Osteoporosis

Risk Factors

100

Name at least 5 risk factors for osteoporosis

200

Osteopenia is defined with a T-score between?

Osteopenia is defined with a T-score between -1.0 and -2.5 standard deviations below peak bone mineral density. Osteoporosis is defined with a T-score <2.5 standard deviations below peak bone mineral density.

300

Which of the following patients is at increased risk for osteoporosis due to medications?

a) A 38-year-old man who requires a 5-day steroid taper every 2-3 years for an asthma flare.

b) A 55-year-old woman on L-thyroxine with a TSH of 1.4 mIU/L.

c) A 35-year-old woman who has been taking oral contraceptives for 10 years.

d) A 60-year-old man with rheumatoid arthritis being treated with methotrexate.

D

400

You diagnose a 65-year-old woman with osteoporosis. Which series of tests are indicated in this woman before initiation of osteoporosis treatment?

a) Check TSH, calcium, phosphorous, alkaline phosphatase, Vitamin D

b) Check estradiol, TSH, and 1, 25OH-Vitamin D 

c) Check PTH-intact, LH, FSH and estrone levels

d) No additional testing is needed

A

Causes of secondary osteoporosis should be considered in all patients at the time osteoporosis is diagnosed. A focused history and physical exam should screen for the lifestyle factors and medical disorders that cause secondary osteoporosis. The most common laboratory abnormalities in women with osteoporosis include abnormalities of serum and urine calcium, vitamin D, and parathyroid hormone (PTH). The most common causes of osteoporosis in men are heavy alcohol use, corticosteroids, and hypogonadism.

500

A 58-year-old man with iron deficiency anemia, low vitamin D, and low urine calcium presents with osteoporosis. What test best establishes the underlying diagnosis?

Tissue transglutaminase IgA (celiac disease)

DXA to Impress

100

For which group of patients is bone density testing universally recommended by all osteoporosis guidelines?

a) All women at menopause

b) All women aged 65 and older

c) Men over the age of 70 years

d) All women aged 50 and older

B

200

A 73-year-old man presents for routine follow up. His wife was just hospitalized with a hip fracture, and never had been evaluated for osteoporosis. He asks whether he should be screened for osteoporosis. Reviewing his past medical history, he has hypertension. His only medication is lisinopril/HCTZ. He never smoked, and he does not drink alcohol. He has never received glucocorticoids. Which one of the following is correct?

a) Check a serum 25-OH vitamin D level; if this is normal, screening for osteoporosis is not indicated. 

b) There are no guidelines on obtaining screening bone density testing in asymptomatic men.

c) Check a bone density DXA scan; screening for osteoporosis is indicated.

d) Check a serum testosterone level; if this is normal, screening for osteoporosis is not indicated.

C

Based on expert opinion, bone density screening in asymptomatic men beginning at age 70 years is recommended by all osteoporosis guidelines except the US Preventive Services Task Force, which found insufficient data exists to make any recommendations in men. Note that Medicare does not cover screening DXA scans in average-risk men; men who have risk factors such as treatment with corticosteroids, diagnosis of hyperparathyroidism, or x-rays suggesting osteoporosis are covered.

300

Which ONE of the following women fulfills World Health Organization diagnostic criteria for osteoporosis?

a) A 55-year-old woman with a history of a traumatic tibia-fibula fracture during a skiing accident and a DXA scan demonstrating a T-score of -1.9 in the femoral neck.

b) A 57-year-old woman, 10 years post-menopausal, who has a routine chest x-ray for preoperative testing that notes "osteopenia."

c) A 56-year-old woman with a history of hyperthyroidism, low back pain, and a DXA scan demonstrating a lumbar spine T score of -2.6 and Z score of -1.5.

d) A 48-year-old woman, perimenopausal, with a DXA scan demonstrating a lumbar spine Z-score of -2.5 and a Z-score in the total hip of -2.0.

C

WHO criteria for diagnosis of osteoporosis are based on T-scores, i.e., the number of standard deviations the patient’s bone density is above or below the average bone density at the age of peak bone mass. The T-score is used to classify bone mineral density values into categories established by the WHO in the early 1990s (see table below). The ability of bone mineral density to predict fracture risk is enhanced by combining bone density values with risk factors in a multivariate model such as FRAX.  Finally, plain x-rays are not used to diagnose osteoporosis; they are neither sensitive nor specific.

• T-score: compares the patient's bone mineral density with that of the average bone mineral density at the time of peak bone mass. USED FOR OLDER than 50
• Z-score: compares the patient's bone mineral density with the average bone density of age-matched controls. USED for YOUNGER than 50

400

A patient is started on pharmacotherapy for osteoporosis. Assessment of response to therapy with repeat DXA scanning should be done in:

a) 3 months

b) 6 months

c) 24 months

d) 36 months

C

Bone density is reassessed 1-2 years after beginning therapy (usually 2 years) to ensure response to treatment. If there is evidence of ongoing bone loss despite treatment, additional evaluation is warranted. Laboratory markers (e.g., PTH-I; urine calcium excretion) are not helpful to assess response to therapy. Note the American College of Physicians recommends against follow up testing for treatment of osteoporosis, specific within the first five years of therapy.

500

In a patient under age 50, which criteria define osteoporosis?

Z-score ≤ −2.0 PLUS evidence of skeletal fragility (e.g., low-trauma fracture)

For individuals younger than 50, we use the Z-score to categorize bone mineral density. A Z-score of -2.0 or worse with evidence of skeletal fragility such as a low trauma fracture is categorized as osteoporosis in a young individual.

• T-score: compares the patient's bone mineral density with that of the average bone mineral density at the time of peak bone mass. USED FOR OLDER than 50
• Z-score: compares the patient's bone mineral density with the average bone density of age-matched controls. USED for YOUNGER than 50

FRAX Around and Find Out

100

Using the FRAX tool, what 10-year risk of hip fracture should prompt pharmacologic treatment to improve bone mineral density?

A. 3%
B. 10%
C. 20%
D. 30%

A.3%
Individuals with osteopenia should have fracture risk assessed with a risk prediction tool. The most commonly used fracture risk prediction tool is the FRAX tool, which calculates a patient's 10-year risk of hip fracture and of any major osteoporotic fracture. The National Osteoporosis Foundation recommends that individuals age 50 years and older with a DXA T-score between -1.0 and -2.5 (i.e., those with osteopenia) should be treated to improve bone mineral density if:

• 10-year risk of hip fracture is 3% or greater
• 10-year risk of any major osteoporosis-related fracture is 20% or greater.

200

A 70-year-old man with a history of peptic ulcer disease is found to have osteopenia by DXA scan.  FRAX risk of major osteoporotic fracture is 24.5%.  You initiate treatment, but he fails multiple oral bisphosphonates due to exacerbation of his GI symptoms.  Which of the following about subsequent therapy is true?

a) Calcitonin has similar side effects and thus should be avoided.

b) An intravenous bisphosphonate, such as zoledronate, is a good option.

c) All bisphosphonates are contraindicated in this patient, due to peptic ulcer disease. 

d) Teriparatide is approved only for prevention and not for treatment, so is not a good option.

B

The intravenous bisphosphonate zoledronic acid is a reasonable option for treatment of osteoporosis in patients who have gastrointestinal intolerance of (or contraindications to) oral bisphosphonates.

300

A 72-year-old woman is diagnosed with osteoporosis based on reduced bone density and a FRAX score of 35% (total body) and 4.7% (hip). Which of the following is appropriate pharmacotherapy for this person?

a) Alendronate 70mg weekly

b) Ibandronate 150mg monthly

c) Teriparatide 210mg subcutaneously monthly

d) Raloxifene 60mg daily

C

There are certain high-risk clinical scenarios in which we anabolic therapy.
High risk scenarios include:
- T score of -3 or higher
- T score of -2.5 with a fragility fracture
- Total body FRAX risk >30% or hip FRAX risk >4.5%

 In those scenarios, pharmacotherapy for osteoporosis is done with any of the following:

• Abaloparatide
• Teriparatide
• Romosozumab

400

What is a fragility fracture?

A fragility fracture, defined as a hip or vertebral fracture resulting from low energy injuries such as a fall from standing height, should prompt treatment for osteoporosis.

500

This radiological finding can falsely elevate lumbar spine DXA readings

Osteoarthritis / vertebral osteophytes

Steroids: Strong Muscles, Weak Bones

100

Which ONE of the following statements about steroid administration and the risk of developing osteoporosis is true?

a) Any patient receiving three weeks or more of daily glucocorticoids should be screened for osteoporosis, regardless of the glucocorticoid dose.

b) Steroids only cause bone mineral density loss in postmenopausal women; younger women and men of all ages are not at risk.

c) Any patient receiving 20mg/day of prednisone should be screened for osteoporosis, regardless of duration of therapy.

d) Prednisone at a dose of 5 mg daily given for at least 3 months increases the risk of osteoporosis and should get a baseline DXA scan

D.

Current treatment guidelines indicate that the risk of osteoporosis from oral glucocorticoids increases when patients are treated with prednisone > 5mg daily for at least three months. Preventive measures to institute in such patients include counseling on adequate calcium and vitamin D intake, weight-bearing exercise, fall prevention, tobacco cessation, and limiting alcohol use to moderate intake.

200

A patient younger than 50 on long-term glucocorticoids should receive pharmacologic osteoporosis treatment only if this clinical event has occurred.

A fragility fracture.

• Patients younger than 50 do not need pharmacotherapy unless they have a fragility fracture. These patients should be counseled on weight bearing exercise, tobacco, and alcohol, but there is no consensus on starting them on a bisphosphonate or similar treatment. 

300

Patients 50 and older who are on chronic steroids <7.5 mg/day with a FRAX score of <10% are treated with?

Lifestyle management.

For individuals 50 and older, we start with the same criteria for dosing and duration of corticosteroid treatment:
- those on prednisone >5mg/day and duration of 3 months or more should be considered for treatment. - These patients will need a baseline DXA scan to determine treatment, as we need to determine their fracture risk to guide therapy. 

- Fracture risk is calculated using a standardized tool (the FRAX risk calculator, discussed later in this module). The FRAX tool determines the 10-year risk of major osteoporotic fracture. 

In patients on glucocorticoids being screened for osteoporosis, we determine their 10-year risk of fracture using the FRAX tool, and then divide them into low (10-year probability of fracture of 10% or less), medium (10-year probability of fracture of 10-20%), or high risk (10-year probability of fracture of 20% or greater). You’ll see that most patients merit pharmacotherapy (with more aggressive options for those at greater risk), but the lowest risk patients should be managed with lifestyle unless their glucocorticoid dose is greater than 7.5 mg/day of prednisone.  

400

Patient 50 and older on chronic steroids should meet these criteria to qualify for treatment of osteoporosis:
- Treatment with prednisone for how long and what dose?
- FRAX score of higher than?
or?

- 5mg for more than 3 months
- FRAX>10%
- or fragility fracture

500

In patients aged 50 or older taking prednisone >5 mg daily for at least 3 months, fracture risk is assessed with FRAX and categorized into three groups. Name the three 10-year fracture-risk categories and their percentage cutoffs

Low risk ≤10%, intermediate risk 10–20%, high risk ≥20%

Treatment

100

A 67-year-old woman is diagnosed with osteoporosis based on a DXA scan report. What is the current recommended total daily calcium intake for this woman?

Recommended calcium intake for all women age 50 and older is 1200mg of calcium daily, including both dietary and supplement sources of calcium. Like many nutrients, calcium is a threshold nutrient and doses exceeding the recommended intake can be harmful. 

Total calcium intake should not exceed 1500 mg per day, as this can cause hypercalciuria and increase the risk of nephrolithiasis.

200

68 year old with PMHx of Barrett's Esophagus is diagnosed with osteoporosis. What options can be used?

Anything except for oral biphosphonates

300

A 72-year-old woman undergoes DXA scanning, which shows her lowest T-score to be -1.7. What is the recommended minimum daily vitamin D supplementation for this woman per National Osteoporosis Foundation Guidelines?

The National Osteoporosis Foundation recommends a vitamin D intake of 800-1000 IU per day for adults aged 50 years and older.  The role of supplemental vitamin D in preventing osteoporosis and reducing fracture risk has been called into question.

400

Of the medications listed, which one is considered anabolic (i.e., directly stimulating bone formation) rather than anti-resorptive (i.e., suppressing bone resorption)?

a) Romosozumab

b) Denosumab

c) Alendronate

d) Calcitonin

A

• Anti-resorptive therapy: reduces bone resorption, allowing bone formation to predominate. Bisphosphonates and monoclonal antibody osteoclast inhibitors (e.g., denosumab) are anti-resorptive drugs.
• Anabolic therapy: stimulates bone formation. Considered a more potent approach to osteoporosis treatment. Human parathyroid hormone analogs (e.g., teriparatide) and monoclonal antibody osteoblast activators (e.g., romosozumab) are anabolic drugs.

500

Each of the following patients has just completed five years of bisphosphonate therapy. Which one is the best candidate for a medication interruption (i.e., medication "holiday")?

a) A 72-year-old woman with a femoral neck T-score of -2.6

b) A 65-year-old woman with a history of osteoarthritis and a femoral neck T-score of -2.3

c) An 88-year-old man with a lumbar spine T-score of -2.1 and a femoral neck T-score of -2.2 whose mother had a hip fracture at age 76

d) A 61-year-old woman with a history of a vertebral fracture and a femoral neck T-score of -1.8

B

After five years of bisphosphonate therapy, consideration should be given to a medication interruption (i.e., medication holiday). Contraindications to medication "holiday" include:

• Vertebral fractures (risk of these increases with medication holidays)
• Most recent DXA showing a femoral neck T-score of -2.5 or lower

Relative contraindications include:

• The very elderly
• Family history of hip fracture
• Personal history of fragility fracture
• Those with increased fall risk

Duration of the medication holiday is determined by individual fracture risk. Lower risk patients whose bone density is no longer in the osteoporosis range may be able to stay off treatment for several years or longer. Medication holidays should only be considered when treating with a bisphosphonate; it is not an option with other classes of medication, as shown in the table below.