Focus on preventing fragility fracture
Osteoporosis – T scoare <= -2.5
Indications for measuring BMD with dual-energy x-ray absorptiometry
- Age >= 65
- Clinic risk factors for fracture (menopausal women, men 50-64yo)
- Fragility # after age 40yr
- High risk medications – aromatase inhibitors, androgen deprivation Tx, Prolonged use of glucocorticoids (> 3/12 of >= 7.5mg daily)
- Parental hip #
- Vertebral # or osteopenia on x-ray
- high alcohol intake
- Current smoking
- low body weight (<60kg) or major wt loss (>10% at 25yo)
- RA
- Disorders associated with osteoporosis:
- Younger adults (<50yo)
- Fragility #
- High risk medications. eg. Prolonged use of glucocorticoids
- Hypogonadism or premature menopause (<45yo)
- Malabsorption syndrome or chronic inflammatory conditions
- Primary hyperparathyroidism
- Other disorders associated with rapid bone loss/#
Recommended biochemical tests for pt being assessed for osteoporosis:
- Calcium, corrected for albumin
- CBC
- Creatinine
- Alkaline phosphatase
- TSH
- SPEP (for pt with vertebral #)
- 25-hydroxyvitamin D –
- measure after 3-4/12 of adequate supplementation.
- Don’t repeat if an optimal level (>75nmol/L) is achieved.
Vertebral # unrelated to trauma
- Defined as vertebral ht loss >=25%. 5x increase in the risk of future vertebral #
- Perform lateral T & L spine x-ray or dual-energy x-ray absorptiometry
Assess 10yr # risk – use FRAX
Low <10%, Moderate 10-20%, High >20%
Uses
- sex, age, BMI, prior #, parental hip #
- Prolonged glucocorticoid use, RA (2o causes of osteoporosis), current smoking, EtOH intake (>= 3unit/day)
- Bone mineral density of femoral neck (optional)
Tx
- Exercise
- Weight-bearing, balance & strengthening exercise
- Smoking cessation
- Fall Prevention
- 1200mg Calcium for >50yo
- Vit D supplementation
- 400-1000IU for healthy adult
- 800-1000IU for >50yo at moderate risk of Vit D deficiency
- up to 2000IU is safe
Pharmacologic Tx
- High risk pt
- >50yo with fragility # of hip or vertebra or >1 fragility #
- Mod risk – consider lateral thoracolumar x-ray (T4-L4) or vertebral # assessment & Tx if
- Additional vertebral fracture(s)
- Previous wrist # in individuals >65yo
- T score <-2.5
- Lumbar spine T score << femoral neck T score
- rapid bone loss or disorders contribute to bone loss
- Men undergoing androgen-deprivation Tx for prostate ca
- Women undergoing aromatase inhibitor Tx for breast Ca
- Long-term or repeated use of glucocorticoids
- Recurrent falls (>2 in 12mo)
- Reassess BMD in 1-3 yr and reassess risk
- Low risk – not req, reassess risk in 5yr
Antiresoprtive agents
1st line for vertebral, nonvertebral, and hip # prevention
- Bisphosphonates: Alendronate, risedronate, zoledronic acid
- Men and Women
- RANKL inhibitor – Denosumab (C/I: hypocalcemia, hypersensitivity, pregnant or nursing)
- Hormone therapy – only for menopausal women requiring Tx for vasomotor symptoms as well
- Second Line – Calcitonin or etidronate
- Testosterone not recommended
1st line for vertebral # prevention
- SERM –Raloxifene
Bone-forming agent
- Teriparatide
- Calcitonin and Teriparatide reduce the pain associated with vertebra #
S/E
- Calcium supplementation
- renal calculi & CV events
- Bisphosphonates (benefits >>>>>>harm)
- self-limited flu-like symptoms
- Osteonecrosis of the jaw – (aveolar bone in the mandible or maxilla doesn’t heal after 8 weeks)
- <1/10000, Increase with
- XRT, ChemoT
- high-dose for bone metastases / glucocorticoids,
- DM, poor dental hygiene or tooth extractions/implants
- <1/10000, Increase with
- Atypical # of the femur (subtrochanteric / diaphysieal regions)
- More common in long-term Tx
- Clean transverse / oblique chalk-like breaks
- Prodromal thigh or groin pain
- esophageal ca or A fib – conflicting results
- Denosumab
- cellulitis
- Raloxifene & hormone Tx
- thromboembolic events
- Teriparatide
- hypercalciuria & hypercalcemia
>50yo on Glucocorticoid (>3mo >7.5mg/day)
- Tx with Bisphosphonate (alendronate, risedronate, zoledronic acid) at the onset or Teriparatide
- second line: calcitoin or etidronate
Women on aromatase inhibitor
- Tx with Bisphosphonate or denosumab
Monitor:
- Initially, BMD 1-3 yr after Tx – good response if unchanged or improved
- If good response, BMD in 5-10yr
- Ref to specialist if poor response despite good compliance
Reference:
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