osteoporosis 06/25/12 josé l. gonzález, pgy3. definition reduction in bone strength increase...
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OSTEOPOROSIS
06/25/12 José L. González, PGY3
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Definition
Reduction in bone strength increase risk of fx
T-score: < -2.5 SDs T-score: 30 yo, matched for sex and race
Osteopenia: <-1 to 2.5 SDs
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Epidemiology
>10 million 8 million women & 2 million men
Most fractures occur in women w/ osteopenia
Rate of colles fx increases initially, later hip May be due to the way we fall
Vertebral > Hip > Colles
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Risk Factors
Age, female sex, cigarette smoking, prior fxs, low body weight, excess etoh
Meds: glucocorticoids, cyclosporine, heparin, levothyroxine, anticonvulsants
Diseases Vision Dementia Chronic inflammatory diseases
RA Crohns
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Bone Remodeling
Bone mass is 50-80% heritable Peak skeletal mass early adulthood.
Constant mass 30-45 yoa, then increased resorption
Estrogens, androgens, vitamin D, PTH 2 functions
Repair microdamage of the skeleton Maintain [Ca2+] serum
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Risk Factors: Parathyroid Hormone Kidneys
1. ↑ hydroxylation 1,25OH vit D 2. decreased Ca2+ loss
Small Intestine ↑Ca2+ absorbtion
Bone Release of Ca2+
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Risk Factors: vitamin D / Calcium Calcium: RDI 1000 – 1200 Vitamin D: RDI 800-1000 units daily
RFs for low vit D: High latitude Low intake Chronic liver or renal disease
Estrogen Physical Activity
↓risk in rural communities
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Diagnosis
US, CT scan, single energy absorptiometry, DXA
DXA Lumbar and hip m.c. used Z-score: age matched T-score: 30 yo, race and sex matched
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Who to test:
All women > 65 yoa Estrogen deficient women @ risk Vertebral abnormality of x-ray
suggestive Primary hyper parathyroidism Steroids > 7.5mg x 3 months Monitoring response to meds Repeat @ 2 year intervals
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Who to treat:
T-score < -2.5 SDs Post-menopausal women w/ RFs
RFs: age, prior fx, family hx, low weight, smoking, RA, etoh
FRAX calculator
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Treatment: SERMs, PTH, Calcitonin Raloxifene:
tx & pv of ER+ breast ca Tx & pv of osteoporosis
PTH: in small amounts Calcitonin: (intranasal)
Hormone produced by thyroid decreases osteoclast activity Decreases vert. fxs only
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Treatment: Estrogens
Estrogens (in the form of combined OCPs) Decrease fracture risk by 50% Increase risk of MI by 29% Increase stroke risk by 40% dementia 2x Increase risk of breast ca by 26% Decrease risk of colon ca by 37% Increase risk of VTE by 100%
10,000 patients: prevents (5 hip, 6 colles & 44 clinical fxs) leads to (8 breast cas, 8 MIs, 18 VTEs)
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Treatment: Bisphosphonates Alendronate:
5mg x 2 yrs, 10mg x 9 months 90% ↓vert. fx, 50% ↓hip fx
70mg PO dose once weekly Risedronate:
use in steroid-induced OP Ibandronate Zolendronic Acid:
70mg IV q yearly for hyperCa2+
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Bisphosphonates: Side Effects Osteonecrosis of the jaw hypocalcemia GI side effects
Esophagitis, ulceration Contraindicated in strictured esophagus Drink w/ full glass H20 and remain upright x
30min
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Sources:
Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2005:946.