Who?
What is the most common form of arthritis?
OA
Can be seen superimposed on other forms of arthritis such as psoriatic
What are the most common joints affected by primary OA? (name 2 of 5)
Small joints of the hands: DIP + PIP + carpometacarpal
Small joints of feet (first metatarsal phalangeal, midfoot)
Spine
Hips
Knees
How much calcium and vitamin D should someone with osteoporosis take?
Calcium intake of 1000 to 1200 mg/day
Vitamin D of 1,000 IU daily
What test is used to assess bone mineral density?
What does it stand for?
DEXA Scan: Dual Energy X-ray Absorption
What type of exercise is best to maintain bone mass?
Impact, weight-bearing, resistance (pilates plug)
Name the modifiable (2) and non-modifiable risk factors (2) for OA
Modifiable: Obesity, Occupation
Non-modifiable: Female gender, Genetics
What are the most common sites for osteoporosis fragility fractures? (Name 1 of 2)
Hip
Vertebra (compression fracture!)
A fall from standing height is pathomneumonic for osteoporosis
What labs can be ordered to evaluate for secondary causes of osteoporosis? Name 2 of many
Calcium/Phosphorous/Creatinine (Malignancy, Hyperpara, CKD)
Vitamin D
PTH (hyperparathyroidism)
TSH (hyperthyroidism)
Liver panel (liver disease)
ALP (Paget's, liver disease)CBC (anemia, think myeloma)
Estrogen/Testosterone (hypogonadal causes)
Cortisol (Cushing's)
Iron levels (hemochromatosis)
When can you stop bisphosphonate therapy?
Drug holiday can be initiated after 3 years (intravenous) to 5 years (oral) of bisphosphonate treatment if at low risk for fractures
What is first line for treatment of glucocorticoid-induced osteoporosis?
Bisphosphonates (first line for all OP, regardless of etiology)
Who do we screen for osteoporosis and when? (Name 1 of 2)
1. Females, age 65
2. Within 6 months of glucocorticoid therapy
Small-framed women at most risk.
No screening recommendations for men
Where do people feel the pain of hip OA?
In the groin
What meds are associated with secondary osteoporosis? (Name 1 of 5)
Phenytoin, Thyroid Replacement (over-treated), Anti-estrogens, Androgen Inhibitors, SSRIs, PPIs
What labs and imaging are needed to diagnose OA?
None
What is 1 common AE to oral bisphosphonate therapy? What 1 common AE of IV bisphosphonate therapy?
Oral: esophagitis, (less common is jaw necrosis)
IV (used when pts can't tolerate oral): Acute phase response=fever, myalgia, and arthralgia may occur within 1 to 3 days after first administration of zoledronic acid in 30% of patients. Use anti-pyretic and reassure the patient
In which patient population is bisphosphonate therapy contraindicated? (3)
CKD (creatinine clearance <30-35 mL/min)
Vitamin D deficiency (replete before starting therapy)
Hypocalcemia (replete before starting therapy)
Younger age
Atypical joint
What liver disorder is associated with secondary OA and OP?
Hemochromatosis (directly damages osteoblasts/direct damage to cartilage AND causes hypogonad-associated OP)
What is seen on imaging in OA? Name 1 of 4
Asymmetric joint-space narrowing
Subchondral sclerosis
Osteophytes
and bone cysts
In whom is empiric Vitamin D supplementation recommend? Name 1 of 3
The Endocrine Society recommends empiric vitamin D supplementation for persons aged 75 years and older, pregnant persons, and persons with high-risk prediabetes.
In which patients should denosumab therapy be considered? Name 1 of 2
Intolerant of bisphosphonates
CKD
What should be started when denosumab therapy is stopped?
Bisphosphonates (the prevention of bone resorption is stopped when denosumab therapy is stopped)
What is a common AE of denosumab?
Hypocalcemia! Must be supplemented daily while on treatment.
denosumab inhibits osteoclast activation = decrease resorption
Define osteopenia on DEXA
T score between -1 and -2.5
Osteoporosis: <-2.5
What agents stimulate bone formation for OP? (Name class, drug name, or MOA)
Anabolic agents teriparatide and abaloparatide (recombinant human PTH-related protein)