Term
| what is the body's reservoir for Ca++? |
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Definition
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Term
| what is the phenotypic manifestation of osteoporosis seen in older women? |
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Definition
| dowager's hump - hunched over/kyphosis |
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Term
| what is the T-score? Z-score? |
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Definition
| T-score: comparison of the pt's bone density to a woman 30-35 y/o (when bones are densest). Z-score: comparison to others of the same age. |
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Term
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Definition
| dual (beam) external x-ray absorptiometry: how the T-score is measured. it scans important areas, such as the *hip bones (not joint) and spine*. units of dexa scan measurements are T-score standard deviations (S.D.) |
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Term
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Definition
| the new name for osteopenia, which describes the state between normal and full-blown osteoporosis |
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Term
| when is the most rapid loss of bone density in women? |
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Definition
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Term
| what biochemical markers can be used to evaluate *bone formation*? |
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Definition
| bone alk phos, osteocalcin, and N+C terminal propeptides of type I collagen (P1NP, P1CP). |
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Term
| what biochemical markers can be used to evaluate *bone resorption*? |
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Definition
| N+C telopeptides of type I collagen (NTX, CTX), pyridinoline, desoxypridinoline (PYR, DPD), and investigational: tartrate resistant acid phosphatase (TRAP), OH-PRO, cathepsin K |
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Term
| what is the re-testing schedule if initial dexa scans were normal (*T score > -1)? |
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Definition
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Term
| what is the re-testing schedule if the pt is in an osteoporosis prevention program? |
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Definition
| every 1-2 yrs until bone mineral density (BMD) is stable, then every 2-3 yrs |
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Term
| what is the re-testing schedule if the pt is on osteoporosis tx/rx? |
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Definition
| every year for 2 years, then when BMD is stable, every 2 years |
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Term
| when should pts get bone turnover markers checked (BTMs) if on rx for osteoporosis? |
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Definition
| every 3-6 mos while on rx, then every 6-12 mos when off rx (or improved BMD) |
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Term
| what 2 things affect response to osteoporosis tx? what factors affect these things? |
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Definition
| *compliance: degree that pts follows dosing schedule (out of dr's control) and *persistence: length of administration. *pt factors that may decreased compliance+persistence: lack of understanding of benefits, pt motivation, cognitive dysfunction, no fracture/symptom hx, and dissatisfaction w/caregiver. *rx-related factors that may decrease persistence+compliance: cost, dosing regimen, frequency, and side effect |
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Term
| what are the risk factors for osteoporosis? |
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Definition
| asian/white, fair skin/hair, fam hx of osteoporosis, personal hx of fragility fracture, 65 y/o+, low BMI, current smoker (interferes w/Ca++ absorption), corticosteroid use 3 mo+ (interferes w/Ca++ absorption), impaired vision (easier to get hurt), estrogen deficiency < 45 yrs, dementia, poor health/frailty, recent/continued falls, low lifetime Ca++ intake, low physical activity, alcohol intake 2 drinks+/day, and rheumatoid arthritis |
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Term
| what is the national osteoporosis risk assessment (NORA) recommendation for when to treat pts based on T-score/risk factors? |
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Definition
| treat at -2.5 S.D. w/o risk factors or at -1.5 S.D. if 1 risk factor+ |
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Term
| what is FRAX? when does it recommend pharmacological therapy? |
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Definition
| FRAX estimates the 10 yr pt-specific risk for hip fracture or other major osteoporotic fractures (i.e. vertebral). *pharmacologic therapy should be considered w/3%+ risk of hip fracture or 20%+ risk of major osteoporotic fracture.* it is country specific, but there is no dose/duration mention of corticosteroid use or any provision for non skeletal factors (falling/vision). |
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Term
| what is the WHO definition for low BMD/osteopenia? |
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Definition
| -1.5 S.D. w/o risk factors |
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Term
| what is the WHO definition for osteoporosis? |
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Definition
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Term
| what is the gold standard for osteoporosis/low BMD dx? |
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Definition
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Term
| what are the other effects of decreased bone density beyond osteoporosis? |
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Definition
| muscle-wasting (protein wasting/lack of exercise = catch 22), joint dysfunction (less lubricated, less ROM), unsteady gait (hard to extend), and vascular complications of the extremities (specifically DVT, b/c muscles around veins aren't contracting). |
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Term
| what is secondary osteoporosis? |
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Definition
| a T-score less than -2.5 S.D. (towards 0) but abnormal labs: CBC, CMP+phos, 24 hr urine for Ca++, PTH, 25 (OH) vit D, and TSH |
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Term
| what % of secondary osteoporosis pts may be asymptomatic? |
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Definition
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Term
| what are the medication risk factors for secondary osteoporosis? |
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Definition
| glucocorticoids, aromatase inhibitors (used in breast CA therapy), depo-medroxyprogesterone (DMPA), GnRH agonists, long term heparin, anticonvulsant drugs, lithium, CA chemo, immunosuppressants, parenteral nutrition, antacids (particularly Al salts), PPIs, and SSRI/SNRIs |
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Term
| what % of secondary osteoporosis pts may have a vit D deficiency and not know it? how is this managed? |
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Definition
| 20%. normal vit D levels: 30-60 ng/mL (can be as low as 6). tx: load pt w/50,000 IU weekly for 8-12 wks (IM/PO), then maintain w/50,000 IU over the next 2 wks and retest. |
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Term
| what characterizes vertebral crushing in osteoporosis? |
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Definition
| vertebral crushing is usually asymmetric - on one side, *flexed (not usually extended, b/c carry wt forward of spine). these fractures narrow the space where the nerves exit and can pinch nerves (painful/numb). only 1/3 are symptomatic at time of fracture. |
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Term
| what are the red flags for a possible symptomatic vertebral fracture? |
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Definition
| height loss > 4 cm (documenting height very important in postmenopausal pts), postural changes, and worsening back pain |
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Term
| how are vertebral fractures treated? |
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Definition
| pain is usually self limiting (2 wks-3 mos), so conservative pain management: pain meds, manipulation, exercise, heat, ice, and rest. surgical management is rarely indicated, but includes: vertebroplasty (injection of acrylic cement for stabilization) and kyphoplasty (inflation of balloons, then cement injection to restore height+shape) |
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Term
| what are complications of osteoporosis? |
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Definition
| respiratory (compression of lungs), digestive (compression of GI = abdominal distention), balance (center of gravity), and falls=injury |
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Term
| what are the primary pharmaceutical treatments for osteoporosis? |
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Definition
| bisphosphonate, SERM, teripartide, and zoleronic acid |
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Term
| what characterizes the effect of bisphosphonate on osteoporosis? ADRs? |
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Definition
| bisphosphonate is an anti-resorptive medication (resorption: osteoclast activity) which increases trabecular thickness, number and connectivity. these are effective for arresting mineral loss after natural/surgical menopause. MOA: bisphosphonates, when attached to bone tissue, are ingested by osteoclasts, (bone cells that break down bone tissue). bisphosphonate mimics pyrophosphate's structure, thereby inhibiting activation of enzymes that utilize pyrophosphate - *effectively killing osteoclasts, halting resorption. ADRs: possible cardiac problems (don't keep pts on this long term). |
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Term
| what characterizes the effect of raloxifene/SERMs on osteoporosis? what parts of the body are they effective in? |
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Definition
| SERM (selective estrogen receptive modulator) is anti-resorptive, increases mineralization, and allows osteoclastic remodeling/osteoblastic refill in 27 hrs. FDA approval is only for osteoporosis of the *spine* (not hip). |
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Term
| what characterizes the effect of teriparatide/PTH on osteoporosis? |
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Definition
| this is a bone formulation stimulating agent, which increases bone mass and restores bone architecture by filling cavities. adm 1x/month. (long term rx may have deleterious effects on bone quality) |
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Term
| what characterizes the effect of zoledronic acid on osteoporosis? |
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Definition
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Term
| is improving bone density enough in terms of treating osteoporosis? |
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Definition
| no, bone quality is also very important. BMD+bone quality = bone strength. |
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Term
| what characterizes estrogen administration as tx for osteoporosis? |
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Definition
| estrogen is *not a primary tx for osteoporosis, it is for menopause HT. but estrogen has a direct effect on osteoblasts/clasts via estrogen receptors and is effective for arresting mineral loss after natural/sx menopause - fractures are significantly reduced for the spine, femur, and wrist. if the pt still has a uterus, they need to have estrogen and progesterone administered simultaneously to protect against endometrial CA but *limited to 5 years w/low as possible dose (to protect against breast CA). if the osteoporosis pt is already on estrogen, then just add bisphosphonate (which has a larger jump in recovery). |
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Term
| where are the majority of fractures associated w/osteoporosis? |
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Definition
| the neck of the femur (to fix – take out ball and trochanter – replace with titanium or steel) |
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Term
| what are the primary symptoms of menopause (lack of estrogen)? |
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Definition
| menstrual cycle changes (oligoamenorrhea - period every once in a while OR amenorrhea - no period for 6 mos), VMS (hot flashes including sleep disturbances), vaginal dryness (atrophy), and irritability |
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Term
| what are the secondary symptoms of menopause (lack of estrogen)? |
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Definition
| urinary stress/urge incontinence, cystitis-like symptoms, psycho-physiologic changes, musculo-skeletal changes (osteoporosis/muscle wasting), decreased concentration, and decreased libido |
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Term
| what characterizes the risk of breast CA w/estrogen HT? |
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Definition
| incidence of breast CA in estrogen HT pts is tied to delayed detection of the CA, not its initial development. WHI: “women without prior hormone use showed no statistically significant increase in breast cancer at any annual exam. women with prior hormone showed significant risk only at (or after) the 5th year”. therefore: possible increased risk of breast CA after 5 yrs. (in perspective, 2 drinks a day increases breast CA risk 40% - only dietary factor associated w/breast CA) |
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Term
| what are the risks of estrogen HT beyond the breast CA possibility? how is this managed? |
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Definition
| CV risks (stroke, MI, CVD), endometrial CA risk, and biliary disease. therefore, tx for the shortest time/lowest dose possible and do not use estrogen as primary medication. |
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Term
| what characterizes bone density loss in menopausal pts? |
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Definition
| BMD is highest in pts 30-35, then decreases slowly until menopause when it decreases rapidly |
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Term
| what are preventative measures against osteoporosis? |
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Definition
| high Ca++ food as much as possible, don't smoke, and exercise. add anti-osteoporosis medication if dexa scan indicates. |
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