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Flashcards in osteoporosis Deck (43):
1

routine screening for osteoporosis

>=65 y.o
earlier for above average risk (other than menopause)
USPTF and AFP recommend age 60 in higher risk women

2

osteoporosis def

T-score<=-2.5 at lumbar spine, total hip or femoral neck on bone mineral density scan
or hx of fragility fracture

3

osteopenia

-1.0 <-2.5

4

who to consider w/u for secondary osteoporosis

all premenopausal women with oeteoporosis
men
postmenopausal women with low z-scores ,-2.0 or less
women who do not respond adequately to initial therapy

5

Meds that cause secondary osteoporosis

glucocorticoids
aromatase inhibitors
depo-medroxyprogesterone acetate
unfractionated heparin
GnRH agonist
anticonvulsants - phenobarbital, phenytoin,carbamezapin (accel vit D metabolism)
phenothiazine
methotrexate (not with low RA doses, 20 mg OK)
excessive vit A intake
cyclosporine-severe trabecular bone loss
tacrolimus

6

secondary causes of osteoporosis (food/disease)

malnutrition/malabsorption
IBD (vit D largely absorbed in jejunum
celiac disease
gastric and bowel resection - ca absorbed in duodenum
eton - inhibits osteoblasts
vitamin D def/insuf

7

Role of Vitamin D

inc calcicum absorption in the gut
suppress PTH release
Dec renal ca and phosp excretion$)

8

generation of bioactive Vit D

exposure to UV light cholecalicferol (D3)
cholecalciferol and ergocalciferol (D2) obtained from diet
D2 and D3 converted in liver to 25-OH vit D (calcidiol- use in liver disease)
1,25-OHD (calcitrol) formed in kidneys through renal conversion (use in kidney disease, $$

9

25-OHD levels

normal > 30
deficiency < 20
insufficiency 20-30

high prevalence esp in elderly, northern latitudes, pregnancy, IBD, celiac disease

10

average daily cholecalciferol need

3000-5000/day

11

choleocalciferol

vitamin D3
preferred therapy
800-1000IU per day for insufficiency

12

VIt D deficiency therapy

50,000 IU Q week for 8 weeks, then 500-1000 IU if deficient
monitor Vit D metabolites levels 3 months after starting therapy - 25-OHD

13

Vit D supplement if kidney disease

Vitamin D metabolites - calcitrol (1-25 OHD)

14

endocrine causes of secondary osteoporosis

hyperthyroidism
hyperparathyroidism - surgical resection improves BMD
Cushings
Hyperprolactinemia

15

misc osteoporosis causes

immobilization
smoker
post organ transplant (esp first 3-6 months
chronic disease - multiple myeloma (inc osteoclast activity)
RA
Chronic renal disease
chronic liver disease
systemic mastocytosis

16

Prevention/tx options for osteoporosis

Ca and Vit D
Weight bearing exercise
Meds: Bisphosphenates, SERM, PTH analogue, Calcitonin, Denosumab

17

calcium recommended intake

1000-1200mg WD for pre-meno and post-meno on anti-resorptive therapy
1500 mg QD for post-meno not on anti-resorptive

18

Vit D recommended intake

800 IU at least

19

Bisphosphonate

analogue of naturally occurring pyrophosphate
accelerates osteoclast turnover
inc BMD and reduces vertebral and non-vert fracture rates
inexpensive, lont-term needs a holiday, usually 12-18 month holiday, no guidelines, base on BMD

20

alendronate (fosamax)

10 mg QD, 70 mg po Q week
44% dec in vert frax
56% dec in hip fx over 4 years

21

risedronate (Actonel)

5 mg po q day
41% dec vert fx in 3 years, 39% dec nonvert fx
35 mg po q week, 75 mg po 2x/mo
as effective as daily dosing
well tolerated

22

ibandronate (boniva)

oral 2.5 mg/day or 20 mg QOD
50% dec in vert gx, no dec in nonvert fx
150 mg PO once monthly
IV 3 mg q 3 mo

23

zoledronic acid

5 mg IV once yearly
70% dec in ver fx, 41% dec hip fx

24

IV bisphosphonate SE

flu like syndrome after infusion
hypocalcemia after infusion
inc r/f afib
no inc r/f jaw necrosis
safety over 3 years not established

25

GI SE of oral bisphosphinates

poorly absorbed, must take on empty stomach 30 before eating, 60 min for ibandronate
ESOPHAGITIS - remain upright for one H afteringestion
CI in those with achalasia and esophageal stricture
GERD is a relative CI

26

duration of tx

consider trial of stopping after 5 years, unless very high risk

27

osteonecrosis of the jaw

most with IV bisphosphenate, associated with dental procedures
stop oral therapy 3 months before procedures, on patients taking oral therapy > 3 years, then restarting after healing is complete
dental exam before starting IV therapy

28

A fib and bisphos

higher a fib, pathogenesis not clear

29

bisphosphonate in renal disease

not recommended with cr cl < 35, lots of secondary osteo, more appropriately managed by endo
these drugs stay in your body for a long time at baseline, greater r/f dynamic bone disease

30

SERM

raloxifene: for prevention and tx of osteoporosis
binds estrogen receptors - antagonist/agonist
2.4 % inc of lumbar spine and hip
30-50 % reduction in vertebral fxs
NO reduction in NON-VERTEBRAL fx

31

SERM SE

inc thrombosis risk, vasomotor sx
dec r/f invasive breast CA
2nd line agent behind bisphos, less potent anti resorptive agent, doesn't help with hip fx

32

calcitonin

potent antiresorptive agent
rapid action on osteoclast
intranasal dose, dec vert fx risk by 33%
not as effective as bisphos or PTH
unclear long-term efficacy
analgesic effect for acute or chronic pain from fx

33

parathyroid hormone (Teriparatide)

recombinant PTH
intermittent dosing stimulates osteoblasts
inc GI Ca absorption
inc renal tubular resorption of Ca leading to bone formation
no more than 1-2 yr tx
dec vert and non-vert fx
dec fx risk after tx discontinued
very expensive, last resort
20 mcg/day SQ

34

PTH SE

N/V, dizziness, hypercalcemia (CI kidney stones), leg cramps

35

PTH monitoring

BMD one year after starting
Ca levels 1,6 and 12 mos
renal function
uric acid

36

PTH and bisphos?

not recommended
coexistent therapy blunts response of PTH
3 month washout period of bisphos
sequential therapy may be beneficial

37

candidates for PTH therapy

T score <-2.5 with fragility fx
those who fail other tx options or are not able to tolerate other tx modalities

38

Denosumab

human IgG antibody to RANKL
controls osteoclast differentiation, activation and survival

39

monitoring osteoporosis therapy

recheck BMD in 1 year, then q2 years
can also check levels of bone turnover after 6 mos
urinary NTX excretion - dec > 50%
serum carboxy-terminal collagen crosslings
if BMD stable or imp - successful
if BMD decreases - confirm compliance, look for further causes, can recheck in one year or change therapy

40

monitoring therapy, pt on corticosteroid

baseline BMD
monitor q6mo, then q 6-12 months if not on therapy
annual follow-up measurements once on therapy

41

oosteoporosis in Men

incidence of fx inc with age, though 10 yrs later than women
mortality from hip and vert fx higher in men
2nd causeID in 40-60% of fx

42

osteo screening in men

screen >70, radiographis osteopenia, loss of height, fragility fx, long term steroids, intestinal disorders

43

therapies for osteoporosis approved for men

bisphos and PTH analogue