Osteoporosis/Osteopenia

Question 1

Metabolic Bone Disease

Answer 1

Any disorder resulting from chemical aberrations ex) hormones, minerals, etc.

Question 2

Who is at the greatest risk of osteoporosis/osteopenia?

Answer 2

women are at greater risk than men. 1 in 2 women, 1 in 4 men > age 50, individuals with small stature

Question 3

Primary type 1 Osteoporosis/Osteopenia:

Answer 3

Post menopausal, most common, loss of extrogen and androgen, increased bone turnover, bone resorption > bone formation, loss of trabecular bone compared to cortical bone

Question 4

Primary type II Osteoporosis/Osteopenia

Answer 4

senile-loss of stem cell precursors, predominant cortical bone loss

Question 5

Secondary form Osteoporosis/Osteopenia

Answer 5

due to presence of treatment of other diseases

Question 6

Risk factors:

Answer 6

hormone deficiency, hormone disorders including Cushings, thyroid disorders, Hyperparathyroidism, Diabetes mellitus, excessive alcohol use, tobacco, malignancy, certain genetic disorders, lack of physical activity, GI disorders, certain medications especially Corticosteroids.

Question 7

After what age does bone remodeling become “unbalanced”?

Answer 7

30

Question 8

Presentation

Answer 8

generally asymptomatic until fracture seen, hyperkyphosis, height loss

Question 9

Fragility fracture

Answer 9

Fracture sustained due to low impact injury (one that would not cause a typical individual to sustain a fracture).

Question 10

What is the best test for diagnosis of osteopenia/osteoporosis?

Answer 10

Dual energy xray absorption (DEXA)

Question 11

Who gets a DEXA screening?

Answer 11

Anyone with risk factors, anyone with a pathologic fracture, all post-menopausal women > 65, younger post-menopausal women with +FH, younger post-menopausal women with risk factors, all men 70+

Question 12

What areas does a DEXA typically scan?

Answer 12

Lumbar spine, hip, sometimes wrist

Question 13

How are DEXA screening results reported?

Answer 13

T score for most patients, Z score for pre-menopausal women and young males

Question 14

What T or Z score range is consistent with osteopenia?

Answer 14

-1 to -2.5

Question 15

What T or Z score range is consistent with osteoporosis?

Answer 15

less than -2.5

Question 16

T score less than -2.5 with pathological fracture = _____

Answer 16

severe osteoporosis

Question 17

What labs should be ordered for a patient suspected of having osteoporosis/osteopenia?

Answer 17

Vitamin D (25-hydroxyvitamin D) primary, may also want serum calcium, urine calcium, albumin, phosphate/Alkaline phosphatase, serum creatnine, LFTs, CBC, Hormone panels

Question 18

What is the best treatment for osteoporosis?

Answer 18

Prevention

Question 19

What are some prevention strategies?

Answer 19

Weight bearing/resistance exercise, fall prevention strategies, adequate dietary calcium or calcium supplementation, adequate vitamin D intake/supplementation, reduced corticosteroid use if possible, smoking cessation, alcohol reduction

Question 20

What is the threshold for pharmacologic treatment?

Answer 20

T-score of less than -2.5 is referred for treatment, 10 year hip fracture risk > 3%, 10 year major fracture risk of 10% +, any patient with a fragility fracture

Question 21

What are the pharmacologic options for osteoporosis?

Answer 21

Vitamin D and Calcium, Bisphosphonates, Denosumab (monoclonal antibody), Teriperatide (PTH analogue), selective estrogen receptor modulators (SERMs), Calcitonin

Question 22

What is the best medication option outside of vitamin D and calcium supplementation?

Answer 22

Bisphosphonates

Question 23

What is the mechanism of action of Bisphosphonates?

Answer 23

Inhibit bone resorption via osteoclasts

Question 24

Bisphosphonates medication names

Answer 24

Alendronate, Risedronate, Zolendronic Acid, Ibandronate. Medication prescribed will be dependent on patient.

Question 25

What are the rare but severe side effects of Bisphonates?

Answer 25

osteonecrosis of the jaw, atypical femur fractures

Question 26

How must (oral) Bisphonates be taken?

Answer 26

In the AM with at least 8 oz of water and 40 minutes before food, patient must remain upright after taking to avoid esophagitis.

Question 27

What is the max amount of time a typical patient can take Bisphonates for?

Answer 27

5 years

Question 28

What form is Zolendronic acid administered in?

Answer 28

IV, given to patients unable to tolerate PO bisphonates

Question 29

Mechanism of action of Denosumab

Answer 29

inhibits osteoclast maturation, RANKL inhibitor

Question 30

What are the indications of use of Denosumab?

Answer 30

treatment of osteoprosis both male and female, treatment of major fragility fracture, treatment of osteopenia with high FRAX score, high fracture risk with breast CA, prostate CA, or hormone deprivation diagnosis.

Question 31

What is the process of administration of Denosumab?

Answer 31

SQ every 6 months

Question 32

What is the mechanism of action of Teriperatide?

Answer 32

Increased parathyroid hormone agonist which causes circulating PTH to decrease, decreased resorption leads to increased formation

Question 33

What is the black box warning of Teriperatide?

Answer 33

Osteosarcoma

Question 34

When are Selective Estrogen Receptor Modulators (SERMs) used?

Answer 34

prevention NOT treatment

Question 35

What is the mechanism of action of Calcitonin?

Answer 35

Inhibits osteoclasts (decreases resorption, promotes Ca2+ deposition in bone

Question 36

True or false Calcitonin is the least effective agent for treatment or prevention of osteoporosis.

Answer 36

True