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ClinMed Lab II > Case 2: Osteoporosis > Flashcards

Case 2: Osteoporosis Flashcards

1
Q

Define osteoporosis

A
  • Reduction in bone mass
  • Disruption of skeletal micro-architecture
  • Fragility of skeleton
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2
Q

What is a person with osteoporosis at increased risk for?

A

Fracture 2/2 decreased bone strength

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3
Q

What happens to the trabecular bone with increasing age?

A

Continuous trabecular network begins to breakdown there is thinning of horizontal trabecula, eventually the vertical trabecula is unsupported.

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4
Q

RF:

A
  • Women>men
  • White or Asian
  • Low body wt <127lbs or BMI <20
  • Fhx or personal hx of fragility fx
  • Long-term glucocorticoids
  • Estrogen deficiency- postmenopausal
  • Testosterone deficiency
  • Increasing age
  • *lifetime osteoporotic fx risk for a women who reaches 50 is 50%.
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5
Q

Causes of secondary osteoporosis

A
  • Meds- steroids, anti epileptics
  • Vit D deficiency
  • Low Ca intake
  • Alcohol >2-3 drinks/day
  • Sedentary lifestyle
  • Current tobacco use
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6
Q

What does FRAX calculate?

A
  • Fracture risk assessment tool
  • Calculates pt’s 10y fx probability
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7
Q

Who can you calculate FRAX score on?

A
  • Postmenopausal women and men age 40-90
  • *only validated for untreated pts, DXA scan input needed.
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8
Q

What is the gold standard for bone density testing?

A

DXA of lumbar spine and hip

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9
Q

Who gets a DXA scan?

A
  • Women ≥65 years old
  • ?men ≥70 years old- no consensus
  • Younger but at risk for osteoporosis or osteomalacia
  • Pathologic fractures
  • Radiographic evidence for diminished bone density
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10
Q

What determines the interval between scans?

A

Based on T score

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11
Q

What is the interval between DXA scans for: T score -1.0 to -1.5 T score -1.5 to -2.0 T score < -2.0

A

T score -1.0 to -1.5: every 5 years

T score -1.5 to -2.0: every 3-5 years

T score < -2.0: every 1-2 years

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12
Q

T score range for normal, osteopenia, osteoporosis, severe/established osteoprorosis?

A
  • Normal: w/in 1 SD, T score > -1
  • Osteopenia: b/w 1 and 2.5 SD below NL, -1 to -2.5
  • Osteoporosis: 2.5 SD or more below, T score < -2.5
  • Severe/Established: 2.5 SD or more below with 1 or more fragility fractures
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13
Q

What is a z score?

A

bone density as standard deviation from age-matched, race-matched, and sex-matched.

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14
Q

Who is Z score used in?

A

Premenopausal women, younger men, and kids

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15
Q

what is the first sign/symptom of osteoporosis?

A

asxs/silent until fx occurs

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16
Q

Clinical manifestations of a vertebral fx:

A
  • Height loss or kyphosis
  • Acute episodes may be associated with pain
  • Often no preceding trauma or minor trauma (ie: speed bump, standing up)
  • Acute back pain with sudden lifting, coughing, bending
  • Usually pain localized to midline spine, variable quality - May refer into flank, anterior abdomen, posterior superior iliac spine, radiation into legs rare
  • May have pain on palpation/percussion of affected vertebrae
17
Q

Xray findings:

A
  • Radiolucency
  • Cortical thinning
  • Occult fx
18
Q

Bone loss has to be greater than __% to be detected?

A

30%

19
Q

Life style modification for osteoporosis

A
  • Smoking cessation
  • Limit alcohol intake
  • Regular weight bearing and muscle-strengthening exercise- At least 30 mins, 3x/week
  • Consume at least 1200 mg of calcium/day
  • Adequate calorie intake
  • Take measures in the home to avoid falls
  • Wearing a brace
20
Q

When should a pt be started on pharmacological tx?

A
  • Hx of hip fx or vertebral fx
  • T-score < -2.5 (DXA) at femoral neck or spine, after evaluation to exclude 2/2 cause
  • T-score b/w -1 and -2.5 at femoral neck or spine, 10 yr probability hip fx > 3%, or other fx > 20%
21
Q

What should total Ca and vit D daily intake be?

A
  • Ca 1200mg/day
  • Vit D 800 units
22
Q

Calcium SE:

A

Supplements ↑ risk nephrolithiasis, may ↑ CV disease (controversial- data points away), dyspepsia, constipation. Interfere with iron & thyroid hormone absorption (take at different times)

23
Q

Vit D SE:

A
  • Excessive amounts- hypercalcemia, hypercalciuria, nephrolithiasis
  • Chronically high levels of Vit D linked to ↑cancer, mortality, and falls
  • Measure vitamin D levels with 25(OH)D
24
Q

1st line tx for osteoporosis

A

Bisphosphonates

25
Q

Bisphosphonate examples and action?

A
  • Alendronate (Fosamax)
  • Risendronate (Actonel)
  • Work on inhibiting osteoclast activity
  • Shown to improve BMD- bone mineral density and decrease fractures
26
Q

Pretreatment evaluation before starting bisphosphonates?

A
  • Calcium
  • 25(OH)D
  • Creatine
  • Correct hypocalcemia and vit D def before starting tx
27
Q

Bisphosphonate contraindications:

A
  • Esophageal disorders
  • After bariatric surgery
  • Unable to follow dosing requirements
28
Q

Bisphosphate directions:

A
  • Must be taken 1st thing in the morning on empty stomach for maximal absorption
  • Take with at least 8 oz water
  • Do not eat, drink or take any other medications for at least ½ hour afterwards
  • Remain upright (sit or stand) for 30 minutes after administration
  • IV regimens available for those who can’t tolerate oral bisphosphonates
29
Q

When to stop taking bisphosphonates?

A
  • If taking alendronate or risendronate (Actonel) for 5 years or zoledronic acid (Reclast) yearly x 3 years + have a stable BMD + no previous vertebral fractures + low risk for fracture in near future -> discontinue drug
  • If highest risk for fracture, continue PO therapy for up to 10 years, IV therapy for up to 6 years.
  • There is some residual benefit after discontinuation.
30
Q

Risks of bisphosphonates?

A
  • Upper GI irritation (reflux, esophagitis, esophageal ulcers- eats into it if it gets stuck)
  • IV bisphosphonates can cause acute-phase reaction (fever, myalgia, arthralgia),
  • Osteonecrosis of the jaw
  • Renal: Not recommended in patients with CrCl <30
31
Q

Calcitonin action?

A
  • Increases spine bone density and may decrease vertebral fracture risk
  • Inhibits osteoclast activity- works on PTH
32
Q

When is calcitonin beneficial?

A

Beneficial for short-term pain relief in those with acute pain related to vertebral fractures

33
Q

Calcitonin adverse rxns?

A
  • Rhinitis
  • Increased malignancy risk
34
Q

Oral analgesics used in osteoporosis?

A
  • Acetaminophen
  • NSAIDs (controversy of impaired bone healing)
  • Narcotics.
35
Q

Kyphoplasty/ vertebroplasty what is it?

A
  • Vertebroplast: Injection of bone cement under image guidance into fractured vertebra
  • Kyphoplasty uses a balloon to expand first
36
Q

Candidates for Kyphoplasty/ vertebroplasty?

A
  • Those unable to achieve pain control
  • Significant benefit to pain control in trials
37
Q

Kyphoplasty/ vertebroplasty adverse events:

A
  • Extravasation of cement
  • Cement PE
  • Infection
38
Q
A

ClinMed Lab II (12 decks)

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