Diagnosis
At what age does the U.S. Preventive Services Task Force start recommending BMD testing in females, regardless of osteoporosis risk factors?
Answer:
65 years or older. Also recommends bone measurement testing to prevent factures in postmenopausal females younger than 65 years wo are at increased risk of osteoporosis.
In men, measuring BMD solely on age is controversial. Some groups recommend BMD testing for all men older than 70 years.
True or False:
Calcium and vitamin D need to be taken at the same time?
Answer: False
Vitamin D needs to be activated by the liver and kidney to be active. It doesn't matter the timing of vitamin D and calcium
TRUE or FALSE:
Medications such as Foreto can only be used for 2 years?
Answer: False
The use of Forteo or Teva's generic teriparatide is no longer limited to 2 years. But it states it should only be considered if a patient remains at or has returned to having a high risk for facture
Tymlos (abaloparatide) still has use beyond 2 years is not recommended
For a patient with a T score = - 2.7 and no fractures, normal renal and liver function, and no other health issues, what is the most common first line therapy?
A. Alendronate
B. Zoledronic acid
C. Romosozumab
D. Teriparatide
E. Denosumab
Answer: A
Oral bisphosphonates are typically first line treatment because of their efficacy, favorable cost, and longer-term safety data.
Zoledronic acid may be consider if a patient is unable to take oral bisphosphonates
Romosozumab or teriparatide can be consider for patients at very high fracture risk ( T score < - 2.5 + fragility fracture, T score < -3 in the absence of fragility fracture, history of severe or multiple fracture)
Denosumab may be considered if IV/PO bisphosphonates are not appropriate (intolerant or not responsive to bisphosphonates, impaired renal function, desire higher BMD gains then achieved with bisphosphonates)
Which of the following is a nonmodifiable risk factor for osteoporosis?
a) Vitamin D deficiency
b) Smoking cigarettes
c) Age
d) Excessive alcohol intake
Answer: C
Age is a nonmodifiable risk factor for osteoporosis in postmenopausal women.
What does the FRAX score determine?
Answer: Estimates the 10-year probability of hip or major osteoporotic fracture (hip, spine, shoulder, or wrist) for an UNTREATED female or male age 40-90 years.
Patient should be diagnosed with osteoporosis if their 10-year risk of hip fracture is > 3% or they have a > 20% of a major osteoporotic fracture and a BMD between -1 to -2.5
What is the recommended amount of vitamin D and calcium for a 55 year old female?
Answer:
- 1200mg of calcium from food and supplements
- 800-1000 IU of vitamin D form food and supplements
Females:
- Calcium: 1000mg < 50 years old
1200mg > 50 years old
- Vitamin D: 800-1000 IU > 50 years old
400-800 IU < 50 years old
Males:
- Calcium: 1000mg < 70 years old
1200mg > 70 years old
- Vitamin D: 800-1000 IU > 50 years old
400-800 IU < 50 years old
It is difficult to get enough vitamin D form sunlight and food alone, so this is just usually supplemented
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. Patient has a history of Roux-en-Y gastric bypass. Which of the following is an appropriate initial medication?
A. Alendronate
B. Calcium + Vitamin D alone
C. Zoledronic acid
D. Raloxeifene
Answer: C
For patients with gastric bypass, oral bisphosphonates should be avoided.
Calcium and vitamin D alone is not appropriate treatment
Raloxeifene is less potent agent and usually reserved for those that are not candidates for a bisphosphonates or denosumab
What is the most common site of osteoporotic fractures?
Answer: 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.
Which of the following patients could be appropriately diagnosed with osteoporosis? SELECT ALL THAT APPLY
a) 71 year old male with a T-score of -2.6 at the femoral neck and no previous fractures
b) 68 year old female with a T-score of -1.8 and and FRAX score 0.5% for hip fracture and 5.6% for major osteoporotic fracture
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
Answer: A and C.
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 FRAX score > 3% hip fracture or > 20% of a major osteoporotic fracture
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?
Answer: Calcium Citrate
Because A.G. is taking pantoprazole. Calcium carbonate requires stomach acid to be absorbed and calcium citrate does not.
What is the mechanism of action of Denosumab (Prolia)?
Answer: 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 GERD, no current glucocorticoid use. He has smoked a pack per day for the last 50 years. He weighs 80 KG and 183 cm tall. FRAX score = 9.2% for major osteoporotic fractures and 4.8% for hip fracture, what pharmacological and non-pharmacological recommendations should we make?
Answer: Healthy diet, smoking cessation, exercise, falls prevention, calcium + vitamin D supplementation, and bisphosphonate therapy.
Which of the following would necessitate restarting a medication on a patient if they are on a drug holiday?
A. Patient with new fracture from a motor vehicle accident
B. BMD remains stable
C. Patient develops a new fragility fracture
D. An increase in BMD
Answer: C
- A bisphosphonate may be restarted in a patient if they have reproducible bone loss (~ 5%) on at least 2 DXA scans taken at least 2 years apart (using the same make and model scanner)
- Evidence of bone loss on one DXA measurement at the spine and the hip.
- Evidence of bone loss on one DXA measurement at either site and accompanied by a fasting C-terminal telopeptide of type I collagen (CTX) >600 pg/mL (ie, above the upper limit of the premenopausal reference range).
Which of the following medications 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?
Answer: > 30ng/mL
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.
If after 2 years of treatment with teriparatide, a patient is no longer considered high risk, which one of the following is generally recommended?
a) Treatment with romosozumab
b) Treatment with abaloparatide
c) Treatment with a bisphosphonate
d) No further treatment is needed
Answer: C
After completion of an agent that builds up the bone, an antiresorptive agent should be started to maintain the bones density gained
May also change to Prolia
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 is the most appropriate starting therapy?
Answer: Teriparatide, abaloparatide, or romosozumab
Since patient has severe osteoporosis it is reasonable to start with an anabolic medication
What lifestyle changes/habits help to prevent the development of osteoporosis? SELECT ALL THAT APPLY
a) Occasional cigarette smoke
b) Limiting alcohol consumption to 1 drink per day
c) Moderate intensity exercise at least 30 minutes a day
d) Drinking less than 8 oz of caffeine per day
e) Eating a diet packed with nutrients and vitamins
Answer: B, C, and E. Excessive alcohol is associated with an increase in fracture risk. Exercise at least 30-40 minute 3-4 days a week, this 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
Answer: A
The T-score which indicates osteopenia or low bone mass is between -1.0 and -2.5.
Which one of the following foods has the highest amount of calcium per serving size?
A. Cottage cheese 2% 4 oz
B. Cooked collard greens 1 cup
C. Pudding 4 oz
D. Cooked Kale 1 cup
Answer: B, I have never had collard greens :)
- 4 oz cottage cheese 105mg CA
- 1 cup cooked collard greens 266 mg CA
- 4 oz pudding has 160mg CA
- 1 cup cooked kale 179 mg CA
Which of the following sequence of medications provides the most increase in BMD?
a) Calcitonin then denosumab
b) Denosumab then teriparatide
c) Abaloparatide then alendronate
d) Zoledronic Acid then romosozumab
Answer: C
The effects of anabolic agents are blunted if an antiresorptive agent is used first. It is very important for hip BMD for the first 12 months.
- When changing from bisphosphonate to anabolic agent the effect on the spine BMD is blunted and there can be a decrease in hip BMD for at least 1 year followed by a modest increase.
- When changing from denosumab to teriparaide there was a decrease in both hip and spine
- When changing from denosubmab to romosozumab the effect on the spine was blunted but hip BMD was maintained
Which of the following medications has a high risk of vertebral fractures when stopped and not replaced with another agent?
A) Alendronate
B) Zoledronic acid
C) Denosumab
D) Calcium
Answer: C
Markers of bone turnover increased within three to six months after discontinuation of denosumab to values above baseline then are similar to baseline values within 24 months of discontinuing therapy. Vertebral fractures that occur are 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
Answer: 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?