Osteoporosis

Source uptodate.com, Family Practice Notebook
Definition: Low bone mass leading to increase risk of fracture
 
Screening
  • goal to identify pt at risk of fracture
  • screen postmenopausal women, prior low impact fracture,men > 65 with risk factors
  • other risk factors
    • age, prior fx, steroid therapy, low body weight, family history, smoking, alcohol
  • Tools
    • FRAX = calculates 10-year RF for hip fx by region and race
    • Bone density or Bone Mineral Density (BMD)
      • typically done women >65 or postmenopausal <65 with risk factors
      • DEXA (Dual-energy x-ray absorptiometry)
        • typically done at hip or spine
        • Screen the following with DEXA scan
          • females 65 yo or older
          • postmenopausal women younger than 65 with risk factors
          • Men with risk factors (x-ray with low osteopenia, low trauma fracture, loss of height >1.5 inches and factors stated above)
    • T scores
      • -1 and above = normal
      • -1 to -2.5 = osteopenia
      • -2.5 or lower = likely osteoporosis
  • Management (for women >65 or postmenopausal women with risk factors)
    • Vitamin D = 800 IU daily
    • Calcium = 1200mg daily (food/supplement)
    • Exercise = 30 min 3x weekly
    • Smoking cessation
    • Pharmacologic
      • start therapy if (for postmenopausal women and men >=50)
        • history of hip/vertebral fx
        • T score < -2.5
        • T score -1 to -2.5
      • Monitor response = Repeat DXA in 2 years, then longer intervals once therapeutic response is adequate (this is the ISCD approach)
      • If BMD is stable or improvement = appropriate response
      • If worsening – check vit D/calcium levels, adherence, GI absorption
        • if <5%, repeat DXA in 2 years
        • if >5% switch to IV bisphosphonate (zOLEDORINC)
    • Bisphosphonate (treatment for postmenopausal women)
      • Candidates are pt with T-scores <-2.5 or -1.0 to -2.5 and high risk (use FRAX)
      • avoid with esophageal disorders or CKD
      • repeat DXA in 2 years
    • alendronate (Fosamax)
      • prophylaxis= daily 5mg or weekly 35
      • treatment = daily 10mg or weekly 70mg 
    • Risedronate = 5mg daily or 35mg weekly or 150 monthly
    • Teripratide (Forteo) = for severe osteoporosis => subQ 20mcg once daily