normal = hip/spine BMD within 1.0 SD of a young adult female
- T-score is > -1.0

Osteopenia = hip/spinal BMD between 1-2.5 SD below a young adult female
- T-score is < -1.0 and > -2.5

Osteoporosis = greater than 2.5 SD below a young adult female
- T-score is < -2.5

Question 4

Non pharmacological therapies

Answer 4

Alcohol moderation

Decrease caffeine intake

• < 2 cups of coffee
• < 5 cups of tea per day

Exercise with strength and balance training

Smoking cessation

Get at least 30 minutes of sunlight exposure 5 days a week

Take vitamin D supplementation 800 IU per day

Question 5

Steps to work up hypercalcemia

Answer 5

1) detect hypercalcemia >10.5 mg/dL total or ionized >5.6 mg/dL
2) conduct careful history and rule out causative medications that could be causing it
3) measure intact PTH

3a) if suppressed
- work up PTHrP, alkaline phosphatase levels and calcitrol levels as well as work up for malignancy
- if above doesn’t work = screen for adrenal insufficiency and hyperthyroidism

3b) if elevated = check a 24 hr urinary calcium level
- low - familial genetic cause
- high = primary or tertiary hyperparathyroidism and get a sestambi scan and set up surgery

Question 6

What are common medications to cause hypercalcemia (secondary osteoporosis)

Answer 6

Phenobarbital, phenytoin

Cyclosporine and tacrolimus

All steroids (glucocorticoids have high chance)

heparin

Lithium

Methotrexate

PPIs

SSRIs

Excessive levothyroxine

Question 7

Risk factors actors for men in osteoporosis

Answer 7

recommend beginning periodic osteoporosis risk assessment in men before 65yrs if they are at increased risk

Risk factors

• elderly <56
• presence of COPD
• underweight