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Episode 10: Osteoporosis

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Today’s podcast is per request of katie smith md on twitter who has suggested osteoporosis and yah n so here’s osteoporosis we are working on e i n and katie smith thank you very much welcome everyone to another fabulous episode this is bay and this is nick and we are yaags over coffee alright so today we’re gonna talk about osteoporosis so learning objectives for

Today number one we’re going to talk about physiology or pathophysiology of osteoporosis as well as risk factors for osteoporosis we’re gonna talk about the diagnosis screening and risk assessment for osteoporosis and then we’ll spend some brief time on therapies and prevention for osteoporosis nick what is osteoporosis osteoporosis fundamentally is just loss of

Bone mass and decline in bone quality leading to increased fracture risk surprisingly i didn’t know before looking at this topic that women are actually at a two fold increased fracture risk over men because women outnumber men they account for approximately 71% of osteoporotic fractures that’s pretty impressive that is they wear it what happens with the bone why

Does osteoporosis happen so i think before we can even talk about osteoporosis nick we’re gonna have to talk about bone physiology in general and go all the way back to how bone is formed how its acquired and then why women as they get older are at increased risk for getting osteoporotic fractures yeah that’s kind of post-traumatic stress there again hitting that

Medical school one more time very cuz 90% of our bone mass is actually acquired during childhood and adolescence establishing healthy habits here is really gonna give you a lot of good long term phone health good nutrition physical activity early on peak bone mass in adolescents has been correlated with a later life fracture as’ bone marrow ization and buildup in

Puberty is optimized by sex steroids predominantly estrogen in both young girls and boys peak density is achieved around age 19 in women and around age 20 in men in adults bone is in what we call physiologic equilibrium so there’s always formation of new bone but at the same time there’s always going to be breakdown or bone resorption and overtime as we get older

This begins to favor resorption more and more the loss of estrogen in menopause remember we talked about how estrogen is actually what helps you build bone before so the loss of it during menopause is going to trigger rapid bone loss in women that is not seen in men now that we’ve talked about how bone is made and broken down what are some of the other factors that

Can determine bone mineral density and fracture risk nick yeah so really 60 to 80 percent of your bone mineral density is influenced by genetic factors so there’s a lot of this stuff that really just kind of comes with you at baseline but there are some things that you can do to help or to minimize your loss of bone mineral density one thing that we can’t help though

Is age it’s not entirely clear how age affects bone quality other than what we’ve talked about with sort of the onset of menopause and rapid bone resorption but a dexa result in a 50 year old and that same result if it happens an eighty year old will actually put the 80 year old at a much higher risk of fracture and it’s not entirely clear why if that 80 year old is

At much higher risk but that’s the case things that we can help though are a lot of things that we always tell our patients about having good nutrition obviously things like anorexia or malnutrition or nutritional deficiency can cause problems with bone formation and particularly if you look at the case of anorexia not only do you suffer with problems with protein

Calcium vitamin d deficiencies but if we talk again about estrogen there’s limited and no production of estrogen in patients with anorexia your anorexia so they’re not really mineralizing bone as well physical activity is another protective modifier walking weight-bearing exercise aerobic exercise all of those can contribute to maintaining bone mineral density and

Then general health considerations cigarette smokers are at higher risk of fractures alcohol use more than three drinks a day is more associated with poor mineral density and in this physicians as well one thing that we always have to think about are medications that we prescribe our patients that may have an impact on mineral density so in gyn there are actually

A lot of medications that we use so think about things like depo-provera or gnrh agonists like lupron or aromatase inhibitors all of those things may suppress or eliminate estrogen or estrogen effects and so then have a negative consequence on bone health especially when used in the long term additionally though do ions are not likely to prescribe these long-term

Glucocorticoids are also another medication to consider that’ll have a negative impact on bone health hmm so if a i guess kind of going forward from here we’ve talked a lot about osteoporosis and those risk factors so how do we diagnosis how do we look for osteoporosis yeah so there are a few screening tests that we can use so the uspstf recommends getting a dexa

Scan or a dual energy x-ray absorptiometry screening in women age 65 or in younger postmenopausal women who are at increased fracture risk based on a formal assessment tool so the dexa scan looks at bone mineral density in three places the femoral neck the hip and the lumbar spine and it provides a t-score and a z-score so the t score is calculated at each site

And it basically compares the patient’s bone mineral density to a cohort of young healthy women so the t score should be better than minus one point zero if the t score is less than minus two point five or less or more negative at any site that is considered osteoporosis and if the t scores between minus one and minus two point five that’s considered osteopenia

Got it the z-score is also calculated and that compares the page bone mineral density two women at her age not just a young healthy women the z-score should not be used to diagnose osteoporosis but it can be used a useful adjunct in comparing one patient to her peer or her age group there are definitely other fracture risk scoring systems and they each have their

Own strengths and limitations but the most commonly encountered one that we use is something called the frack stool so the frack score is modified based on the patient’s race it looks like a bunch of other things things like their age their bmi their personal or family history of hip fractures all those risk factors that we talked about before like smoking alcohol

Steroid use and secondary osteoporosis history and optionally a previous bone mineral density score from the dexa scan to calculate a 10-year risk of major fracture and separately a risk of hip fracture if the fraks calculates a greater than 20% risk of major fracture or a greater than 3% risk of hip fracture that’s also an indication for treatment of osteoporosis

If that fracks score is greater than nine point three percent in a patient who’s younger than 65 or has any of these risk factors it may be worth considering performing that dexa before the age of 65 got it so the fraks just one more time quickly is race age emi family or personal history of hip fracture smoking alcohol steroids secondary osteoporosis and optionally

That bone mineral density score so we talked about screening we’ve talked about all these risk factors so what am i supposed to do if i actually have a patient that does have osteoporosis so yeah if we’re looking at a patient and say that she has a particularly low z-score because we decided to get a dexa before age 65 or say she actually had no co-product fracture

At a young age at that point it’s probably worth consulting with an endocrinologist or internal medicine doctor to consider secondary osteoporosis acog does have a practice bullets in osteoporosis number 129 and has an excellent table of all the possible suspects but this table is literally a whole page long of possibilities of what can cause secondary osteoporosis

And even the bullets an admitted it was beyond the scope of the document to consider all of these things so if you’re thinking about pseudopseudohypoparathyroidism it might be worth chatting with a consult but let’s keep it simple fail let’s just talk about kind of run-of-the-mill classic osteoporosis and we’ll run through a lot of the classic therapies here so

The first-line therapy classically are bisphosphonates you may remember them from studying pharmacology with a suffix of drone eight these definitely are efficacious in reducing fracture risk 35 to 65 percent depending on the agent therapies often limited to less than five years due to limited data on use beyond that point the thing to remember with bisphosphonates

Are these weird side effects so the things people always talk about are significant reflux or trauma of the esophagus talk tell patients to stand upright for 30 to 60 minutes after they take the medicine to prevent these things then the other weird one asked you necrosis of the jaw fortunately these are rare things to find but again these weird side effects or the

Testable side effects another medication you can consider is raloxifene which is a serm and if you remember with the serbs they have selective responses at different types of estrogen receptors so at the bone it’s an has an agonist effect and an antagonist effect on breast and uterus so this is a good choice in patients who have a risk of breast cancer or uterine

Cancer the big side effect to consider with raloxifene is that there is an increased risk of having a venous thromboembolism so definitely should be considered carefully in someone who does have a history of stroke pe or dvt other therapies that you can consider our calcitonin de notion ab and recombinant parathyroid hormone but if you’re curious you can read it a

Little bit about them in the practice bulletin but i also would think that if you’re thinking about prescribing these things you might want to chat with an endocrinologist first really in the practice bulletin and probably for cree augs 2 or how much calcium in vitamin you’re supposed to be recommending to patients and i always feel like i have to ask this question

Too if i see somebody and they have like oh this much vitamin d this much calcium prescribed i never know if it’s like the right amount or if it’s the recommended amount exactly where it needs to be fortunately acog gives us a nice little breakdown of how much dietary calcium and vitamin d patients are supposed to be taking for the prevention of osteoporosis and

We’ll put the table on our website but really the ones to remember are between ages 19 and 50 they should have a thousand milligrams calcium and six hundred units of vitamin d between 51 and 70 that increases to 1200 milligrams of calcium and vitamin d stays the same at 600 and then at age 71 and older right the same amount of calcium 1,200 milligrams but then 800

Units of vitamin d what about hormone replacement therapy doesn’t that work to treat osteoporosis as well so sort of hrt has been shown to reduce the risk of fracture and parry and postmenopausal women by about a third based on the women’s health initiative and while it can be used in this preventive sense hrt is not approved as a treatment for osteoporosis so

Again it’s one of those adjuncts you can add to maintain bone health but not something that you could use like in place of a bisphosphonate will tackle hrt more in another episode so i think that brings us to the end of our osteoporosis episode so let’s go back and review everything so first of all osteoporosis loss of bone mass decline in bone quality leads to

Increased fracture risk women are at a two-fold risk compared to men for the basic bone to physiology remember that you’re gonna acquire 90% of your bone mass and childhood and adolescence so you need to set a good foundation early peak bone densities achieved at age 19 in women and then from that point onward the bone is comparatively in sort of this equilibrium

State but bone eventually starts to get resorbed and the bone gets weaker and weaker until you hit menopause and then you really get a weakening because of the reduction an estrogen there are multiple risk factors that are both modifiable and non-modifiable those things are like genetics age nutrition physical activity general health so things like avoiding things

Like cigarette smoking and alcohol use in certain medication in terms of screening for osteoporosis the united states preventive service task force recommends the dexa scan at age 65 or in younger postmenopausal women who are at increased risk of fracture based on something like the fraks tool and in terms of treating these women bisphosphonates raloxifene maybe

Calcitonin de nossa madame recombinant pth but again once you’re getting to this point you really should be talking to your endocrinologist friends and also remember calcium and vitamin d and possibly hrt but we’ll cover that at a different episode so once again i’m nick i’m say and this is crayons over coffee and remember got milk guys if you liked this episode

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Episode 10: Osteoporosis By Creogs OverCoffee