osteoporosis 602
What is the duration of bisphosphonate therapy?
3-5 years?
Explain age-related osteoporosis.
Age-related osteoporosis occurs in older adults because of accelerated bone turnover rate and reduced osteoblast bone formation. These bone changes result from hormone, calcium, and vitamin D deficiencies and/or changes in their absorption and metabolism
How is osteoporosis diagnosed?
BMD measurement or presence of fragility fracture • Diagnosis is based on a low-trauma fracture or central hip and/or spine DXA using WHO T-score thresholds
How does bone loss occur?
Bone loss occurs when bone resorption exceeds bone formation, usually from high bone turnover; when the number or depth of bone resorption sites greatly exceeds the rate and ability of osteoblasts to form new bone.
What are the 2 types of bone and where are they found? What is bone composed of?
Cortical bone makes up the majority of the skeleton (80%) and is found mostly in the long bones Trabecular bone is found mostly in the vertebrae and ends of long bones Bone is made of collagen and mineral components The collagen component gives bone its flexibility and energy-absorbing capability. The mineral component gives bone its stiffness and strength.
What effects dose estrogen have on the bone remodeling process? Testosterone?
Estrogen: many positive effects - most help to maintain a normal bone resorption rate. Suppresses proliferation and differentiation of osteoclasts and increases osteoclast apoptosis Testosterone: • Effects are mostly related to metabolism to estradiol and the above bone effects of estrogens • Increases OPG production, which will inhibit bone resorption • Increases osteoblast proliferation and differentiation
What are the medical conditions associated with osteoporosis in children and adults?
Hyperthyroidism, DM, GI disorders, RA, Lupus, COPD, CKD, HIV/AIDS, genetic diseases
What results in low BoneMineralDensity?
It can occur as a result of failure to reach a normal peak bone mass or bone loss.
Why are men at a lower risk for developing osteoporosis and osteoporotic fractures?
Larger bone size, greater peak bone mass, increase in bone width with aging, fewer falls, and shorter life expectancy.
When is calcitonin used?
Last-line for women at least 5 years past menopause
What are osteocytes? Osteoblasts?
Osteocytes: bone cells Osteoblasts: bone-forming cells
12. When is peak bone mass attained? Why does it matter how much peak bone mass is attained?
Peak bone mass is attained by age 18 to 21 years The higher the peak bone mass, the more bone one can lose before being at an increased fracture risk.
What are the signs and symptoms of osteoporosis? What tests are performed?
Symptoms: • Frequently asymptomatic • Pain • Immobility • Depression, fear, and low self-esteem from physical limitations and deformities Signs: • Shortened stature (>1.5-in [3.81-cm] loss), kyphosis, or lordosis • Atraumatic vertebral, hip, wrist, or forearm fracture (fragility fracture)
what are fragility fractures?
Those occurring after falls from no more than a standing height and with minimal or no trauma
What effects do vitamin D, PTH, and calcium have on bone?
Vitamin D and PTH work together to maintain calcium homeostasis.
osteoporosis
bone disorder characterized by low bone density, impaired bone architecture, and compromised bone strength that predisposes a person to increased fracture risk.
osteopenia
low bone density
does osteoporosis increase with age?
prevalence dose increase with age
When do people start to lose bone mass?
the third to fourth decade of life, during menopause and perimenopause, predominantly due to increases in bone resorption secondary to estrogen deficiency, Older adults steadily lose bone mass as a consequence of an accelerated rate of bone remodeling combined with reduced bone formation.
How do you calculate the amount of calcium in a food?
• Add zero to the percentage of the daily value listed on food labels (30% = 300 mg calcium)
What is a bone healthy lifestyle? When is prescription therapy considered?
• Adequate intake of calcium and vitamin D • Moderation of alcohol intake • Smoking cessation • Exercise • Fall prevention
Why is preventing hip fractures so important?
• After a hip fracture, only 50% of patients regain their ability to perform basic activities of daily living, which 20% become nonambulatory • Of patients age 50 and over, almost one quarter die within 1 year either from complications of the hip fracture or other comorbid disease processes
The WHO model uses which risk factors?
• Age • Race/ethnicity • Sex • Previous fragility fracture • Parent history of hip fracture • BMI • Glucocorticoid use (current or past use for 3 or more months of prednisolone 5 mg daily or equivalent doses of glucocorticoids) • Current smoking • Alcohol use >3 drinks/day • Rheumatoid arthritis • Select secondary causes with femoral neck BMD data optional to predict an individual's percent probability of fracturing in the next 10 years
What medications are associated with increased bone loss and/or fracture risk?
• Anticonvulsants (phenytoin, carbamazepine, phenobarbital, valproic acid) • Aromatase inhibitors (letrozole, anastrozole) • Furosemide • Glucocorticoids • GnRH agonists/analogs (leuprolide, goserelin) • Heparin/LMWH • HIV meds • Nucleoside reverse transcriptase inhibitors (antiretroviral therapy - zidovudine, didanosine, lamivudine) • Protease inhibitors (nelfinavir, indinavir, saquinavir, ritonavir, lopinavir) • Medroxyprogesterone acetate depot • PPI (long term) • SSRIs • Thiazolidinediones • Thyroid hormone • Vit A
How does decreased testosterone affect bones?
• Bone loss • Loss of metabolism to estradiol
What should you look for in a patient assessment for osteoporosis?
• Bone loss • Postural changes (i.e., kyphosis) • Loss of height (greater than 1.5 inches is considered significant) • Risk factor assessments, osteoporosis questionnaires, peripheral and central DXA or ultrasonography, and bone turnover biomarkers
Which therapies are antiresorptive?
• Calcium • Vitamin D • Bisphosphonates • Estrogen agonists antagonists • Calcitonin • Denosumab • Estrogen • Testosterone
How does exercise affect osteoporosis?
• Can decrease risk of falls and fractures by stabilizing bone density and improving muscle strength, coordination, balance, and mobility • Especially important early in life; lack of exercise during growth can lead to suboptimal loading/straining, decreased stimulation of bone deposition, and subsequently reduced peak bone mass • Moderate-intensity weight-bearing activity daily and a resistance activity recomended
When is calcium carbonate used? Calcium citrate?
• Carbonate: salt of choice - contains highest amount of elemental calcium (40%) and is least expensive o Taken with meals to enhance absorption • Citrate: absorption is acid dependent and need not be administered with meals (don't take with PPI)
How does estrogen deficiency affect bones? (postmenopausal)
• Causes significant bone density loss and compromises bone architecture • Increases proliferation, differentiation, and activation of new osteoclasts and prolongs survival of mature osteoclasts • Increases interleukins, prostaglandin E2, TNF-alpha, and interferon gamma, resulting in more RANKL and less OPG • Increases calcium excretion and decreases calcium gut absorption through decreases in TRPV6 activity and 1,25 dihydroxyvitamin D binding proteins
What is central DXA (GOLD STANDARD) and how is it used?
• Central Dual-Energy X-ray Absorptiometry • Measures BMD • High precision, short scan times, low radiation dose, and stable calibration
What are the drug treatments of first choice?
• Combined with adequate calcium and vitamin D: CHOICE: • Alendronate- 10 mg orally daily or 70 mg orally weekly (treatment) Prevention: 5 mg orally daily or 35 mg orally weekly o Risendronate - Treatment and Prevention: 5 mg orally daily, 35 mg orally weekly, 150 mg orally monthly o • Zoledronic acid- Treatment: 5 mg IV infusion yearly; Prevention: 5 mg IV infusion every 2 years o o Denoxumab- Treatment: 60 mg subcutaneously every 6 months • ALTERNATIVE CHOICE: • Ibandronate- Treatment: 150 mg orally monthly, 3 mg IV quarterly Prevention: 150 mg orally monthly o o Teriparatide- 20 mcg subcutaneously daily for up to 2 years o Raloxifene- 60 mg daily • Last choice: • Calcitonin- 200 units (1 spray) intranasally daily, alternating nares every other day. 100 units subcutaneously daily
How much calcium supplementation is needed? How effective is calcium therapy?
• Difference between an individual's dietary consumption and recommended dietary allowance • Increases BMD, but its BMD effects are less than other antiresorptive and formation osteoporosis medications • Fracture prevention only documented with concomitant vitamin D therapy
Which fractures are considered the major osteoporotic fractures?
• Fractures of vertebrae, hip, forearm, or humerus
What are the consequences of osteoporosis?
• Fragility fracture - can lead to increased morbidity and mortality and decreased quality of life • Depression due to fear, pain, loss of self-esteem from physical deformity, and loss of independence and mobility • Patients with severe kyphosis (hunchback) can experience respiratory problems as a result of compression of the thoracic region and GI complications, such as poor nutrition, from intraabdominal compression. • Women and men who suffer a symptomatic vertebral fracture have a lower survival rate compared with those without fracture history • Wrist fractures - pain and weakness, and decreased instrumental activities of daily living • Hip fractures most highly associated with morbidity and mortality
How is osteoporosis treated in older adults?
• Healthy bone lifestyle - calcium and vitamin D and implement measures to prevent falls • Walking and resistance exercise with low weights • Home safety evaluation for falls
How is osteoporosis in children treated?
• IV bisphosphonate pamidronate or oral alendronate, have demonstrated increases in BMD • Teriparatide is a NO
What is a bone healthy diet?
• Limit salt, alcohol, caffeine, and excessive protein • Being thin/anorexic decreases bone mass
What are the risk factors for osteoporosis and osteoporotic fractures?
• Low bone mineral density • Female • Advanced age • Race/ethnicity • History of previous fragility fracture • Osteoporotic fracture in a first-degree relative • Low body weight or BMI • Premature menopause • Secondary osteoporosis • Past or present systemic oral glucocorticoid therapy • Cigarette smoking • Alcohol intake >3 drinks/day • Low calcium intake • Low physical activity or immobilization • Vitamin D insufficiency • Recent falls • Cognitive impairment • Impaired vision
What are sources of vitamin D?
• Most abundant source: endogenous production from skin exposure to UV B light • Dietary: cholecalciferol and ergocalciferol
Describe osteoporosis in premenopausal women? How are they treated?
• Most have an identifiable secondary cause • Should undergo central DXA testing
Which bisphosphonates are oral? IV? How are they taken?
• Oral - all; daily, weekly, monthly, or quarterly • IV - ibandronate, zolendronic acid; annual
What is peripheral DXA and how is it used?
• Quantitative ultrasonography (Dual-energy X-ray absorptiometry) • pDXA of the forearm, heel, and finger uses a low amount of radiation and requires personnel with special training • Easy to use, portable, fast
What are the reasons for fall risk? How are falls prevented?
• Result of balance, gait, and mobility problems, poor vision, reduced muscle strength, impaired cognition, multiple medical conditions, and polypharmacy • Association with medications such as benzodiazepines, antidepressants, antipsychotics, sedative hypnotics, and opioids • Prevention: vitamin D supplementation, regular exercise program, resolving vision, low BP, HR and rhythm, and wearing proper footwear • External hip protectors
What is the role of calcium? How much calcium is recommended? Which foods have the highest amount of calcium?
• Role of calcium: adequate intake is necessary for development of bone mass during growth and for its maintenance throughout life • How much is recommended: age-dependent o 0-6 months: 200-1000 mg calcium; 400-100 units vitamin D o 6-12 months: 260-1500 mg calcium; 400-1500 units vitamin D o 1-3 years: 700-2500 mg calcium; 600-2500 units vitamin D o 4-8 years: 1000-2500 mg calcium; 600-3000 units vitamin D o 9-18 years: 1300-3000 mg calcium; 600-4000 units vitamin D o 19-50 years: 1000-2500 mg calcium; 600-4000 units vitamin D o 51-70 years (men): 1000-2500 mg calcium; 600-4000 units vitamin D o 51-70 years (women): 1200-2500 mg calcium; 600-4000 units vitamin D o >70 years: 1200-2000 mg calcium; 800-4000 units vitamin D • Foods high in calcium: o Carbohydrates, fat, lactose increase absorption
What are the most common risk factors for osteoporosis for men?
• Smoking • Low body weight • Weight loss • Age • Long term glucocorticoid use • Androgen deprivation therapy • Low testosterone concentrations
What is the recommended intake of vitamin D? What are the main sources of vitamin D? what causes inadequate concentrations of vitamin D?
• Sources: sunlight, diet, and supplements. D3 comes from oily fish, eggs, and fortified dairy products. D2 comes from fungi and eggs. • Inadequate concentrations can be caused by: o Malnourishment or obesity o Institutionalization o Northern latitude o Insufficient intake, dietary fat malabsorption, decreased sun exposure, decreased skin production, or decreased liver and renal metabolism o Decreased production Covered skin (clothes or sunscreen) Darkly pigmented skin
What is the T-score? Z-score? What are the cut offs for osteopenia? Osteoporosis?
• T-score: comparison of the patient's measured BMD to the mean BMD of a healthy, young, sex-matched white reference population; no adjustments for race/ethnicity o Number of standard deviations from the mean of the reference population • Z-score: compares the patient's BMD to the mean BMD for a healthy sex- and age-matched population; takes race into consideration o Z-score value of </= -2.0 is sometimes helpful in determining whether a secondary cause for osteoporosis is present and is used for diagnosis in children, premenopausal women, and men under 50