Osteoporosis & Fragility Fractures

Question 1

What is Osteoporosis?

Answer 1

Chronic disease characterized by bone microarchitecture deterioration due to reduced bone mineral density - decreased bone strength, bone fragility and increased fracture.

Question 2

What are the etiologies of osteoporosis?

Answer 2

Primary = menopausal and aging
Secondary - due to diseases such as endocrine disorders, malabsorption, treatment (glucocorticoids) and idiopathic

Question 3

How is osteoporosis being diagnosed?

Answer 3

Based on Bone Mineral Density (BMD) in relation to reference standard

T score of less dow or equal to -2.5 T score

Question 4

What is the normal T score

Answer 4

greater than or equal to -1 T score

Question 5

What is the score for osteopenia?

Answer 5

Low bone mass or osteopenia which is between -1 and -2.5 T score

Question 6

Among the adult populatin, who should be screened for osteoporosis?

Answer 6

All postmenopausal women
Men aged 50 and above
Adults with clinical risk factors (personal hx of fracture, low BMI, inflammatory arthritis, medications , alcoholisms, current smokers)

Question 7

Among the adult population, what factors increase the risk of osteoporosis?

Answer 7

Advanced age (>70)
Fagility fracture hx
menopause or untreated early menopause
Parental hx of osteoporosis/ fracture
excessive alcohol (>3.5 units per day)
Smoking
Frailty or low level of physical activity

Question 8

What comorbidities increase the risk of osteoporosis?

Answer 8

Diabetes
Hyperparathyroidism or other endocrine disease
RA
SLE
IBD
Malabsorption
Chronic Liver Disease
Neurological disease (Alzheimer’s, Parkinson’s, MS, Stroke)
Mod to Sev Kidney disease
Bronchial Asthma
HIV
Institutionalized patients with epilepsy

Question 9

What medications increase osteoporosis?

Answer 9

Glucoroticoids
Antidepressants,
Anti-epileptic agens
Aromatase inhibitors
GnRH agonists for prostate cancer
PPIs
Thiazolidinediones
Anticoagulatns
Methotrexate
Thyroid Hormones

Question 10

What tool should be used for osteoporosis screening?

Answer 10

FRAX (fracture risk assessment tool)
OSTA (osteoporosis self-assessment tool) as an alternative

Question 11

Among adult population, what is the clinical presentation of osteoporosis?

Answer 11

may include any of the following:
acute onset back pain
height loss
thoracic kyphosis
previous fability fracture
menopause or untreated early menopause,
parental hx of osteoporosis and/or fracture
alcohol consumption >3.5 units per day
smoking
low weight of BMI of < 18.5
4cm or more height loss or thoracic kyphosis

Question 12

Among at risk of PMW, should BMD measurement using dual energy xray absorptionmetry (DEXA) be used to diagnose osteoporosis?

Answer 12

YES.
Criteria:
history of fragility fracture/s
BMD T-score of 2.5 or less
Low bone mass (BMD <1.0 and <2.5) with fragility fracture
high fracture risk accdg to FRAX

IF at risk of vertebral fracutre, VFA (vertebral fracture assessment using DXA or lateral spine radiograph
or
FRAX w/o BMD if latter is unavailable. Fracture intervention threshold of 3.75% for major osteoporotic fracutres and/or 1.25% for hip fractures

Question 13

Is FRAX can be used in male in the Philippines?

Answer 13

NO. only in PMW

Question 14

Among PMW with osteoporosis, are the anti-resorptive agensts, i.e. alendronate, ibandronate, zoledronate, denosumab, raloxifene, effective in reducing vertebral, non-vertebral, hip fractures compared to placebo?

Answer 14

YES as an initial therapy (alendronate, denosumab, risedronate and zoledronate)
Alternatives: ibandronate, raloxifene

Question 15

Among PMW with severe osteoporosis, is teriparatide, abaloparatide and romosozumab effective in reducing, vertebral, non-vertebral and hip fractures compared to placebo? How long should treatment duratin be?

Answer 15

YES. Abaloparatide and romosozumab prevent vertebral, non-vertebral and hip fracture
Teriparatide reduces the risk of further vertebral and non vertebral fracture

Teriparatide x 24 months
romosozumab x 12 months

Question 16

Among PMW with osteoporosis, should calcium and vitamin D supplementatin be given to reduce fragility fracture risk?

Answer 16

Calcium at 700-1200 mg/day and vitamin D at least 800 IU per day are recommended along with anti-osteoporosis medication

Higher doses for homeboud, institutionalized Chron’s , achlorhydria, post bariatric, use of PPI

Question 17

Among post-menopausal women diagnosed with osteoporosis, should serumc alcium and vitamin D levels be normalized prior to initiating anti-resorptive therapy?

Answer 17

YES for both calcium and vitamin D

Question 18

What is fragility fracture?

Answer 18

Any fracture in an older person, though not all geriatric fracture.

Question 19

among patient swith previous fragility fractures, what is the effect of pharmacologic intervetion ont he risk of having a subsequent or second fracture?

Answer 19

biphosphonates and teriparatide are recommended to reduce risk of subsequent fractures

Question 20

Among patients with acute displaced fragility fractures of the distal radius, is early surgical intervention superior to conservative management for improving functionality?

Answer 20

NOT recommended especially among 65 years old and above

Question 21

Among patients who sustained fragility fracturs of the hip, is earlyintervetin superior to delayed surgical intervention in improving overall survival, morbidity, mortality and functionality of patients?

Answer 21

Suggested early within 24 to 48 hrs be done

Question 22

In patients with a previous osteoporotic fragility fracture, will enrollment in a secondary fracture prevention program or fracture liaison service (FLS) improve treatment adherence and prevent re-fractures?

Answer 22

it is recommended that they be managed within a formal integrated system of care that incorporates a fracture liaison service (FLS) to prevent re-fractures and improve adherence to osteoporosis treatment.

Question 23

Among adults receiving osteoporosis treatment, what is the appropriate interval between central DXA scans in monitoring treatment response?

Answer 23

it is recommended that central DXA test should be done every 1-2 years especially in patients at high risk of fracture, then at longer intervals thereafter once definite satisfactory treatment response is achieved.

Question 24

Among patients with recent fragility fracture/s, should an immediate referral to bone specialist be done for better evaluation and management?

Answer 24

patients with the following risk factors/conditions be referred to an osteoporosis specialist:
• patients with fragility fracture and/or subsequent fragility fractures
• BMD T-score ≤ − 3.5
• Tx with high dose glucocorticoids (≥7.5 mg/day of prednisolone or equivalent over 3 months) patients with co-morbidities such as CKD, endocrine and rheumatic diseases

Question 25

Should at-risk PMW and older men receive calcium supplementation and/or Vitamin D supplementation for prevention of osteoporosis and fragility fractures?

Answer 25

Among at-risk adults with normal FRAX and BMD scores, calcium and vitamin D supplementation is recommended for those who cannot meet country-specific reference standards.

Question 26

What is the recommended dose of calcium?

Answer 26

calcium (minimum 700 mg daily) is preferably achieved through dietary intake or otherwise by supplementation other studies shows that Calcium of 1000-1200 mg/day and Vitamin D of 800 IU/day reduce risk of any fracture and hip fracture

Question 27

Among PMW and older men, what doses of calcium and Vitamin D are associated with reduced fragility fracture risk?

Answer 27

Among PMW and older men, supplementation with Vitamin D at 400 to 600IU/day and Calcium at 700 to 800 mg/day is recommended.

Question 28

Among PMW and older men, what is the benefit of physical activity in the prevention of osteoporosis and fragility fractures?

Answer 28

Among PMW and older men, regular physical activities using a combination of exercise types (such as weight bearing, balance training, flexibility or stretching exercises, endurance and progressive strengthening exercises) are recommended to increase BMD and reduce the risk of fragility fractures.

Question 29

Among PMW and older men, does smoking cessation prevent osteoporosis and fragility fractures?

Answer 29

Among postmenopausal women and older men, smoking cessation is recommended to reduce risk of osteoporotic fractures.

Question 30

Among PMW and older men, what diet is effective in the prevention of osteoporosis?

Answer 30

Among PMW and older men, a balanced diet or nutrient-dense diet is recommended to prevent osteoporosis and fragility fractures.

Question 31

Should at-risk postmenopausal women receive (MHT) for the prevention of fragility fractures? What is the duration of use for MHT?

Answer 31

Among at risk peri and postmenopausal women with climacteric symptoms but without contraindications to MHT, it is recommended that MHT be given for a minimum duration of 2 years but not longer than 3 years to reduce fracture risk. Among at-risk peri and post-menopausal women with climacteric symptoms but with contraindications to MHT, MHT is not recommended.

Question 32

Ia HRT recommended for osteoporosis prevention?

Answer 32

YES

Question 33

What is the duration of MHT use?

Answer 33

5-7 years significantly decrease the incidence of spine, hip and nonvertebral fractures

Question 34

When should Menopausal Hormone Therapy be initiated to reduce fracture risk?

Answer 34

Among women younger than 60 years of age, initiation of MHT may be of greater benefit in fracture risk reduction.

Question 35

Up to when should menopausal hormone therapy be given?

Answer 35

It is ideally started during the perimenopausal stage and continued until age 60 In the absence of contraindications, women younger than 60 or within 10 years of menopause onset, systemic hormone therapy is recommended to decreased bone loss

Question 36

Which hormone preparation should be used for fracture risk reduction?

Answer 36

Among hysterectomized PMW, it is recommended to give estrogen only replacement therapy for fracture risk reduction. Addition of progestins is recommended for women with intact uterus to prevent endometrial pathology.

Question 37

What are the risk of MHT?

Answer 37

Continuous estrogen + progesterone hormone therapy increases risk of coronary events, stroke, venous thromboembolism, breast cancer, death from lung ca and gallbladder disease Estrogen only increases risk of coronary events, stroke, VTE, breast Cancer and gallbladder disease All MHT increases risk of breast Ca except vaginal estrogens. more from estrogen+ progesterone therapy than estrogen alone therapy

Question 38

Among at-risk postmenopausal women, should SERMS be considered an alternative to MHT for prevention of osteoporosis?

Answer 38

SERMS - selective estrogen receptor modulators (SERMS) Raloxifene is used to treat and prevent ostoporosis and prevent breast Ca. use of raloxifene after 2-3 years increases bone density of the lumbar spine

Question 39

How are adverse events monitored in women receiving MHT for osteoporosis prevention?

Answer 39

1. Among women on MHT who are at risk of breast cancer, it is recommended for them to undergo annual mammograms. 2. Among women with postmenopausal bleeding on MHT, it is recommended for them to undergo transvaginal ultrasound. 3. Among women on MHT, it is recommended that they be monitored for signs and symptoms of venous thromboembolism, cardiovascular and cerebrovascular diseases.

Question 40

What is AMH

Answer 40

Anti-mullerian hormone is a good predictor of early bone loss as correlated with bone mineral density measurement in the early perimenopausal period

Question 41

Women should be evaluated for osteoporosis using?

Answer 41

Bone DXA after at least 2 years of therapy If MHT is discontinued, benefits quickly disappears. Markers of bone turnover returned to pretereatment after a few months, whereas BMD decreased within 1 to 2 years of stopping medication