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
Which of the following statements about teriparatide is TRUE?
A. It is a bisphosphonate that inhibits bone resorption.
B. It is administered orally once daily.
C. It stimulates new bone formation by activating osteoblasts.
D. It is contraindicated in patients with a history of fractures.
Answer: C
Teriparatide is a recombinant PTH that stimulates osteoblast activity
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. Denosumab
C. Romosozumab
D. Teriparatide
Answer: A
Oral bisphosphonates are typically first line treatment because of their efficacy, favorable cost, and longer-term safety data.
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)
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)
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 patient with osteoporosis?
Answer:
- 1200mg of calcium from food and supplements
- 800 IU of vitamin D form food and supplements
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. After RYGB, the stomach pouch is much smaller and more sensitive, increasing the risk of ulceration or inflammation if BP is taken orally. RYGB significantly changes the anatomy of the gastrointestinal tract, bypassing parts of the small intestine where alendronate is normally absorbed.
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.
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.
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 non-pharmacological recommendations should we make?
Answer: Healthy diet, smoking cessation, exercise, falls prevention
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) Metformin
c) Proton Pump Inhibitors
d) Fluoroquinolones
A and C.
Glucocorticoids decrease bone formation by increasing osteoblast apoptosis and decreasing growth factors involved in regenerating bone, Steroids also increase bone resorption secondary to decreased levels of gonadotropins (LH, FSH, testosterone, and estrogen). Lastly, steroids have been shown to induce a calcium deficiency by decreasing gastrointestinal absorption of calcium from the intestines and increasing renal excretion of calcium.
PPIS. Decrease in calcium absorption and possibly direct effects on bone metabolism
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?
A. Teriparatide
B. Denosumab
C. Calcium + Vitamin D
D. Zoledronic acid
Answer: Teriparatide
Since patient has severe osteoporosis it is reasonable to start with an anabolic medication
Which cells are responsible for breaking down bone matrix?
A. Osteoblasts
B. Osteocytes
C. Osteoclasts
D. Chondrocytes
Answer: C
Osteoblasts produce and secrete the bone matrix which later becomes mineralized with calcium and phosphate, forming hard bone.
Osteocytes are osteoblasts that become embedded in the bone matrix. They help maintain the bone matrix
Chondrocytes are cells that help maintain the mechanical properties of cartilage, allowing it to resist compression and provide smooth surfaces for joint movement
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
Which of the following vegetables provides the highest amount of absorbable calcium per cooked cup?
A. Spinach
B. Kale
C. Zucchini
D. Iceberg lettuce
Answer: B
Spinach is high in calcium, but contains oxalates that significantly reduce calcium absorption. Kale has a high calcium content and excellent bioavailability
List the following medications from lowest to highest risk for causing osteonecrosis of the jaw
A. Alendronate
B. Denosumab
C. Romosozumab
D. Abaloparatide
Answer: D, C, A, B
Alendronate: 0.07-0.1%
Denosumab: 0.3%
Romosozumab: 0.03%-0.05%
Abaloparatide: 0%
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.
A patient scheduled for a DEXA scan asks for heartburn relief. Which medication should be avoided before the scan?
A. Calcium carbonate
B. Famotidine
C. Milk of magnesia
D. Bismuth subsalicylate
A
Calcium can obscure imaging of the DEXA scan
Calcium can also skew the results. A higher concentration of minerals present during examination will lead to higher than normal absorption rates from X-rays used in assessing bone density and strength