Osteoporosis Nick Camposeo POPPF DidacticsOnline.com.
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Transcript of Osteoporosis Nick Camposeo POPPF DidacticsOnline.com.
Case Presentation
• CC: R wrist pain• HPI: 42 yo female, pain is constant for past 6
hours, after slipping and falling forward in kitchen. – Pain is 8/10 localized to R medial wrist– ROS:
– Gen: No fever, + weight loss, +fatigue– HEENT: No blurry vision, No HA, No difficulty swallowing– Chest : No SOB, No palpitations– GI: No N/V + diarrhea– EXT: No N/T/W in UE
Case Presentation • Past Medical History
– Celiac’s disease, 1986– GERD 92
• Surgical Hx– Non contributory
• Social– +TOB ½ pack /day– +EtOH 2-4 drinks/week
• Diet/Exercise– No gluten, Vegetarian– No exercise
• Meds– Omeprazole
• NKDA• Sexual:
– married– LMP – irregular, 6 months ago, occasional spotting
Case Presentation
• Objective– Vitals: BP 142/84 HR:74 Resp: 16 O2 :99% – Weight 115, Height 5’6 BMI: <18– GEN: Scaphoid appearance, AAOx3, in moderate distress– HEENT: NC, PERRLA, EOM intact, No AV nicking , No
papilledema, no polyps, no bulging eyes– CHEST : CTA BL, S1S2 no murmurs no gallops– ADB: BS present, no abd bruits, No CVA tenderness– EXT: DTR 2/4 symm BL, sensory and motor intact, edema and
tenderness at medial R distal radius, no ecchymosis. No scaphoid tenderness.
– Osteopathic: Hypertonic R wrist extensors, C5C6 FRlSl, hypertonic upper R thoracic paraspinals
Case Presentation
• A/P– R Arm pain, secondary to possible colles fracture or
distal radius, or possible scaphoid fracture. • Plain radiograph of distal R arm
– Possible Iron def. anemia, Osteoporosis due to poor nutrition and malabsorption• Biochemistry profile • 25-hydroxyvitamin D• Complete blood count• Urinary calcium excretion• Serum PTH
Osteoporosis, what is it?
• Osteoporosis– skeletal disorder characterized by compromised
bone strength predisposing to an increased risk of fractures.
– Multifactoral– Primary or secondary
Osteoporosis, what is it?
• Osteoporosis– estimated nine million osteoporotic fractures
worldwide in 2000 – Reduction of primarily trabecular (spongy) bone
and cortical bone.– Osteoporosis related fractures• 50% in women over 65yo• 20% in men over 65yo
Osteoporosis, what is it?
• Reduced bone mineral density– leads to microarchitectural disruption • leads to increases skeletal fragility
– Osteoclasts >osteoblasts– Increase in reactive oxygen species• Estrogens• RANKL/RANK/OPG axis
– Receptor activator for nuclear factor kB ligand
• IL-1, IL-6, TNF
What do you look for?
•Evaluate fall risk• Hip fractures– Increase DVT risk
• Fat emboli• 25% fatal
– OSTEOPOROSIS IS SILENT UNTIL FRACTURE
Who is at risk for osteoporosis?
• Age– Death, taxes and the jets not making the superbowl.
• Menopause• Endocrine disorder• Family history of osteoporosis– Idiopathic osteoporosis
• Previous fracture
Who is at risk for osteoporosis?
• Tobacco smoking• Malnourished • Underactive• Chronic disease (esp kids)• Lactation
What do you look for?
• Labs • Biochemistry profile • 25-hydroxyvitamin D• Complete blood count• Urinary calcium excretion• Serum PTH
Who should you diagnose?
• Candidates for BMD testing– Pt with risk factors• Fracture Risk Assessment Tool
– women 65 years of age and older and in postmenopausal women younger than 65 years of age with clinical risk
– FRAX• World health organization fracture assessment tool
– Assess 10year fracture risk
Diagnosis
• Dual energy X-ray (DEXA)– Testing
• Femoral neck, lumbar spine, one third radius
– T-Score• Based on average bone density of 30yo man/women
– Peak bone mass– Used to compare post menopausal, men over 50
– Z score• Number of SD a pt’s BMD differs from average BMD of their peers
– Used in premenopausal women,– men under 50yo– And kids
Diagnosis
• Biomarkers– urinary N-telopeptide (NTX) or serum carboxy-
terminal collagen crosslinks (CTX)• By products of type 1 collagen breakdown
– Useful in pts where DEXA scan is a contraindications• Pregnancy• to skeletal structural abnormalities, such as severe
osteoarthritis, surgical hardware, or scoliosis.
How can we prevent osteoporosis?
• Screening• Best defense is a good offense– LIFE STYLE CHANGES!• Change any modifiable risk
– Diet– Exercise– Smoking– Alcohol
How can we prevent osteoporosis?
– Maximize peak bone mass in younger years• Adequate Ca++ intake and Vit. D
» Calcium supplements• Postmenopausal women need at least 1200mg daily
» Vit. D supplementation • 600 international units daily in younger • 800 international units for older adults
• Physical activity • No TOB and EtOH
How can we treat osteoporosis?
• Osteoporosis is silent until fracture!• Osteopathic– Normalize joint motion–Balance• Normalize gate
Well, how do you treat it?
• Bisphosphonates– Aledronate – fosamax– Risedronate – Actonel– Ibandronate – once a month
Well, how do you treat it?
• Bisphosphonates– Oral
– Poorly absorbed (less than 1% per dose)– Must be taken on empty stomach to increase absorption
– IV (Zoledronic acid) Zole dro nick– Ideal for pt who cannont tolerate oral
» Difficulty swallowing, unable to sit upright for 60 mins, poor compliance
– Osteonecrosis of Jaw
Well, how do you treat it?
• Selective Estrogen Receptor Modulator– Raloxifene• Who cannot tolerate bisphosphonates • Relative contraindications
» Achalasia, scleroderma esophagus, esophageal strictures.
Well, how do you treat it?
• PTH– calcium and phosphate homeostasis, calcitriol– PULSATILE• Double edged sword
– For severe osteoporosis• T score < -2.5 and at least one fragility fracture.
Well, how do you treat it?
• Denosumab– Inhibits RANKL, a protein involved with
osteoclastogenesis. – acts like osteoprotegerin as both act as decoy
receptors
Monitoring
• monitoring– For patients starting out on therapy
• DXA scan every 2 years of hip and spine
– If BMD is stable or improved less frequent monitoring s needed
• Chemical biomarkers– urinary N-telopeptide (NTX) or serum carboxy-terminal
collagen crosslinks (CTX• Biomarkers increase urine conc. when increase bone reabsorption.
– This approach (with markers of bone resorption) is only useful with antiresorptive therapy, not with recombinant PTH (markers would increase).