Week 1

Question 1

If suspect that someone might have osteoporosis, why does it matter to ask if they smoke?

Answer 1

Can be a risk factor for osteoporosis, b/c interferes w/ calcium absorption.

Question 2

If you have osteoporosis, what will your calcium levels look like?

Answer 2

could look normal, maybe a little low DON’t let that fool you!

Question 3

If a patient presented to the clinic with lower back pain, would you order a CMP?

Answer 3

YES

Question 4

Primary hyperparathyroidism would do what to bone strength?

Answer 4

this could lead to secondary bone loss & high blood calcium levels

Question 5

Why do you look @ sedimentation rate when you are concerned about osteoporosis?

Answer 5

b/c multiple myeloma can present like osteoporosis, but it exhibits a high sedimentation rate. Why this is important to check…

Question 6

What could hyperthyroidism cause? What happened back in the day?

Answer 6

hyperthyroidism could cause an increase in bone turnover & osteoporosis…this is why you should look @ TSH & free T4…
Back in the day: over-treatment for hypothyroidism would cause hyperthyroidism & osteoporosis.

Question 7

What are some possible causes of acute back pain?

Answer 7

osteoarthritis
sciatica
muscle strain of back muscles
compression fracture (due to osteoporosis)
aortic aneurysm

Question 8

Compression fracture = ________ fracture.

Answer 8

stress fracture

Question 9

Why does a patient w/ acute lower back pain not likely have spinal stenosis?

Answer 9

b/c spinal stenosis would cause chronic pain most likely

Question 10

Spinal stenosis can present similarly to what type of disease?

Answer 10

vascular disease

Question 11

Why might Margery’s previous forearm fracture be concerning?

Answer 11

b/c it could be indicative of weak bones & osteoporosis

Question 12

Why is the fact that Margery is post-menopausal & hasn’t undergone hormone replacement therapy worth noting?

Answer 12

b/c lack of estrogen can put you at greater risk for osteoporosis

Question 13

Is it significant that Margery’s mom had a history of osteoporosis?

Answer 13

YES! Family hx is a huge deal!

Question 14

Why is the fact that Margery uses an inhaler for her asthma worth noting?

Answer 14

b/c systemic corticoid steroids used for a long period of time (less so inhaled) can put you at risk for osteoporosis.

Question 15

What is the ideal intake of calcium for a woman like Margery? What is in a typical dairy food serving? Should she take a vitamin supplement of calcium?

Answer 15

Ideal: 1000-1200 mg/day
Dairy Serving: 300-400 mg.
YES SHE SHOULD

Question 16

Is the multivitamin Margery is taking sufficient for her Vit D needs? How much Vit D is recommended per day for a postemenopausal woman?

Answer 16

Multivit is insufficient
Recommended: 800-1000 mg/day
**she should take a supplement

Question 17

Should Margery swim?

Answer 17

no, she should engage in weight-bearing exercise, however. This could help strengthen her bones over time.

Question 18

Why might we not want to use HRT w/ Margery? When might we want to use HRT?

Answer 18

might not want to use b/c WHI makes us think that it is associated w/ heart attack & stroke
indicated to use to alleviate symptoms of menopause right after menopause.

Question 19

What are the negative sides to calcium citrate & calcium carbonate?

Answer 19

Calcium citrate: has less calcium per tablet

Calcium carbonate: causes more bloating & constipation

Question 20

Aside from smoking, what other social question factor puts you at risk for osteoporosis?

Answer 20

alcohol intake that is excessive

Question 21

What should we recommend that Margery do now?

Answer 21

Bone mineral density test–gives baseline for treatment
Imaging of back, just to assure that it isn’t cancerous.
Treat her lower back pain with pain meds
physical therapy (not weight bearing yet, but working up to it)–including back extension exercises to strengthen vertebrae
Calcium & vit D suppléments

Question 22

What are good predictors of bone strength?

Answer 22

bone mineral density
family history 
muscle strength
age
activity
medications (such as corticosteroids)
serum PTH
serum Ca++

Question 23

What will happen if a patient experiences impingement on the spinal cord itself?

Answer 23

this will affect functions at all levels

Question 24

What will happen if a patient experiences impingement of a specific nerve as it exits the spine thru the neural foramina?

Answer 24

then it will only affect the dermatome of that specific nerve

Question 25

What are the major regulators of bone metabolism?

Answer 25

``` PTH Vit D Calcitonin GH IGF-1 Androgens Estrogens ```

Question 26

Why could osteoporosis cause a huge lifestyle burden for a patient or a huge cost for society?

Answer 26

b/c 15% of postmenopausal women will have a hip fracture & 30% of those women will have to go into longterm nursing care...osteoporosis makes this more likely.

Question 27

What is a vertebral wedge fracture?

Answer 27

Vertebrae goes from square structure to collapsed, wedge-looking structure.

Question 28

If you saw the calcium density of a fractured vertebrae...what might it be like?

Answer 28

It would seem artificially high b/c there is less matter all of a sudden. But don't be fooled.

Question 29

What factors go into determining bone strength?

Answer 29

bone quality, bone density, architecture, bone turnover, bone mineral content

Question 30

Which ethnicities are less likely to get osteoporosis?

Answer 30

African American Women | Hispanic Women

Question 31

What are some important risk factors for osteoporosis?

Answer 31

``` Maximum bone density in early adulthood personal history of fracture as an adult fragility fracture in 1st degree relative low body weight (hypogonadal-low estrogen) current smoking oral corticosteroid therapy > 3 months impaired vision estrogen deficiency (can be caused by low body weight) dementia recent falls low calcium intake low physical activity more than 2 alcoholic drinks/day ```

Question 32

How many glucocorticoids is too much?

Answer 32

more than 7.5 mg/day is a large dose

Question 33

In a woman's life, when do you lose the most calcium in your bones?

Answer 33

the first 5-7 years after menopause | after this point, there is only a little loss

Question 34

What is the fracture threshold?

Answer 34

a level of bone mass | if you bone mass is beneath this level, you are more likely to fracture.

Question 35

What is a Colles' fracture & when does someone get this?

Answer 35

this is a fracture in the forearm. this is the type of fracture that someone gets when they fall on an outstretched arm & they have weak bones.

Question 36

Which occurs earlier: hip or vertebral fractures?

Answer 36

vertebral fractures occur earlier

Question 37

When do white women start hitting the fracture threshold?

Answer 37

at around age 65

Question 38

How does a t-score relate to osteoporosis diagnosis?

Answer 38

t-score relates your bone strength to that of a healthy 30 year old woman. If you are w/i -1 standard deviation: normal -1.5--> -2.5: osteopenia < -2.5 osteoporosis

Question 39

What are the sites where you should measure a person's bone density?

Answer 39

Spine: L1-L4 Hip: total hip & femoral neck **sometimes forearm

Question 40

What are the indications for measuring the bone density of someone's forearm?

Answer 40

if a patient is very obese | hyperparathyroidism

Question 41

What are some things that could cause an artificially high bone density?

Answer 41

calcified aorta | osteophytes in the spine

Question 42

What does DXA measure? What does FRAX calculation show?

Answer 42

DXA measures bone mass | FRAX calculation shows risk.

Question 43

T/F Calcium supplements should be taken w/ Vit D supplements.

Answer 43

TRUE. Weird study showed that if they weren't taken together, could have higher risk of myocardial infarction.

Question 44

When should you initiate therapy?

Answer 44

if T score is worse than -2.5 | if fracture risk is greater than 20%

Question 45

What would the be the advantages & disadvantages of taking Raloxifen instead of Estrogen to increase bone strength in a woman w/ osteoporosis?

Answer 45

This targets only the bone, & not the uterus or breast. Therefore, doesn't put people at greater risk for breast or uterine cancer. There is an increased risk of clotting, however.

Question 46

What is the therapy that is given to a patient w/ osteoporosis as far as meds?

Answer 46

bisphosphonates | pill or infusion

Question 47

If bisphosphonates & other drugs don't work...the last line of treatment is a partial PTH like drug. What does this drug & how must it be administered to increase & not decrease bone strength?

Answer 47

must be given intermittently to increase bone strength | increases calcium in bones, (probably targets osteoblasts)

Question 48

When do men usu reach their fracture threshold?

Answer 48

later than women, around the age of 80 b/c they have a higher fracture threshold & more gradual drop off of calcium than women.

Question 48

When do men usu reach their fracture threshold?

Answer 48

later than women, around the age of 80 b/c they have a higher fracture threshold & more gradual drop off of calcium than women.