Diagnosis
At what age does the U.S. Preventive Services Task Force start recommending BMD testing in females, regardless of osteoporosis risk factors?
65 years or older. All postmenopausal women over the age of 50 should undergo osteoporosis assessment and fracture risk (PMH and PE)
What is the maximum amount of calcium that is recommended in a SINGLE DOSE for a 68 year old woman diagnosed with post-menopausal osteoporosis?
For optimal absorption, a dose of 600 mg per dose is recommended, regardless of the preparation. For patients requiring more than 600 mg in a day, the dose should be divided.
What is the maximum duration of treatment with medications such as Abaloparatide and Teriparatide?
AACE guidelines recommend limiting treatment to 2 years with abaloparatide and teriparatide.
Which of the following are risk factors included in FRAX scores? SELECT ALL THAT APPLY
a) Hispanic ethnicity
b) PMH of hypertension
c) Family history of diabetes
d) Rheumatoid arthritis
e) History of traumatic brain injuries
A and D. Ethnicities such as white, black, hispanic, and asian are all included in FRAX. Rheumatoid arthritis is also considered in a FRAX score.
Which of the following is a nonmodifiable risk factor for osteoporosis?
a) Vitamin D deficiency
b) Smoking cigarettes
c) Age
d) Excessive alcohol intake
Age is a nonmodifiable risk factor for osteoporosis in postmenopausal women.
Which of the following patients could be appropriately diagnosed with osteoporosis?
a) 71 year old male with a T-score of -2.2 and no previous fractures
b) 68 year old female with a T-score of -1.8 and a history of smoking and excessive alcohol intake (more than 3 drinks daily)
c) 58 year old female with a T-score of -1.9 and previous fragility fracture of her pelvis
d) 83 year old male with a T-score of -0.5 and no previous fractures
The answer is C - 58 year old female with a T-score of -1.9 and previous fragility fracture of her pelvis. According to AACE, osteoporosis is diagnosed by:
1. T-score − 2.5 or below in the lumbar spine, femoral neck, total proximal femur, or 1/3 radius
2. Low-trauma spine or hip fracture (regardless of BMD)
3. T-score between − 1.0 and − 2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm
4. T-score between − 1.0 and − 2.5 and high FRAX
T/F: Calcium and Vitamin D supplementation is the same for all individuals who have been diagnosed with osteoporosis
False - Patient factors such as age, obesity, and malabsorption can all influence vitamin D and calcium supplementation
True/False: A holiday is recommended for a non-bisphosphonate antiresorptive drug?
False - a drug holiday is not recommended for non-bisphosphonate antiresorptive drugs. Treatment is recommended to last as long as clinically appropriate.
However, for patients taking bisphosphonates, a "bisphosphonate holiday" may be considered for high risk patients after 5 years of stability with oral bisphosphonates or 3 years of IV zoledronate. Appropriate lengths of holidays have not been established.
A patient comes in to the clinic with an osteoporosis diagnosis. They have never taken any medications for osteoporosis and are looking to start on alendronate 70 mg daily. Recent labs show the patient has a CrCl of 23. What do you tell the patient?
This medication is not recommended with a CrCl under 35 mL/min.
***However, based on limited data, use of an unadjusted dose may be considered in patients with CrCl of >25 to <35 mL/minute and without underlying CKD-mineral and bone disorder when the benefits outweigh the risks***
What is the most common site of osteoporotic fractures?
Spinal fractures or vertebral compression fractures are the most common sites of osteoporotic fractures.
According to the American Academy of Orthopaedic Surgeons, spinal fractures are twice as common as other fractures.
How often is BMD testing reassessed in patients?
Every 2 years
A.G is a 63 year old female recently diagnosed with Osteoporosis. She has a PMH of GERD for which she is taking Pantoprazole 40 mg daily to treat. Unfortunately, A.G is unable to reach her recommended daily calcium intake with just food alone. Which calcium product would you recommend for her?
Calcium Citrate. Because A.G. is taking pantoprazole and calcium carbonate requires stomach acid to be absorbed, calcium citrate would be the best product for her to reach her recommended daily calcium intake.
What is the mechanism of action of Denosumab (Prolia)?
Denosumab (Prolia) is a monoclonal antibody which binds to nuclear factor-kappa ligand (RANKL) blocking the interaction between RANKL and RANK, subsequently preventing osteoclast formation, function, and survival.
ST is a 77 YO Caucasian male. He does not have a history fractures and a recent T-score of –1.3 (femoral neck), -1.1 (left hip), and –2.2 (lumbar spine). ST has a PMH of rheumatoid arthritis and GERD, no current glucocorticoid use. He has also smoked a pack per day for the last 50 years. He weighs 80 KG and 183 cm tall. With this diagnosis of osteopenia, what pharmacological and non-pharmacological recommendations should we make?
Healthy diet, smoking cessation, exercise, falls prevention, supplementation if needed.
He has a FRAX score gives him a 10-year probability of a hip fracture = 8.2%. A bisphosphonate is reasonable to start.
________ are found within and are responsible for building up the bone matrix. While ________, which are also found in the, breakdown the bone matrix.
Osteoblasts are found within the spongy bone and are responsible for building up the bone matrix.
While Osteoclasts, also found in the spongy bone, breakdown the bone matrix.
Which of the following medication can commonly cause secondary osteoporosis? SELECT ALL THAT APPLY
a) Glucocorticoids
b) Tricyclic Antidepressants
c) Proton Pump Inhibitors
d) Fluoroquinolones
A and C. Glucocorticoids and Proton Pump Inhibitors are medications that can cause secondary osteoporosis.
What is the preferable range to maintain the serum 25-hydroxyvitamin D (25[OH]D) in patients with osteoporosis?
In patients with osteoporosis, maintain serum 25-hydroxyvitamin D (25[OH]D) ≥30 ng/mL (preferable range, 30 to 50 ng/mL). This is often done with vitamin D3 supplementation of 1,000-2,000 IU daily.
Once a patient completes 2 years of treatment with teriparatide what should follow
a) Treatment with romosozumab
b) Treatment with abaloparatide
c) Treatment with a bisphosphonate
d) No further treatment is needed
After completion of an agent that builds up the bone, an antiresorptive agent should be started to maintain the bones density gained
JT is a 68 YO female with a recent diagnosis of osteoporosis. Her PMH includes T2DM, depression, and hypertension. Her T-score at the time of diagnosis was –3.9 on her spine and JT has already had multiple fractures. What medication does JT automatically qualify to start?
Since patient has severe osteoporosis it is reasonable to start with an anabolic medication (teriparatide or abaloparatide). If a bisphosphonate or denosumab is used first it can blunt the effects of the anabolic agent.
What lifestyle changes/habits help to prevent the development of osteoporosis? SELECT ALL THAT APPLY
a) Occasional cigarette smoke
b) Limit alcohol consumption to 1 drink per day
c) Moderate intensity exercise at least 30 minutes a day
d) Drinking more than 8 oz of caffeine per day
e) Eating a diet packed with nutrients and vitamins
B, C, and E. Excessive alcohol is associated with an increase in fracture risk. At least 30-40 minute 3-4 days a week is associated with a small increase in BMD.
What T-score is considered osteopenia (or low bone mass)?
a) -1.7
b) -2.6
c) -0.9
d) -3.5
The correct answer is A, 1.7. The T-score which indicates osteopenia or low bone mass is between -1.0 and -2.5.
What is the recommended daily calcium intake for female patients over the age of 50.
For adults over the age of 50, the recommended calcium intake is 1,200 mg/day. This includes diet in addition to supplementation if needed.
Which of the following medications is used for both prevention and treatment of postmenopausal osteoporosis?
a) Calcitonin (Miacalcin)
b) Denosumab (Prolia)
c) Teriparatide (Forteo)
d) Zoledronic Acid (Reclast)
Zoledronic Acid (Reclast) is used for both prevention and treatment postmenopausal osteoporosis. The difference between the two are the frequencies, with prevention being treated with 5 mg IV every 2 years, and treatment with 5 mg IV every year.
Which of the following medications has a high risk of vertebral fractures when stopped an not replaced with another agent?
A) Alendronate
B) Zoledronic acid
C) Denosumab
D) Calcium
Markers of bone turnover increased within three to six months after discontinuation of denosumab to values above baseline but were similar to baseline values within 24 months of discontinuing therapy. Vertebral fractures were often multiple and occurred 8 to 16 months after the last dose, raising concerns about a rebound in fracture risk when denosumab wears off.
When an individual has primary hyperparathyroidism, what are the effects on bone and calcium levels?
a) Stimulates osteoclast activity > osteoblast activity, thereby increasing calcium levels
b) Inhibits osteoclast activity > osteoblast activity, thereby decreasing calcium levels
c) Stimulates osteoblast activity > osteoclast activity, thereby increasing calcium levels
d) Inhibits osteoblast activity > osteoclast activity, thereby decreasing calcium levels
A - PTH increases calcium levels by stimulating osteoclast activity and inhibiting osteoblast activity. PTH can also increase calcium through reabsorption in the kidneys.
Bonus question - why do we use teriparatide and abaloparatide to treat osteoporosis?