Osteoporosis

Nick Camposeo POPPFDidacticsOnline.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?

• Evaluation– HISTORY!!• Past medical• Surgical• Meds• Family history• Social

Objective findings

• Look for declining weight and height– Increased kyphosis , dowagers hump

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

Well, how do you treat it?

• Calcitonin– Directly inhibits osteoclast activity

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).

The end

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