Download Table 73-1 Risk Factors for Osteoporosis and

Table 73-1 Risk Factors for Osteoporosis and Osteoporotic Fractures
Low bone mineral densitya
Female sexa
Advanced agea
Race/ethnicitya
History of a previous fragility fracture as an adulta (especially clinical vertebral fracture or hip
fracture)
Osteoporotic fracture in a first-degree relative (especially parental hip fracturea)
Low body weight or body mass indexa
Premature menopause (<45 years old)
Secondary osteoporosisbb (especially rheumatoid arthritisa)
Past or present systemic oral glucocorticoid therapya,c
Cigarette smokinga,c
Low calcium intake
Low physical activity or immobilization
Vitamin D insufficiency
Recent falls
Cognitive impairment, Impaired vision
Patient Assessment
Bone pain, postural changes (i.e., kyphosis), and loss of height are simple useful physical
examination findings. A height loss greater than 1.5 inches (3.8 cm) from the tallest mature
height is considered significant and warrants further investigation. Low bone density or
osteopenia reported on routine radiographs is a sign of significant bone loss and requires further
evaluation for osteoporosis.
Risk Factor Assessment
The aim of an initial osteoporosis risk assessment (see Table 73-1) is to identify those patients
who are at highest risk for low bone density and who would benefit from further evaluation.
Many risk factors for osteoporosis have been identified and are similar for both sexes. The
majority of risk factors are predictors of either low BMD (e.g., female sex, ethnicity) or an
increased fracture and fall risk (e.g., cognitive impairment, previous falls). The most important
risk factors are those associated with fracture risk independent of BMD and fall risk. These
major risk factors, in combination with BMD, are used to determine which patients are at
greatest risk for fracturing and would benefit most from pharmacologic intervention.
Central Dual-Energy X-ray Absorptiometry
BMD measurements at the hip or spine (or radius if these bones cannot be scanned) can be
used to assess fracture risk, establish the diagnosis and severity of osteoporosis, and
sometimes confirm osteoporosis as causative for low-trauma fractures.1,6–8,35 Central DXA is
considered the gold standard for measuring BMD.
A central DXA BMD report provides the actual bone density value, T-score, and Z-score.
The T-score is used for diagnosis and is a comparison of the patient’s measured BMD to the
mean BMD of a healthy, young (20- to 29-year-old), sex-matched white reference population; no
adjustments for race or ethnicity. The T-score is the number of standard deviations from the
mean of the reference population. The Z-score is similar but compares the patient’s BMD to the
mean BMD for a healthy sex- and age-matched population. Patient-reported race or ethnicity
should be used for the Z-score if available. A Z-score value of ≤ -2.0 is sometimes helpful in
determining whether a secondary cause for osteoporosis is present and is used for diagnosis in
children, premenopausal women, and men younger than 50 years of age.
Laboratory Tests
 Routine tests: complete blood count, metabolic profile, creatinine, calcium, phosphorous,
electrolytes, alkaline phosphatase, albumin, 25(OH) vitamin D, thyroid-stimulating
hormone, total testosterone (for men).
The primary goal of osteoporosis care should be prevention and patient education. Optimizing
skeletal development and peak bone mass accrual in childhood, adolescence, and early
adulthood will ultimately reduce the future incidence of osteoporosis. Once low bone mass or
osteoporosis develops, the objective is to stabilize or improve bone mass and strength and
prevent fractures.
**** Treatment scheme >> focus on the sequence of medications (i.e. 1st line, 2nd line, etc.)
Nonpharmacologic Therapy
Nonpharmacologic therapy, referred to as a bone-healthy lifestyle, includes proper nutrition,
moderation of alcohol intake, smoking cessation, exercise, and fall prevention. A bone healthy
lifestyle that is employed early in life will help to optimize peak bone mass and if continued
throughout life, it will minimize bone loss over time. Not only does a bone healthy lifestyle target
BMD, but it also contributes to decreasing the risk of falls and fragility fractures.
Diet
Overall, a diet well balanced in nutrients and minerals and limited in salt, alcohol, caffeine, and
excessive protein is important for bone health.
Calcium
Table 73-4 Recommended Dietary Allowances and Upper Limits of Calcium and Vitamin D
Group and
Elemental
Calcium Upper
Vitamin D
Vitamin D Upper
Ages
Calcium (mg)
Limit (mg)
(units)a
Limit (units)
Adults
19–50 years
51–70 years
(men)
51–70 years
(women)
>70 years
1,000
2,500
600b
4,000
1,000
2,000
600b
4,000
1,200
2,000
600b
4,000
1,200
2,000
800b
4,000
Pharmacological
Table 73-6 Dosing of Medications Used in Prevention and Treatment of Osteoporosis
Brand
Drug
Dose
Comments
Name/Formulation
Antiresorptive Medications—Nutritional Supplements

Calcium
Various

Supplement
dose is the
difference
between
adequate daily
intake, which
varies by age
(200–1,300
mg/day; see
Table 73-4),
and dietary
intake.
Might need
divided doses.
Available in different
salts including
carbonate and citrate
and different
formulations including
chewable, liquid. Give
calcium carbonate with
meals to improve
absorption.
Antiresorptive Prescription Medications
Bisphosphonates
Alendronate

Fosamax

Treatment: 10
mg orally daily

70 mg dose is
available as a
tablet,
Drug
Brand
Name/Formulation

Binosto
(effervescent
tablet)
Dose

Comments
or 70 mg orally
weekly
Prevention: 5
mg orally daily
or 35 mg orally
weekly





Ibandronate
Boniva

Risedronate


Actonel
Atelvia
(delayed
release)
Treatment: 150
mg orally
monthly, 3 mg
IV quarterly
Prevention: 150
mg orally
monthly
Treatment and
Prevention: 5 mg orally
daily, 35 mg orally
weekly, 150 mg orally
monthly


effervescent
tablet, or
combination
tablet with 2,800
or 5,600 units of
vitamin D3.
Administered
first thing in the
morning on an
empty stomach
with 6–8 ounces
(177–237 mL) of
plain water. Do
not eat and
remain upright
for at least 30
minutes
following
administration.
Do not
coadminister
with any other
medication or
supplements,
including
calcium and
vitamin D.
Avoid if CLcr <35
mL/min (0.58
mL/s)
Administration
instructions
same as for
alendronate,
except must
delay eating and
remain upright
for at least 60
minutes.
Avoid if CLcr <35
mL/min (0.58
mL/s)
Only 35-mg
dose also
available as a
delayed-release
product.
Drug
Brand
Name/Formulation
Dose
Comments




Zoledronic acid
Reclast

Treatment: 5
mg IV infusion
yearly;
Prevention: 5
mg IV infusion
every 2 years


Administration
instructions
same as for
alendronate,
except delayedrelease product
is taken
immediately
following
breakfast.
Avoid if CLcr <30
mL/min (0.5
mL/s)
May
premedicate
with
acetaminophen
or NSAIDs to
decrease
infusion
reaction.
Contraindicated
if CLcr <35
mL/min (0.58
mL/s)
Also marketed
under the brand
name Zometa
with different
dosing for
prevention of
skeletal-related
events from
bone
metastases from
solid tumors.
RANK ligand inhibitor

Denosumab
Prolia
Treatment: 60 mg
subcutaneously every 6
months


Administered by
a healthcare
practitioner.
Correct
hypocalcemia
before
administration.
Also marketed
under the brand
name Xgeva
Drug
Brand
Name/Formulation
Dose
Comments
with different
dosing for
prevention of
skeletal-related
events from
bone
metastases from
solid tumors.
Estrogen agonist antagonist
Raloxifene
Evista
60 mg daily
Bazedoxifene
Viviant
20 mg daily
Bazedoxifene with
conjugated equine
estrogens
Aprela
20 or 40 mg plus 0.45
or 0.625 mg conjugated
equine estrogens daily

Contraindicated
in breast and
uterine cancers

Refrigerate until
opened for daily
use, then room
temperature.
Prime with first
use.
Calcitonin

Calcitonin (salmon)


Miacalcin
Fortical

200 units (1
spray)
intranasally
daily, alternating
nares every
other day.
100 units
subcutaneously
daily

Formation Medication
Recombinant human parathyroidhormone(PTH 1–34 units)
Teriparatide
Forteo
20 mcg subcutaneously
daily for up to 2 years
**** focus on the contraindications and frequency of administration
Side effects of bisphosphonates are related to the GI they include esophageal ulcerations.