Flashcards in Osteoporosis Deck (39):
What is the definition of osteoporosis?
Loss of bone mass, dec bone strength & inc risk of fx
What is the prevalence of osteoporosis for men and women?
10 million people in U.S. >50 yo have osteoporosis & 34 million have osteopenia
80% Women and 20% men
Are men or women more likely to die form a hip fracture?
1 in 2 women >50 yo will have a fracture in their lifetime
1 in 5 w/ hip fracture will die within 12 months
Men are more likely than women to die within a year from problems related to hip fracture
One fracture risk of sustaining another fracture
How do you identify a pt at risk for osteoporosis?
1. Medical hx
B Risk factors
2. Physical exam
3. Bone densitometry
A. women >65 years of age
B Men > 70 years of age
What are the risk factors for osteoporosis?
1. Advancing age
A. F>M females have lower peak bone mass and smaller bones than men
A. Caucasian and Asian > African American and Hispanic
4. Low Body Wt <127 #
6. FH of osteopenia / osteoporosis or low trauma fx
A. Parental hx of hip fx
7. Excessive alcohol consumption
8. Previous fracture
9. Glucocorticoid therapy
10. Rheumatoid Arthritis
11. Secondary osteoporosis
A. Malabsorption disorders
B. Gastric bypass pts
Define primary osteoporosis
1. Hormone deficiency
B. Testosterone (in men)
2. Sedentary lifestyle
5. Body size
Define secondary osteoporosis
1. Hormone excess
A. Cushing’s Syndrome
3. Celiac Disease
A. Chronic steroid use
What is the pathophys of osteoporosis?
Pathogenesis of osteoporosis not 100% clear, imbalance of
bone resorption and formation
What are the sxs of osteoporosis?
1. Typically asymptomatic until fracture occurs
2. Loss of height
A. 1.5 inches or more since young adult
B. .5 inches in one year
A. Dowager’s hump
What is the mneumonic for osteoporosis risk factors?
What are the dx studies for osteoporosis?
1. Serum VD 25 (OH)
What are the 25 (OH) Vitamin D3 results?
1. 31-100 ng/ml (normal)
2. < 31 ng/ml = Vit D insufficiency
3. < 20 ng/ml= Vit D deficiency
4. Levels < 31 ng/ml risk of fracture
What is vitamin D deficiency related to?
1. Has been linked to inc risk of developing:
A. Autoimmune diseases
C. Type I diabetes
D. Also associated w/ HTN and Cardiovascular disease
What are the risk factors contributing to vitamin D deficiency?
1. Advancing age
2. Inadequate sun exposure
3. Insufficient dietary intake of vit D
4. Dark skin complexion
5. Malabsorption disorders, liver diseases and kidney disease
What is a bone density scan?
1. Dual-energy x-ray absorptiometry(DXA scan)
2. Determines density of LSS and hip (distal 1/3 radius)
3. Bone Mineral Density (BMD)
A. T- score: Bone density of pt compared to bone density of young normal mean, expressed as SD
B. Z- score: Bone density in premenopausal women, children and younger men
4. Repeat every 2-3 years
5. Non-invasive test- less radiation exposure than background radiation exposure in one day
What is the gold standard for diagnosing osteopenia and osteoporosis?
Dual-energy x-ray absorptiometry(DXA scan) aka Bone Density Test
When should a DXA be ordered?
1. Age 65, UNLESS risk factors are present, earlier screening
A. Late menarche and/or early menopause
B. Low BMI < 21 or wt <127 lbs
D. Hx of low trauma fracture of hip, wrist, spine, possibly ankle
E. Hx of hip fx in parent
F. FH of osteopenia/osteoporosis
G. Pts on chronic steroids or other meds known to contribute to bone loss
What is a normal DXA scan result?
BMD T score > 1.0
What is an osteopenia DXA scan result?
BMD T score - 2.5 < x < - 1.0
What is an osteoporosis DXA scan result?
BMD T score <-2.5
What is a severe osteoporosis DXA scan result?
BMD T score <-2.5 and the presence of 1 or more fragility fractures
Who should be treated to reduce fracture risk in osteoporotic pts?
Postmenopausal women and men > 50 with
A. Hip or vertebral fracture
B. Other prior fractures and low bone mass
C. T score , 2.5 by central DXA at the femoral neck, total hip or spine
D. Low bone mass and high risk of fracture such as glucocorticoid use or immobilization
E. Low bone mass and 10 year probability of hip fracture >3% or a 10 year probability of any major osteoporosis-related fracture > 20%
What is preventative management for osteoporosis/osteopenia?
1. Prevention and early detection of osteopenia/osteoporosis is KEY!
2. Meeting daily calcium and vitamin D requirements throughout entire lifetime
3. Weight-bearing activities
4. Smoking cessation
5. Limit alcohol intake
6. Limit excessive caffeine intake
What meds are known to cause a dec in bmd and inc rsk of fracture?
1. Pts on chronic steroids
A. Transplants, COPD, RA, IBD
2. GERD pts on PPI’s
3. DM pts on rosiglitazone (Avandia)
4. Pts with celiac dz
What are the Rx options for ostepenic/osteoporotic pts?
1. Calcium and VD3 daily
2. Keep active/ WB exercise
3. Fall prevention
5. Teriparatide (Forteo)
6. Raloxifene (Evista)
7. Denosumab (Prolia)
What are the Calcium and VD3 daily supplement Rx recommendations?
1. Calcium carbonate (or citrate) 500-600 mg po BID if 51 years old or older (500 mg BID 19-50 yo) (adolescents 1300 mg daily)
2. Oral Vitamin D3 800-2000 IU po Daily
What are the exercise recommendations?
walking, upper body dumbbells and lower body leg weights, senior programs aerobics/water aerobics
What are the fall prevention recommendations?
Balance and gait training, light weights- Refer to PT
What is the moa of bisphosphonates and what are some examples?
1. Fosamax (alendronate), Actonel or Atelvia (risedronate), Boniva (ibandronate)
2. Reclast (zoledronic acid) IV
3. Inhibits osteoclast-induced bone resorption
What is the moa of Teriparatide (Forteo)?
1. Daily SQ injection for 2 years followed by a bisphosphonate to keep the bone mass gained by Forteo
2. PTH analog that stimulates production new bone matrix
3. 2.4 mL delivery pen Q28 days - 20 mcg SQ daily injection for 2 years
4. Need to be put on bisphos after 2 yrs
5. Only medication for osteoporosis that will actually build bone
6. New bone doesn’t get mineralized unless you have normal vitamin D levels
What is the moa of Raloxifene (Evista) ?
1. 60mg po QDaily
2. Dual purpose: prevent bone loss and prevent risk of invasive breast cancer
4. Acts like estrogen on bones to reduce bone loss
5. Dec risk of invasive breast cancer
What is the moa of Denosumab (Prolia)?
1. SQ injection Q6 mos. in abdomen, arm, thigh,
2. Monoclonal ab that inhibits osteoclast activity
3. RANK ligand (RANKL) inhibitor
A. Prevents bone resorption
What are the misc about bisphosphonates?
1. Must be taken with full glass of water (tap) first thing in the morning.
2. No eating, drinking, or taking other medications for 30 minutes
3. Must remain upright for 30 minutes to dec risk of GI side effects and help w/ absorption
4. Do not take calcium along with bisphosphonate
5. Non-compliance can be an issue
A. weekly and monthly oral dosing it is better than in the past with daily dosing
B. bone turnover markers can improve compliance of treatment
What are the SE of bisphosphonates?
A. Dyspepsia, GERD, esophagitis, esophageal ulcers
B. DO NOT give to pts with hx of any of the above!
C. Most common SE are nausea and heartburn after taking pill
B. Osteonecrosis of the Jaw (ONJ)
-RARE. Reported cases were in cancer patients receiving IV med (zoledronic acid IV for MM)
0.01% - 0.04% incidence on oral meds
0.8% - 12% incidence on IV meds
Overall Risk is < 1 in 2,260 (greater chance of being struck by lightning)
3. Inc risk of ‘atypical femur fracture’ (coined in 2008)
A. Subtrochanteric and diaphyseal region of femur which are strongest part of femur
B. Not typical osteoporotic fracture at femoral neck
How long can pts remain on bisphosphonates?
5 yr max. on bisphosphonates, then drug holiday
What are the SE and contraindications for raloxifene?
A. DVT or PE history or stroke
2. Side effects
A. Hot flashes, flu-like sxs, joint pain, HA
What are the SE and contraindications for Teriperitide (Forteo)?
A. Irritation at injection site, joint pain, dizziness, nausea, (osteosarcoma in rats studies)
A. Hx radiation therapy
What are the SE of Denosumab (Prolia)?
Back pain, hypercholesterolemia, pain in arms or legs, muscle pain, osteonecrosis of jaw (ONJ)