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Osteoporosis

Osteoporosis. Nick Camposeo POPPF DidacticsOnline.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

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Osteoporosis

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  1. Osteoporosis Nick CamposeoPOPPF DidacticsOnline.com

  2. 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

  3. Case Presentation • Past Medical History • Celiac’s disease, 1986 • GERD 92 • Surgical Hx • Non contributory • Social • +TOB ½ pack /day • +EtOH2-4 drinks/week • Diet/Exercise • No gluten, Vegetarian • No exercise • Meds • Omeprazole • NKDA • Sexual: • married • LMP – irregular, 6 months ago, occasional spotting

  4. 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

  5. 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

  6. Osteoporosis, what is it? • Osteoporosis • skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fractures. • Multifactoral • Primary or secondary

  7. 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

  8. 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 kBligand • IL-1, IL-6, TNF

  9. What do you look for? • Evaluation • HISTORY!! • Past medical • Surgical • Meds • Family history • Social

  10. Objective findings • Look for declining weight and height • Increased kyphosis , dowagers hump

  11. What do you look for? • Evaluate fall risk • Hip fractures • Increase DVT risk • Fat emboli • 25% fatal • OSTEOPOROSIS IS SILENT UNTIL FRACTURE

  12. 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

  13. Who is at risk for osteoporosis? • Tobacco smoking • Malnourished • Underactive • Chronic disease (esp kids) • Lactation

  14. What do you look for? • Labs • Biochemistry profile • 25-hydroxyvitamin D • Complete blood count • Urinary calcium excretion • Serum PTH

  15. 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

  16. 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

  17. 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.

  18. How can we prevent osteoporosis? • Screening • Best defense is a good offense • LIFE STYLE CHANGES! • Change any modifiable risk • Diet • Exercise • Smoking • Alcohol

  19. 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

  20. How can we treat osteoporosis? • Osteoporosis is silent until fracture! • Osteopathic • Normalize joint motion • Balance • Normalize gate

  21. Well, how do you treat it? • Bisphosphonates • Aledronate – fosamax • Risedronate – Actonel • Ibandronate – once a month

  22. 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) Zoledro nick • Ideal for pt who cannont tolerate oral • Difficulty swallowing, unable to sit upright for 60 mins, poor compliance • Osteonecrosis of Jaw

  23. Well, how do you treat it? • Selective Estrogen Receptor Modulator • Raloxifene • Who cannot tolerate bisphosphonates • Relative contraindications • Achalasia, scleroderma esophagus, esophageal strictures.

  24. 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.

  25. Well, how do you treat it? • Denosumab • Inhibits RANKL, a protein involved with osteoclastogenesis. • acts like osteoprotegerin as both act as decoy receptors

  26. Well, how do you treat it? • Calcitonin • Directly inhibits osteoclast activity

  27. 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).

  28. The end • Any q or comment please send them to us at didactics online.

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