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Questions and Answers
What is the bone loss rate during the 10 years after menopause?
What is the bone loss rate during the 10 years after menopause?
Osteoporosis is characterized by increased bone density and strength.
Osteoporosis is characterized by increased bone density and strength.
False
What is the T-score indicating osteopenia at the femoral neck for Mrs. Miller?
What is the T-score indicating osteopenia at the femoral neck for Mrs. Miller?
-1.8
The natural history of bone mineral density indicates a _____ bone loss rate per year after menopause.
The natural history of bone mineral density indicates a _____ bone loss rate per year after menopause.
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Which of the following is a common site for osteoporosis-related fractures?
Which of the following is a common site for osteoporosis-related fractures?
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Mrs. Miller has a family history of osteoporosis.
Mrs. Miller has a family history of osteoporosis.
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What medication is Mrs. Miller currently taking for hypertension?
What medication is Mrs. Miller currently taking for hypertension?
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Match the following T-scores with their corresponding conditions:
Match the following T-scores with their corresponding conditions:
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What is Mrs. Miller's diagnosis based on her DXA report?
What is Mrs. Miller's diagnosis based on her DXA report?
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The FRAX score includes only bone mineral density (BMD) data to assess fracture risk.
The FRAX score includes only bone mineral density (BMD) data to assess fracture risk.
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What is the T-score at the vertebrae for Mrs. Miller?
What is the T-score at the vertebrae for Mrs. Miller?
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Mrs. Miller is a 72-year-old white female with a family history of __________.
Mrs. Miller is a 72-year-old white female with a family history of __________.
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What is the 10-year major osteoporotic risk percentage indicating that treatment may be considered?
What is the 10-year major osteoporotic risk percentage indicating that treatment may be considered?
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Match the following T-score values with their corresponding classifications:
Match the following T-score values with their corresponding classifications:
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The FRAX tool is only for postmenopausal women.
The FRAX tool is only for postmenopausal women.
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What medications is Mrs. Miller currently taking?
What medications is Mrs. Miller currently taking?
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Which T-score indicates the most severe osteoporosis risk for Mrs. Miller?
Which T-score indicates the most severe osteoporosis risk for Mrs. Miller?
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Osteoporosis treatment is rarely indicated for older adults.
Osteoporosis treatment is rarely indicated for older adults.
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What is the first-line treatment for osteoporosis?
What is the first-line treatment for osteoporosis?
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Mrs. Miller has a serum calcium level of ______ mg/dL.
Mrs. Miller has a serum calcium level of ______ mg/dL.
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Match the non-pharmacologic treatments with their descriptions:
Match the non-pharmacologic treatments with their descriptions:
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What percentage of people with osteoporosis die within one year of diagnosis?
What percentage of people with osteoporosis die within one year of diagnosis?
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A man's risk of breaking a bone is lower than his risk of getting prostate cancer.
A man's risk of breaking a bone is lower than his risk of getting prostate cancer.
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What is one of the medications known to increase the risk of osteoporosis?
What is one of the medications known to increase the risk of osteoporosis?
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The most common bone disease affecting millions is called __________.
The most common bone disease affecting millions is called __________.
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Match the risk factors with their categories:
Match the risk factors with their categories:
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Which of the following groups should be screened for osteoporosis?
Which of the following groups should be screened for osteoporosis?
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All individuals with rheumatoid arthritis do not need to be screened for osteoporosis.
All individuals with rheumatoid arthritis do not need to be screened for osteoporosis.
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What does T-Score indicate in the context of osteoporosis?
What does T-Score indicate in the context of osteoporosis?
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Approximately ___ million Americans have low bone density.
Approximately ___ million Americans have low bone density.
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Which of the following is NOT considered a disease that affects osteoporosis risk?
Which of the following is NOT considered a disease that affects osteoporosis risk?
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What is the recommended calcium intake per day for women over 50?
What is the recommended calcium intake per day for women over 50?
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Calcium supplements should be taken without regard to meals.
Calcium supplements should be taken without regard to meals.
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Name one natural source of calcium.
Name one natural source of calcium.
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The optimal level of 25-OH Vitamin D is above ______ ng/mL.
The optimal level of 25-OH Vitamin D is above ______ ng/mL.
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Match the following agents with their classification:
Match the following agents with their classification:
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Which of the following conditions is a contraindication for bisphosphonate therapy?
Which of the following conditions is a contraindication for bisphosphonate therapy?
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All patients can absorb the same amount of calcium at a time.
All patients can absorb the same amount of calcium at a time.
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What is the usual dosing schedule for Denosumab?
What is the usual dosing schedule for Denosumab?
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Calcium _______ requires acid for absorption.
Calcium _______ requires acid for absorption.
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What is a common side effect of taking bisphosphonates?
What is a common side effect of taking bisphosphonates?
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It is safe to take calcium supplements with antacids at any time.
It is safe to take calcium supplements with antacids at any time.
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What is the primary mechanism of action of Denosumab?
What is the primary mechanism of action of Denosumab?
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Atypical Femoral Fractures (AFF) are most commonly associated with the use of _______.
Atypical Femoral Fractures (AFF) are most commonly associated with the use of _______.
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Match the following 25-OH Vitamin D levels with their interpretation:
Match the following 25-OH Vitamin D levels with their interpretation:
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Study Notes
Osteoporosis Overview
- A bone disease, occurring when the body loses bone, makes too little bone, or both
- Bones become weak and may fracture easily
- Bone strength depends on density and bone quality
Learning Objectives
- Recognize prevalence and risk factors for osteoporosis
- Describe negative outcomes of osteoporosis
- Interpret T-scores to diagnose osteoporosis/osteopenia
- Calculate FRAX scores to determine if osteopenia needs treatment
- Identify non-pharmacological strategies to decrease fall and fracture risk
- Compare and contrast pharmacological agents for osteoporosis treatment
- Recommend non-pharmacological and pharmacological strategies for osteoporosis treatment
Meet Mrs. Miller
- 72-year-old white female
- PMH: hypertension, type 2 diabetes, GERD, no history of fractures
- Family history: mother had osteoporosis and a hip fracture
- Social history: non-smoker, occasional alcohol (1 glass of wine with dinner 3 times per week)
- Medications: lisinopril, metformin, pioglitazone, famotidine
- Vitals: weight 125 lbs, height 5'4"
- DXA Report (10/31/2022):
- T-score total hip: -0.9
- T-score femoral neck: -1.8
- T-score vertebrae: -2.2
Osteoporosis - "Porous Bone"
- Bone disease characterized by low bone mass and microarchitectural deterioration of bone tissue
- Results in increased bone fragility, leading to a high risk of fractures
Bone Remodeling
- Continuous process where bone is broken down (resorption) and new bone is formed (formation)
- Osteoclasts break down old bone tissue
- Osteoblasts are responsible for bone formation
Natural History of Bone Mineral Density
- Bone loss rate is 0.2-0.5% per year
- Bone mass decreases with age
- Bone loss rate is 1-5% per year during the 10 years after menopause
Common Sites of Fracture
- Vertebral fractures
- Hip fractures
- Wrist fractures
Poll Question
- What percent of women will have an osteoporosis-related fracture during their lifetime? -75%
Osteoporosis Statistics
- 10 million Americans have osteoporosis
- 44 million Americans have low bone density
- A woman's risk of fracture is comparable to the combined risk of breast, uterine, and ovarian cancer
- A man is more likely to break a bone than to get prostate cancer
Negative Outcomes of Osteoporosis
- 24% die within one year
- 40% unable to walk independently
- 80% restricted in activities of daily living
- 33% placed in a nursing home
Risk Factors for Osteoporosis
- Postmenopausal women
- Ethnicity
- Low body weight
- Family history
- Calcium or vitamin D deficiency
- Inactivity
- Smoking
- Excess alcohol
- Rheumatoid arthritis
- Diabetes
- Secondary hyperparathyroidism
- Hyperthyroidism
- Anorexia nervosa
- Celiac disease
- Vitamin D deficiency
- Immobilization
- Depression
- Steroids (prednisone> 5mg daily for >3 months)
- Aromatase inhibitors (anastrozole)
- Proton pump inhibitors (omeprazole, pantoprazole, esomeprazole)
- Glitazones (pioglitazone, rosiglitazone)
- Antiepileptics (carbamazepine, phenobarbital, phenytoin)
- Medroxyprogesterone injections
- Heparin
- SSRIs (citalopram, escitalopram, sertraline)
NOF Screening Recommendations
- Women age 65 and older, regardless of clinical risk factors
- Younger postmenopausal women, women in the menopausal transition, and men aged 50-69 with clinical risk factors for fracture
- Adults with fractures after age 50
- Adults with conditions (e.g., rheumatoid arthritis) or taking medications (e.g., steroids) associated with low bone mass or bone loss
Screening Modalities
- DXA scan
T-Score vs Z-Score
- T-score: compares results to healthy young adults (20-35)
- Used for diagnosis
- Z-score compares results to people of the same age and gender
- Used to determine if further work-up is needed
Interpreting T-Scores
- -4 to -2.5: osteoporosis
- -2.5 to -1: low bone density (osteopenia)
- 0 and above: normal
Candidates for Treatment
- Osteoporosis by T-score
- Patients with fragility fracture
- Osteopenia that meets FRAX criteria
FRAX Score
- Decision-making tool for treating osteopenia
- Takes multiple risk factors beyond BMD into account
- Determines 10-year fracture risk (hip and major osteoporotic)
Mrs. Miller's DXA Scan Results (10/31/2022)
- T-score total hip: -0.9
- T-score femoral neck: -1.8
- T-score vertebrae: -2.2
FRAX Score Exercise
- Calculate Mrs. Miller's FRAX score using the provided info
Poll Question
- Should Mrs. Miller receive treatment at this time? -Requires calculation of FRAX score for a definitive answer
Treatment of Osteopenia and Osteoporosis
- Calcium
- Vitamin D
- Risk Reduction
- Falls Reduction
- Exercise
- Pharmacotherapy
Calcium Supplementation
- Calcium from diet preferred over supplements
- Recommended daily calcium intake based on age and sex groups
Sources of Calcium
- Natural sources (beans, lentils, canned sardines, salmon, leafy greens, seeds)
- Fortified foods (milk, yogurt, cheese, orange juice, cereal)
- Supplements (multivitamins, calcium carbonate, calcium citrate)
Calcium in Foods
- Nutritional information about calcium content in foods
Calcium Supplementation Pearls
- Only 500 mg of calcium is absorbed at a time
- Calcium carbonate absorption requires stomach acid; not as well absorbed by those on PPI or H2 blockers
- Calcium citrate doesn't require acid for absorption
- Some patients have difficulty swallowing pills
- Calcium may interact with other medications
Common Supplements
- Table comparing various calcium supplements (brand names, elemental calcium, vitamin D, tablets per day, and cost)
Sources of Vitamin D
- Natural sources (salmon, liver, mushrooms, egg yolks, sun exposure)
- Fortified foods (milk, orange juice, yogurt, butter)
- Supplements (multivitamins, ergocalciferol, cholecalciferol)
25-OH Vitamin D Levels
- Concentration levels:
- Optimal: Above 30 ng/mL
- Insufficient: 21-29 ng/mL
- Deficient: Less than 20 ng/mL
Vitamin D Supplementation
- Cholecalciferol (Vitamin D3): OTC; daily dose of 1,000-2,000 IU
- Ergocalciferol (Vitamin D2): Prescription; 50,000 IU once weekly for 8-12 weeks to treat deficiency (25-OH vitamin D < 20 ng/mL)
Falls Reduction - Statistics
- Falls are the leading cause of death and disability in seniors
- 25% of people over 65 fall each year
- <50% of people who fall tell their doctor
- 20 minutes: time until death in cases of falls
- 95% of hip fractures are caused by falls
Risk Factors for Falls
- Medications
- Lower body weakness
- Vitamin D deficiency
- Gait and balance disturbances
- History of recent falls
- Vision impairment
- Improper footwear
- Home hazards (rugs, steps, handrails, poor lighting)
Lifestyle Measures
- Weight-bearing exercise
- Muscle-strengthening exercise
- Smoking cessation
- Limiting alcohol intake
Pharmacotherapy
- First-line: bisphosphonates and denosumab
- Second-line: calcitonin, raloxifene, estrogen
- Severe osteoporosis: PTH analogs and sclerostin inhibitor
Bisphosphonates
- First-line treatment in most patients
- Approved for women, men, and steroid-induced osteoporosis
- Decreases hip and vertebral fractures
- Zoledronic acid decreases mortality after hip fracture
- Cost-effective
- Mechanism of action (MOA)
- Dosing (oral and intravenous)
- Adverse effects (esophagitis, acute phase reaction, muscle/bone/joint pain, hypocalcemia, rare effects: ONJ, AFF)
Bisphosphonates: Contraindications
- Hypocalcemia
- Inability to remain upright for 30 minutes
- Esophagitis
- Esophageal strictures
- Barrett's esophagus
- Swallowing disorders
- CrCl <35 mL/min (alendronate, zoledronic acid)
- CrCl <30 mL/min (ibandronate, risedronate)
Starting a Bisphosphonate
- Baseline lab tests (calcium, vitamin D, SCr)
- DXA scan to monitor response to therapy
- Counseling points (administration, timing, adverse effects like pain, food intake)
Bisphosphonate Holidays
- Consider holiday for low-risk patients >3 years (zoledronic acid), >5 years (alendronate/ibandronate)
- Patients high risk of fracture or with decline in BMD should restart bisphosphonate
- Treat high-risk patients (history of a fracture, osteoporosis diagnosis, steroid use) for up to 10 years
Denosumab (Prolia)
- Receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor
- MOA
- Dose: 60 mg subcutaneously every 6 months
- Administration (by healthcare professional, refrigerated)
- Adverse effects (hypocalcemia, infections, rare: ONJ, atypical femur fractures)
- Contraindications
- Cost
Denosumab (Prolia): Discontinuation
- BMD decreases rapidly upon discontinuation
- Bone turnover markers increase above baseline in 12 months
- Rebound fracture risk
- Alternative agents to maintain BMD if discontinuing (bisphosphonate)
Second Line Agents
- Calcitonin (vertebral fracture pain)
- Raloxifene (osteopenia of the spine, high breast cancer risk)
- Estrogen (vasomotor symptoms in women)
Selective Estrogen Receptor Modulator (SERM)
- Raloxifene
- MOA and indication
- Dose (60 mg PO daily)
- Adverse effects (increased risk for DVT/PE and death from stroke, CHD, menopausal symptoms)
Conjugated Estrogens/Bazedoxifene (Duavee)
- Equine estrogen/SERM combination
- Indication, Contraindications, Dosing, Side effects, Boxed Warnings
PTH Analogs
- Analogs of human parathyroid hormone, stimulating osteoblast activity, increasing bone formation.
- Decreases risk of vertebral and non-vertebral fractures
- Used in patients with high risk of fracture.
- A history of vertebral fractures or multiple fractures.
- T-score < -3
- Due to safety issues, the cumulative lifetime treatment duration is restricted to 2 years or less
- Followed by a bisphosphonate or denosumab to maintain BMD
Teriparatide (Forteo)
- Treatment for post-menopausal osteoporosis, osteoporosis in men, steroid induced osteoporosis
- Dosing (20 mcg subcutaneously daily)
- Adverse effects (transient orthostasis, arthralgia, leg cramps, hypercalcemia, osteosarcoma)
PTH Analogs – Abaloparatide (Tymlos)
- Indication, Treatment for post-menopausal osteoporosis in women.
- Dose (80 mcg subcutaneously daily), considerations
Romosozumab (Evenity)
- Sclerostin inhibitor
- MOA, Dosing (210 mg subcutaneously every month), and indication
- Adverse effects (hypcalcemia, arthralgia, injection site reactions), boxed warning (CV risks)
- Considerations, cost
Monitoring Therapy
- DXA scans 1-2 years after initiation of therapy (Medicare covers testing every 2 years).
- Assessment of proper administration, tolerability, and side effects.
- Assessment of medication adherence.
Mrs. Miller (additional questions)
- What labs should be obtained before starting treatment?
- What other information is needed before selecting appropriate treatment?
- The presented lab results for serum calcium and 25-hydroxyvitamin D, and CrCl. Additional considerations include a history of falls and non-pharmacological interventions.
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Description
Test your knowledge about osteoporosis, bone loss rates, and key diagnostic criteria such as T-scores and fractures. This quiz covers crucial information that nursing students need to understand about bone health, particularly in postmenopausal women. Challenge yourself with case studies and practical questions related to osteoporosis management.
