Diagnosis
-H&P.
–Screening guidelines.
–Risk Factors for Osteoporosis and Related Fractures, reviewed and patient counseled.
-The ten-year fracture risk determined using the FRAX tool from the WHO are:
–The 10-year probability of a hip fracture is: ___ %
–The 10-year probability of a major osteoporosis-related fracture is: ___%
–BMD assessment with DXA scan shows:
–Nonpharmacologic Therapy to Reduce Fractures discussed.
–Indications for pharmacologic therapy discussed.
-Labs: Serum 25-hydroxyvitamin D, calcium, phos, creatinine, PTH, and TSH to identify secondary causes of osteoporosis.
-Will get CMP to look at eGFR before starting Zolendronic acid. Will also look at Alkaline Phosphatase and LFTs.
-CBC.
-Will consider spot urine calcium/creatinine.
Treatment
-Contraindications to zoledronic acid include hypocalcemia.
–Pharmacotherapeutic options reviewed. Oral bisphosphonates are the 1st-line treatment for most patients.
Follow-up:
“• Patients not requiring medical therapies at the time of initial evaluation should be clinically re-evaluated when medically appropriate
• Patients taking FDA-approved medications should have laboratory and bone density re-evaluation after 2 years or more frequently when medically appropriate
• Vertebral imaging should be repeated if there is documented height loss, new back pain, postural change, or suspicious finding on chest X-ray, following the last (or first) vertebral imaging test or in patients being considered for a temporary cessation of drug therapy to make sure no new vertebral fractures have occurred in the interval
• Regularly, and at least annually, assess compliance and persistence with the therapeutic regimen” NOF
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“Osteoporosis-related fractures affect approximately 50% of all white women and 20% of all white men in their lifetime.” AAFP 2015
When should you rescreen women with normal DXA scans? Answer: Intervals of at least four years appear safe (AAFP 2015)
Osteopenia – repeat in 2 years.
“Monitoring patients
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Perform BMD testing 1 to 2 years after initiating medical therapy for osteoporosis and every 2 years thereafter.
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More frequent BMD testing may be warranted in certain clinical situations.
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The interval between repeat BMD screenings may be longer for patients without major risk factors and who have an initial T-score in the normal or upper low bone mass range.
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Biochemical markers can be repeated to determine if treatment is producing expected effect.” NOF
***FRAX estimates 10 y risk of major osteoporotic fracture if the patient is NOT treated.
If parathyroid hormone causes osteoporosis, how come teriparatide (a recombinant PTH) is used to treat osteoporosis?
Risk factors for osteoporosis include female gender, non-Hispanic white ethnicity, smoking, and low BMI.
Secondary prevention of fractures is an important component of care following a hip fracture. If a patient with untreated osteoporosis has a fracture, start pharmacotherapy to prevent future fracture.
“Normal bone density is defined as a T-score greater than or equal to -1 standard deviations. Osteopenia (also known as low bone mass), is diagnosed with a T-score of between -1 and -2.5 standard deviations. Severe osteoporosis occurs with the presence of one or more fractures and a T-score of less than or equal to -2.5 standard deviations.”
“Whenever an athlete suffers multiple stress fractures, especially women, a prompt work up for osteoporosis should be done along with questioning about the female athlete triad which includes eating disorders, amenorrhea, and osteoporosis.”