Osteoporosis

Question 1

What are the two types of bone?

Answer 1

Cortical (80%)
Cancellous (trabecular) (20%)

Question 2

What is the cortical?

Answer 2

Dense, forms outer shell

Question 3

What is the cancellous?

Answer 3

Porous, forms interior structures

Question 4

What are the 3 types of bone cells?

Answer 4

Osteoblasts
Osteoclasts
Osteocytes

Question 5

What bone changes does advancing age cause?

Answer 5

Oxidative stress
Osteoblast senescence
Autophagy declines

Question 6

What hormones are involved with the bones?

Answer 6

Estrogen
Androgens
Parathyroid - calcitonin
Glucocorticoid

Question 7

What is calcium required for?

Answer 7

Mineralization of bone

Question 8

What is vitamin D required for?

Answer 8

Helps regulate calcium

Question 9

What does osteocyte death lead to?

Answer 9

Increased surface remodeling
Replacement with weaker mineralized connective tissue
Disruption in repair signaling
Decrease in bone vascularity

Question 10

How much bone will women lose?

Answer 10

50% of trabecular and 35% of cortical bone

Question 11

What are the most common fractures?

Answer 11

Vertebral, followed by hip and distal forearm

Question 12

How often is the skeleton replaced?

Answer 12

Every 10 years

Question 13

What are the risk factors associated with osteoporosis?

Answer 13

Race
Calcium intake
Age
Menopause
Fam history
Sex
Small stature
Weight

Question 14

What drug has the biggest risk factor?

Answer 14

Glucocorticoid therapy

Question 15

Presentation of osteoporosis

Answer 15

No symptomatic manifestations until fracture occurs
Osteoporosis does not cause pain - the fracture does

Question 16

What might indicate a vertebral fracture?

Answer 16

Unexplained pain and height loss

Question 17

What % of men and women die within 1 year of a hip fracture?

Answer 17

33% of men
28% of women

Question 18

What is diagnostic of osteoporosis?

Answer 18

Vertebral compression fracture, hip fracture, or > 1 fragility fracture over 50 years of age

Question 19

What is a fragility fracture?

Answer 19

Trauma of falling from a normal height

Question 20

Difference in BMD T-score for osteoporosis and osteopenia

Answer 20

Osteoporosis: </= -2.5 SD normal peak
Osteopenia: -1 to -2.5 SD normal peak

Question 21

Elements of physical test for osteoporosis

Answer 21

Weight loss of >10% since age of 25
Prospective height loss >2cm
Historical height loss >6cm
Rib to pelvis distance <2 fingers width
Occiput to wall distance >5cm

Question 22

What are the recommended biochemical tests?

Answer 22

Calcium, corrected for albumin
Phosphate
Creatinine (eGFR)
ALP
TSH
25-OH-D
CBC

Question 23

How is BMD testing done?

Answer 23

Dual-energy x-ray absorptiometry (DXA)

Question 24

When is a t-score used?

Answer 24

For adults >50

Question 25

When is a Z-score used?

Answer 25

For adults <50

Question 26

What are the indications for BMD testing in adults?

Answer 26

Previous fracture, after age 40 years Glucocorticoids (>3mo in last year, prednisone >/=5mg/day) Falls >2 in last year Current smoker Alcohol >3 drinks

Question 27

what are the risk assessment tools for osteoporosis?

Answer 27

CAROC FRAX Estimate 10 year absolute risk

Question 28

Who is CAROC validated for?

Answer 28

Postmenopausal women and men >50

Question 29

Which risk assessment incorporates more factors?

Answer 29

FRAX

Question 30

What is the preferred assessment tool?

Answer 30

FRAX

Question 31

Why is exercise good for osteoporosis?

Answer 31

Stimulates osteoblast activity Lower fall risk Decrease fracture risk Possibly better maintenance of BMD

Question 32

What is the recommended dietary allowance for calcium?

Answer 32

Men: >70 1200mg/day Women: >50 1200mg/day

Question 33

What are the % of elemental calcium in each calcium salt?

Answer 33

Carbonate = 40 Citrate = 21 Lactate = 13 Gluconate = 9

Question 34

Which calcium salt is preferred with a PPI?

Answer 34

Citrate because carbonate requires some acidity

Question 35

What is the maximum amount of elemental calcium absorbed at once?

Answer 35

550mg

Question 36

What is the RDA for vitamin D?

Answer 36

70: 800IU/day

Question 37

What is the preferred form of vitamin D?

Answer 37

D3 - cholecalciferol

Question 38

What are the antiresorptives?

Answer 38

Bisphosphonates Denosumab Raloxifene Hormone therapy Calcitonin

Question 39

What are the anabolic treatments?

Answer 39

Teriparatide Romosozumab

Question 40

When should we recommend pharmacotherapy?

Answer 40

10 year fracture risk >/= 15% OR t-score <2.5

Question 41

What is the first line treatment?

Answer 41

Bisphosphonates

Question 42

What is the recommended treatment for very high risk patients?

Answer 42

Teraparatide or romosumab (anabolic) Should be followed by a bisphosphonate

Question 43

What do Bisphosphonates do?

Answer 43

Halt BMD decline and slightly reverse loss

Question 44

What are the Bisphosphonates?

Answer 44

Alendronate Risedronate Zoledronic acid (IV form)

Question 45

How can alendronate be taken?

Answer 45

10mg daily or 70mg weekly

Question 46

How can risedronate be taken?

Answer 46

5mg daily or 35mg weekly or 150mg monthly

Question 47

How often is zoledronic acid given?

Answer 47

5mg/100ml IV yearly

Question 48

Administration instructions for Bisphosphonates

Answer 48

Space from all medications (poor F) For IR: empty stomach with 1 cup of water, >30 minutes before food, drink and other meds. Remain upright for 30 minutes. For DR: take with 1 cup of liquid immediately after breakfast. Remain upright for 30 minutes.

Question 49

What fractures are reduced the most by Bisphosphonates?

Answer 49

Vertebral - hip reduced the least

Question 50

Common side effects of Bisphosphonates

Answer 50

GI complaints** Headache Dizziness Musculoskeletal pain

Question 51

What are the serious side effects of Bisphosphonates?

Answer 51

Osteonecrosis of the jaw Atypical sub-trochanteric fractures (abnormal place) Severe musculoskeletal pain Acute renal injury Atrial fibrillation (not typical) Esophagitis, reflux and ulcers Esophageal cancer

Question 52

Contraindications of Bisphosphonates

Answer 52

Esophageal abnormalities Inability to stand/sit up for 30 minutes Hypocalcemia CrCl <35ml/min

Question 53

What is the second line agent?

Answer 53

Denosumab (prolia)

Question 54

What is duration of therapy for Denosumab?

Answer 54

Indefinite treatment recommended Benefits lost upon discontinuation

Question 55

Dosing for Denosumab

Answer 55

60mg once every 6 months

Question 56

Side effect of Denosumab

Answer 56

Very well tolerated Serious: - hypocalcemia - osteonecrosis of the jaw - atypical fractures - effect on immune system - increase risk of infection - rebound fracture risk upon discontinuation

Question 57

CI for Denosumab

Answer 57

Hypocalcemia Pregnancy or lactation

Question 58

What is raloxifene?

Answer 58

Only used for women - third line prevention for postmenopausal women - women with increased risk of invasive breast cancer Typically lifelong therapy

Question 59

Side effects of raloxifene

Answer 59

Flushing Flu-like sx Leg cramps Peripheral edema Increase in triglycerides Serious: VTE Stroke

Question 60

CI of raloxifene

Answer 60

Pregnancy History of VTE

Question 61

DI of raloxifene

Answer 61

Decrease absorption of levothyroxine Bile acid sequesterants decrease absorption of raloxifene

Question 62

Where is ralofifenes main benefit?

Answer 62

Primarily vertebral fractures - also ineffective in pre menopausal women

Question 63

How long is teriparatide used for?

Answer 63

2 years (daily injections)

Question 64

How long is romosozumab used for?

Answer 64

1 year (monthly injections)