Term
|
Definition
1 year mortality rate: > 30% for men, 17% for women
2.5 fold increase of repeat hip fracture
less than half of hip fracture survivors regain pre-fracture level of independence |
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|
Term
| what is the gold standard for DIAGNOSING osteoporosis? |
|
Definition
| dual energy x-ray absorptiometry (DXA) |
|
|
Term
| what indicates a diagnosis of osteoporosis? |
|
Definition
T-score of -2.5 at the femoral hip
a postmenopausal woman has a hip fracture after falling while vacuuming the floor |
|
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Term
| diagnosis of osteoporosis |
|
Definition
measurement of bone mineral density (BMD)
dual energy x-ray absorptiometry (DXA):
gold standard
establish or confirm diagnosis
monitoring after diagnosis or treatment
femoral neck (hip), total hip, and lumbar spine BMD
can diagnose patients with risk factors who have a low trauma fracture as having osteoporosis
particularly postmenopausal females age > 40 years |
|
|
Term
| diagnostic evaluation: T-scores |
|
Definition
use in postmenopausal females and males > 50 years
normal = -1 or above
low bone mass (osteopenia) = between -1 to -2.5
osteoporosis = -2.5 or below
severe or established osteoporosis = < or = to -2.5 with fracture |
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|
Term
| diagnostic evaluation: Z-scores |
|
Definition
use in premenopausal women, men < 50 years, and children
abnormal Z score indicates a secondary cause of osteoporosis
do not diagnose with Z scores
low BMD for chronological age = less than -2
within the expected range for age = greater than -2
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|
|
Term
| WHO Fracture Risk Algorithm (FRAX) |
|
Definition
calculates 10-year probability of:
hip fracture
major osteoporotic fracture
only use in postmenopausal women and men >/= 50 years
for pre-treatmtne assessment |
|
|
Term
| risk factors for osteoporosis related fractures |
|
Definition
genetic:
ethnicity - Caucasian
gender - FEMALE > male
AGE >/= 65 YEARS
PARENTAL HISTORY OF HIP FRACTURE or osteoporosis
LOW BMD OF HIP
PRIOR OSTEOPOROTIC FRACTURE
LOW BODY WEIGHT (<127 POUNDS)
lifestyle factors:
low calcium intake
vitamin D deficiency
excess vitamin A, caffeine, salt, or ALCOHOL INTAKE
SMOKING
inadequate physical activity, immobilization
falling or high risk for falls |
|
|
Term
| factors that may accelerate bone loss |
|
Definition
endocrine disorders:
EXCESSIVE THYROID
hypogonadism
GI disorders:
malabsorption issues
celiac disease
gastric bypass
neuromuscular disorders (limited physical activity):
muscular dystrophy
paraplegia
autoimmune:
RHEUMATOID ARTHRITIS
chronic renal disease or liver disease (vitamin D cannot be hydroxylated to the active form) |
|
|
Term
| medications affecting bone health |
|
Definition
accelerates bone loss:
GLUCOCORTICOIDS >/= 5 MG/D OF PREDNISONE FOR >/= 3 MONTHS
antiepilepsy drugs - especially phenytoin (effects vitamin D synthesis)
cancer chemotherapy
lithium
depo-medroxyprogesterone
aromatase inhibitors - will block whatever estrogen the post menopausal women has left
proton pump inhibitors - increased risk long term use (5-10 years); thought to block Ca absorption
thiazolidinediones - affect the osteoblast activity in the bones
increase risk of falling or fractures:
sedative and hypnotics
antihypertensive agents
narcotic analgesics |
|
|
Term
| indications for BMD testing |
|
Definition
all females >/= 65 years and males >/= 70 years
younger post menopausal females with risk factors
adults with low trauma fractures after age 40
low trauma = fall from standing height
osteopenia identified radiographically
postmenopausal females discontinuing estrogen |
|
|
Term
| calcium and vitamin D recommendations in adult women and men |
|
Definition
19-49 years: 1000 mg calcium and 400-800 IU vitamin D
>/= 50 years: 1200 mg calcium and 800-1000 IU vitamin D
do not exceed 1500 mg/day of calcium
increases cardiovascular risk; calcification may occur in the blood vessels |
|
|
Term
| estimating dietary Ca intake |
|
Definition
milk 8 oz. = 300 mg
yogurt 8 oz. = 300 mg
cheese 1 oz. = 200 mg
+
Ca from other dietary sources = 250 mg |
|
|
Term
|
Definition
separate doses: maximum 500-600 mg/dose
calcium carbonate:
take with food
poor choice for patients taking acid suppressive therapy
calcium citrate - may be taken anytime
ADRs: gas, constipation
drug interactions: iron, thyroid, TCN, FQs |
|
|
Term
|
Definition
optimal vitamin D level: >/= 30 ng/mL
deficiency: < 20 ng/mL
insufficiency: 21-29 ng/mL
types of vitamin D:
D2 (ergocalciferol)
D3 (cholecalciferol) - more potent
sources:
UVB radiation
dietary: fortified milk, OJ, cereal, egg yolks, fatty fish
pharmaceutical supplementation with vitamin D2 or D3
if patient is deficient:
50,000 IU once a week for 8 weeks
OR
6000 IU daily for 8 weeks
after that maintain at 1500-2000 IU daily |
|
|
Term
| universal recommendations |
|
Definition
adequate intake of calcium and vitamin D
regular weight bearing and muscle strengthening exercise
tobacco avoidance
identification and treatment of alcoholism
limit caffeinated beverages to 1-2 servings/day |
|
|
Term
| evaluation and prevention of fall risk |
|
Definition
personal history of falling
environmental risk factors: stairs, lighting, bathtubs, ice, cords, loose rugs, pets
medical risk factors |
|
|
Term
| patient with low BMD work up |
|
Definition
look for secondary causes
obtain blood work:
Ca (serum and urine), vitamin D, phosphorous, TSH, SrCr, CBC
use FRAX to determine fracture risk
T-score between -1 and -2.5 |
|
|
Term
|
Definition
prevent fractures by improving bone strength and reducing fall risk
relieve symptoms of fracture and skeletal deformity
maximize physical function |
|
|
Term
| candidates for drug therapy |
|
Definition
patients with hip or vertebral fractures
T-score -2.5 or below at femoral neck, spine, or total hip
post menopausal women and men > 50 years with:
T-score between -1 and -2.5
AND
10 year hip fracture probability >/= 3%
OR
a 10 year major osteoporosis related fracture probability >/= 20%
assess all patients for Ca and vitamin D intake and supplement as necessary |
|
|
Term
|
Definition
FDA approved for osteoporosis prevention only
34% reduction of vertebral and hip fractures over 5 years
23% reduction of other fractures
only effective while taking medication
compelling indication: severe hot flashes and non-estrogen meds are inappropriate
risks:
estrogen + progestin: CHD, stroke, breast cancer, VTE
estrogen: VTE, stroke |
|
|
Term
| selective estrogen receptor modulators (SERMs) |
|
Definition
estrogen agonist: bone
estrogen antagonist: breast, uterus, urogenital, CNS
raloxifene (evista) is primary SERM used for osteoporosis
reduces risk of invasive breast cancer
positive lipid effects: TC and LDL reduction
ADRs: VTE, hot flashes, night sweats, leg cramps
not the best choice to give someone who is pre-menopausal b/c of hot flash ADR (from anti-estrogen effects
use in patients who have risk of breast cancer and with osteoporosis
SERMs are used for the prevention or treatment of osteoporosis in postmenopausal women
bone loss returns to pre-treatment BMD when discontinued
30-50% reduction of vertebral fracture |
|
|
Term
|
Definition
directly inhibits osteoclastic bone resorption and increases mineral stores in bones
nasal spray - only form that has been shown to prevent fracture; alternate nostril daily
IM/SQ injection:
used for osteoporosis and cancer pain
injectable form has not been shown to prevent fractures
calcitonin is for women who are >/= 5 years postmenopausal
tolerance may develop after 12-18 months; pulse therapy can be used to prevent this
ADRs - rhinitis, epistaxis (nose bleed)
36% reduction in vertebral fractures with nasal spray only, no fracture data with injection
effectiveness lost within 1-2 years after d/c |
|
|
Term
|
Definition
inhibit osteoclast mediated bone resorption
alendronate (fosamax), risedronate (actonel, atelvia), ibandronate (boniva), zoledronic acid (reclast)
avoid use with CrCl < 30 mL/min |
|
|
Term
|
Definition
DIFFERENT DOSES FOR PREVENTION OR OSTEOPOROSIS AND TREATMENT OF OSTEOPOROSIS
50% reduction of spine, hip, vertebral fracture over 3 years |
|
|
Term
|
Definition
SAME DOSE FOR PREVENTION AND TREATMENT
no generic available
up to 50% vertebral fracture reduction
36% non-vertebral fracture reduction |
|
|
Term
|
Definition
for treatment only
acid suppressive therapy may interfere with absorption
non-inferior to actonel for increasing BMD
difference is this one you take WITH FOOD; all others are taken on an empty stomach |
|
|
Term
|
Definition
SAME DOSE FOR PREVENTION AND TREATMENT
50% reduction of vertebral fractures
no hip fracture data |
|
|
Term
| bisphosphonates oral administration |
|
Definition
poor bioavailability
ADRs: irritation of upper GI mucosa and esophagus
take in AM on empty stomach with 8 oz. of water only
except for Atelvia - take immediately after breakfast
do no lie down for >/= 30 minutes
no food, drink, or other medications for 30-60 minutes
alendronate, risedronate - waite 30 minutes
ibandronate - wait 60 minutes |
|
|
Term
| zoledronic acid (reclast) |
|
Definition
treatment dose given yearly
prevention dose given q2 years
post treat with acetaminophen to prevent acute phase reaction (muscle soreness, fever)
70% reduction of vertebral fractures
41% reduction of hip fractures
25% reduction of nonvertebral fracture |
|
|
Term
|
Definition
alendronate, risedronate, and zoledronic acid reduce hip, vertebral, and non-vertebral fractures
ibandronate reduces vertebral fractures only
FACT trail:
alendronate vs. risedronate
both significantly increased BMD
alendronate increased BMD 0.56%-0.75% greater than risedronate
BEST are aledronate, risedronate, and zoledronic acid |
|
|
Term
| osteonecrosis of the jaw (ONJ) |
|
Definition
associated with tooth extraction and/or local infection with delayed healing
risk factors: invasive dental procedures, diagnosis of cancer, concomitant therapy with chemo or steroids, poor oral hygiene |
|
|
Term
| bisphosphonate induced atypical fractures |
|
Definition
femoral shaft fractures have been reported in patients receiving bisphosphonates
patients present with prodromal symptoms
rule out femoral fracture in patients presenting with new thigh or groin pain
unclear how long to treat with bisphosphonate
re-assess need for continuted bisphosphonate use after 5 years of therapy |
|
|
Term
|
Definition
parathyroid hormone
given once daily - stimulates osteoblast activity
only drug to increase bone formation, mainly in the spine
SQ injection daily
65% reduction of vertebral fractures
53% reduction of non-vertebral fractures
only medication that builds bone (anabolic); all others just prevent breakdown
caused osteosarcoma after 12 months in rats, no evidence in humans
do not use in presence of osteosarcoma risk factors:
Paget's disease
unexplained elevations of Alk Phos
hypercalcemia
patients with history of bone radiation therapy
patients with open epiphyses (children and adolescents)
do not use > 2 years
ADRs: orthostatic hypotension, leg cramps |
|
|
Term
|
Definition
human monoclonal antibody that targets RANKL and inhibits osteoclast development/activity
used for osteoporosis and osteopenia secondary to aromatase inhibitor
68% decrease in vertebral fracture
40% decrease in hip fracture
20% decrease in non-vertebral fracture
increase BMD at spine, hip, and forearm
role in therapy:
previous osteoporosis related fracture
multiple risk factors
intolerant or failure with other osteoporosis medications
ADRS:
hypocalcemia (have to correct the patient's calcium levels before beginning this medication!!)
pain in back, arms, legs, muscle, bone
elevated cholesterol
increase incidence of infections (b/c it is a monoclonal antibody)
skin reactions |
|
|
Term
|
Definition
1st line agents:
alendronate
risedronate
zoledronic acid
denosumab
2nd line agents:
ibandronate
raloxifene
last line:
calcitonin
teriparatide: consider for those with very high fracture risk or in whom bisphosphonate therapy was ineffective or intolerable |
|
|
Term
|
Definition
osteoporosis advantages in men:
higher peak bone mass
slower bone loss
lack of menopause
shorter life expectancy
greater mortality rates after hip fracture compared to women
bisphosphonates preferred |
|
|
Term
| glucocorticoid induced osteoporosis |
|
Definition
concerned with doses equivalent to prednisone >/= 5 mg/day for > 3 months
bone loss can occur rapidly due to multiple mechanisms:
reduces bone formation and increases bone resorption
decreases androgens and estrogens
decreases intestinal Ca absorption and increases urinary Ca excretion
American College of Rheumatology recommends:
calcium 1000-1500 mg/day
vitamin D 800 IU/day
bisphosphonate for: high risk, history of low trauma fracture, T-score below -1 |
|
|
Term
|
Definition
every 2 years generally
every 6-12 months if on long term glucocorticod use:
only necessary for 1st 2 years of steroid treatment
then every 2 years long term |
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