Osteoporosis
Source: CME talk by Dr Dinesh Mahendran | Endocrine
- Bone mass peaks around 30.
- Total Hip BMD is a better treatment target
- Whereas Lumbar BMD targets are good for patients at risk of vertebral #
Risk factors
- Previous #: is the single highest predictor. Dramatically increases the risk of subsequent #.
- Back pain
- Smoking
- Low weight
- Menopause age
- Hypogonadism
- Vitamin D deficiency
- Calcium intake
- Steroids
- Alcohol
- Fall risk
- Diabetes Mellitus
Vitamin D article
Calcium
Dietary sources: HL milk 2 cups daily, high calcium soy milk 2 cups daily, low fat high calcium yogurt
FRAX score
- If DM, to tick the RA button
- >20% major osteoporotic, >3% hip # is cut off
- DM, increases vertebral # risk 10%
- >30% / 4.5% on FRAX --> Osteoanabolic tx
Tx options
High risk
- No #: hip <= -2.8, lumbar <= -3
- # >2 yrs ago: multiple # => anabolic rx
- # <2 yrs ago: spine/pelvis/hip # => anabolic rx
Denosumab
- Cannot stop / miss
- If stopped, have to use 1-2 years of bisphosphonates as "consolidative tx", or else the improvement in BMD will reverse.
- BMD will drop to baseline by 12 months of stopping
- Vit D must be replenished, or will become calcium deficient
Daily Teriparatide
- refer endocrine
- must be started BEFORE denosumab
Romosuzumab (evenity)
- Monthly injection x 12 months, $1k/month, then consolidate
- use first line
- CI: MI/CVA
Anabolic treatment
- Consider refer endocrine
- Romosuzumab/alendronate | Romosuzumab/denosumab | Teriparatide/denosumb
Time course
Treat to target in 3 years, then consider drug pause, then later recheck/restart treatment
Atypical femoral fractures (AFF)
Asian women are at increased risk. Presents with hip pain.
Osteonecrosis of the jaw (ONJ)
Good dental hygiene. No need dental clearance. 1 in 10,000 chance. Increased chance in cancer treatment.