Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-21T01:44:46Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 01:44, 21 July 2020
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	* High alcohol intake ≥3 units daily		* High alcohol intake ≥3 units daily

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	* Fragility fracture		* Fragility fracture

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2020-07-04T01:17:48Z

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== Definition ==

* Disorder of bone mineral density (quantity) and bone quality leading to decreased bone strength and increased fracture risk
* T-score < -2.5 and elevated FRAX/CAROC risk

=== Fragility Fracture ===

* A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less, excluding craniofacial, hand, ankle, and foot fractures

== Pathophysiology ==

* Resorption by osteoclasts
* Affects trabecular bone first
* Osteoblasts release RANK-ligand, which signals osteoclasts RANK receptor

== Differential Diagnosis ==

* Normal age-related bone loss
* Metabolic
** Vitamin D deficiency
** Primary hyperparathyroidism
** Hypercortisolism
** Hyperthyroidism
** Growth hormone deficiency
** Diabetes mellitus
* Gastrointestinal
** Malabsorption: celiac disease, postoperative
** Inflammatory bowel disease
** Cirrhosis
* Hematologic
** Multiple myeloma
** Chronic hemolytic anemia
** Systemic mastocytosis
* Rheumatologic
** Rheumatoid arthritis
** Osteogenesis imperfecta
** Ehlers-Danlos syndrome
** Marfan syndrome
** Homocystinuria
* Drug-induced
** Alcohol
** Heparin
** Glucocorticoids
** Thyroxine suppressive therapy
** Anticonvulsant drugs
** Antidepressants (SSRIs and TCAs)
** Gonadotropic-releasing hormone analogs
** Cyclosporine
** Chemotherapy
** HIV meds: tenofovir disoprostol fumarate
* Renal
** Hypercalciuria
** Renal disease
* Miscellaneous
** Eating disorders
** Immobilization
** Hepatic disease
** Smoking

== Screening ==

* Older adults ≥50 years
* Anyone ≥65 years
* Menopausal women or Men 50-64 with risk factors
** Fragility fracture after age 40 years
** Prolonged glucocorticoids (≥7.5mg/d for 3+ months)
** Use of high-risk medications, such as aromatase inhibitors or androgen-deprivation therapy
** Parental hip fracture
** Vertebral fracture or osteopenia identified on radiography
** Current smoking
** High alcohol intake
** Low body weight < 60kg or major weight loss >10% of body weight at age 25 yrears
** Rheumatoid arthritis
** Other disorders strongly associated with osteoporosis
* Age < 50 years
** Fragility fracture
** Prolonged use of glucocorticoids (≥7.5mg/d for 3+ months)
** Use of high-risk medications, such as aromatase inhibitors or androgen-deprivation therapy
** Hypogonadism or premature menopause
** Malabsorption syndrome
** Primary hyperparathyroidism
** Other disorders strongly associated with rapid bone loss or fracture with high FRAX (preferred over CAROC)

== Risk Factors ==

* Race: Latino > white > black
* Increasing age (70% over 80 years)
* Early menopause or oopherectomy
* Prednisone use >7.5mg daily for 3+ weeks

== Clinical Assessment ==

* Inquire about falls in the last 12 months
* Prior fragility fractures
* Parental hip fracture
* Steroid use
* Current smoking
* High alcohol intake ≥3 units daily

== Clinical Presentation ==

* Fragility fracture
* Risk factors, including poor dietary intake, early menopause, steroid use
* Screening for spinal compression fractures with 2s and 6s
** Height loss >2cm measured or 6cm historical
** Pelvis-rib space <2 fingers
** Occiput-to-wall >6cm

=== JAMA RCE ===

* Weight <51kg (LR+ 7.3)
* Occiput-to-wall distance (LR+ 4.6, LR- 0.5)
* Rib-to-pelvis distance < 2 fingers (LR+ 3.8, LR- 0.6)
* Tooth count less than 20
* Height loss
* Humped back (self-reported) (LR+ 3)

=== Falls Risk ===

* Gait
* Balance
* Timed get-up-and-go ≥12 sec (3m/10ft)
* Medications including antihypertensives
* Home environment, including clutter and footwear

== Investigations ==

* Screen with bone-mineral density > 65yrs
** DEXA T-score -1 to -2.5 is osteopenia
** DEXA T-score less than -2.5 is osteoporosi
** CAROC or FRAX tool for risk stratification
* Bloodwork
** Calcium, albumin
** CBC
** Creatinine
** ALP (r/o Paget's)
** TSH
** SPEP if vertebral fractures (r/o myeloma)
** 25-OH-vitamin D, repeated 3-4 months after adequate replacement if low

== Management ==

=== Indications for treatment ===

* Any fragility fracture
* Calculate FRAX score
* Moderate-risk patients
** Vertebral fracture or wrist fracture
** Rapid bone loss or low lumbar T_score
** Falls ≥2/yr
** Concurrent high-risk medications, including glucocorticoids, hypogonadism, primary hyperparathyroidism, rheumatoid arthritis, or aromatase inhibitor therapy

=== Non-pharmacologic ===

* Environment modification
* Weight-bearing exercise
* Tai Chi
* Increased dietary vitamin D and calcium
** Calculator available on Osteoporosis Canada website
* Local falls-prevention programs may be available

=== Pharmacologic ===

* Vit D supplementation
** 400-1000 IU for <50 years
** 800-2000 IU for ≥50 years
** every additional 1000 IU raises Vit D levels by 15 over 3 months
* Calcium 1200mg po daily if dietary intake inadequate

==== Bisphosphonates ====

* Kills osteoclasts
* Prevents vertebral, hip, and non-vertebral fractures
* Plan for 5 years then reassess
** Continue if still high risk
* Give sitting up, no food 30min before or 1-2h after, stay upright for 1-2h after
* Alendronate
* Risderonate
* Side effects
** Pill esophagitis
** Osteonecrosis of the jaw (rare)
** Atypical femoral fractures
*** Subtrochanteric fracture
*** More in Asians and diabetes

==== Denosumab ====

* RANK-L inhibitor
* Prevents vertebral, hip, and non-vertebral fractures

==== Teriparatide (PTH analogue) ====

* Prevents vertebral and non-vertebral fractures, but not hip fractures

==== SERMs ====

* Decreases release of RANK-L from osteoblasts
* Protect against vertebral fractures, but not hip or non-vertebral fractures

==== Estrogen ====

* Decreases release of RANK-L from osteoblasts
* Prevents vertebral, hip, and non-vertebral fractures

== Prognosis ==

* Hip fracture in women: 23% die within 1 year

== Further Reading ==

* Papaioannou ''et al''. [https://doi.org/10.1503/cmaj.100771 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary]. ''CMAJ'' 2010;182(17):1864-1873.
* [https://osteoporosis.ca/wp-content/uploads/Quick_Reference_Guide_October_2010.pdf Osteoporosis Canada Quick Reference Guide 2010]

[[Category:Endocrinology]]

Osteoporosis - Revision history

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

Maintenance script: Imported from text file