ClinMed - Rheumatology

Osteopenia

1. What is it?
2. Why is it clinically important?
3. How do different T-scores correlate to hip fx risk?
4. How is the T-score calculated?
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Terms in this set (40)
Osteopenia

1. What is it?
2. Why is it clinically important?
3. How do different T-scores correlate to hip fx risk?
4. How is the T-score calculated?
1. What is it?
BMD is between 1.0- 2.5 SD below the gender-matched adult mean

2. Why is it clinically important?
Fracture risk increases as bone mineral density declines

3. How do different T-scores correlate to hip fx risk?
~ -1 score--> 16% chance
~ -2 score --> 27%
~ -2.5 score --> 33%

4. How is the T-score calculated?
FRAX calculator
Osteoporosis

1. What is it?
2. Causes (3)
3. Demographic
4. Presentation
5. How could you reproduce pain sx?
6. Imaging
7. Labs
8. Tx - NonPharm
9. Tx - First Line
10. Tx - Second Line
11. Prevention
12.
1. What is it?
abnormal bone remodeling --> decrease in total bone volume --> increase in fx

2. Causes (3)
- PRIMARY: aging or menopause
- SECONDARY: medical conditions or medications (long term pred)

3. Demographic
>70y

4. Presentation
- height loss (>1cm or >0.8 inch)
- Kyphosis and cervical lordosis (dowager's hump)
-Acute pain = fx, usually of vertebra, hip, or forearm

5. How could you reproduce pain sx?
Palpate spinous processes

6. Imaging
- DEXA is GOLD STANDARD (>=-2.5 in spine, fem neck, or hip in absence of fx)
- Plain XR to see fx

7. Labs
- CBC (anemia, malignancy)
- Serum chemistry
- 24h urine to identify calcium malabsorption/hypercalciuria
- Serum 25-OH vitamin D
- other labs to look at secondary causes

8. Tx - NonPharm
- Diet: Ca, vit D, protein
- Weight-bearing exercise (impact exercise, strength w/ weights, balance training)
- No smoke, mod EtOH
- Hip protectors to reduce hip fx
- Consider PT/OT

9. Tx - First Line
- Ca and Vit D
- Alendronate, Risedronate
- Zoledronic Acid
- Denosumab
- to reduce fx: PTH, Raloxifene, Estrogen

10. Tx - Second Line
- Nasal calcitonin (also SQ) (also have analgesic effect w/ painful acute vert fx)
Image: Osteoporosis 1. What is it? 2. Causes (3) 3. Demographic 4. Presentation 5. How could you reproduce pain sx? 6. Imaging 7. Labs 8. Tx - NonPharm 9. Tx - First Line 10. Tx - Second Line 11. Prevention 12.
Osteoporosis

1. Prevention
2. Follow up
3. When to refer
1. Prevention
F: screen at 65y or younger if equal risk
M: screen at 70y
- DEXA of hip or L-spine
- Postmenopausal women and men >50y who are on steroids x 3 months --> bisphosphonate therapy
- Premenopausal women of nonchildbearing potential and younger men on steroids x 1-3 months --> bisphosphonates

2. Follow Up
- Repeat DEXA q1-2y - May d/c bisphosphonates after 5y of stability or 6-10y of stability in high-risk patients
- If BMD declines or dx, restart tx

3. When to refer
- normal BMD + low-trauma fx
- recurrent fx or continued bone loss despite therapy
- less common secondary condition
- unexpectedly severe osteoporosis or unusual features
has a complicating condition (e.g., renal failure)
What osteoporosis medication should be limited to 2 years?

What is an important note about IV Zoledronic Acid as tx for osteoporosis?
2 years: teriparatide

ZOLEDRONIC ACID: consider a drug holiday after 3 annual doses in moderate-risk patients and after 6 annual doses in higher-risk patients
When does bone mass peak and then begin to decline?

When is there a disproportionate loss of trabecular bone?
PEAK THEN DECLINE: 30y

DISPROPORTIONATE LOSS: menopause
See slide 8 for Osteoporosis Risk Factors
...
Women with osteoporosis or osteopenia AND a previous hip or spine fragility fracture should receive ___

Women should also be considered for medication if they have a T-score of between ___ and ____, if FRAX major osteoporotic fracture probability is ≥20%, or if hip fracture probability is ≥3%
medication therapy, beginning with a bisphosphonate

-1.0 and -2.5
Osteomalacia

1. What is it?
2. Cause
3. How is it different from Rickets?
4. Presentation
5. Labs
6. Imaging
7. Tx
1. What is it?
Low bone density from defective mineralization

2. Cause
Severe/prolonged vit D deficiency (any condition that results in inadequate Ca or P mineralization of bone osteoid)

3. How is it different from Rickets?
Rickets: in kids before epiphyseal fusion
Osteomalacia: in adults w/ fused epiphyses

4. Presentation
MAY BE ASYMPTOMATIC
- Bone pain and muscle weakness
- Bone tenderness
- Fx
- Difficulty walking/waddling gait
- Positive Chvosteks, spasms
- vague constitutional sx (lethargy, fatigue, paresthesias)

5. Labs
- ⬆️ Alk Phos
- ⬆️ PTH
- ⬇️ Ca and P
- ⬇️ Urinary Ca
- ⬇️ 25- OH vit D

6. Imaging
- Bone densitometry (degree of osteopenia)
- XR: biconcave vert, compression fx, trefoil pelvis (acetabular protrustion), Looser's zones

7. Tx
- Face, arms, hands, or back need sun x 15 min 2x/week
- If not possible, then vit D prophylactically
- Vit D def: vit D2 50,000 IU qw
- malabsorption or bad nutrition: Ca supp (best w/meals)
What are Looser's zones? What are 3 common locations of them?
Poorly healing stress fx

1. Neck of scapula
2. Neck of femur
3. Pubic bones
What is the difference between Vit D deficiency and Vit D Insufficiency?
Vit D Deficiency
serum 25-OHD: <20

Vit D Insufficiency
serum 25-OHD: 20-30