1. Osteoporosis Ambulatory Lecture
Kendall Bell PGY1

2. OBJECTIVES
Identify patients who are at high risk for developing osteoporosis.
Learning how to utilize the WHO diagnostic criteria and the FRAX multivariate model
Evaluation secondary causes of osteoporosis.
Learning the therapeutic options available for treating low bone density.
Treatment of special populations such as individuals under age 50 and patients on glucocorticoid therapy.
Strategies to minimize long term risks of bisphosphonate therapy.

3. Osteoporosis Pathophysiology
Estrogen Regulates Osteoclastic and Osteoblastic activity
When sex hormones diminish, osteoclastic activity becomes predominant resulting in net bone loss

4. Osteoporosis Definitions
NIH Definition:
"A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture."
Bone Strength 2 Components
Bone Mineral Density: Measured by Dexa Scan
Bone Quality: Microarchitecture, Mineralization
No practical tools for screening

5. A 52-year-old woman presents for an annual checkup
A 52-year-old woman presents for an annual checkup. She has no significant past medical history. She takes no medications or supplements. Family history is notable for hypertension in both parents; her mother is 80 and otherwise healthy. The patient does not smoke, and review of systems is notable for menopause at age 48. She sees TV commercials for osteoporosis treatment and asks if she should be tested for this. Which ONE of the following is correct?
a) Since she is post-menopausal, she should be screened now.
b) She should be screened when she is 5 years post-menopausal.
c) She should be screened for osteoporosis beginning at age 65.
d) She should be screened for osteoporosis only if she has risk factors.

6. A 52-year-old woman presents for an annual checkup
A 52-year-old woman presents for an annual checkup. She has no significant past medical history. She takes no medications or supplements. Family history is notable for hypertension in both parents; her mother is 80 and otherwise healthy. The patient does not smoke, and review of systems is notable for menopause at age 48. She sees TV commercials for osteoporosis treatment and asks if she should be tested for this. Which ONE of the following is correct?
a) Since she is post-menopausal, she should be screened now.
b) She should be screened when she is 5 years post-menopausal.
c) She should be screened for osteoporosis beginning at age 65.
d) She should be screened for osteoporosis only if she has risk factors.

7. Osteoporosis Screening Intervals

8. Osteoporosis Screening
Screening Interval: Every 2 years
New Evidence Suggests Screening should be based on baseline bone density
Young women (i.e., women 65 – 68) who have normal bone mineral density or mild osteopenia (i.e., T-score no worse than -1.5) with their initial scan take up to 15 years to transition to osteoporosis
No Guidelines for screening premenopausal women, or men <50
DEXA Scan is Screening Tool of Choice,
T Score Used in Older Individuals
Z Score Used in Younger Individuals

9. A 50-year-old perimenopausal Caucasian woman presents to your office for a physical examination. Her last menses was 2 years ago. She has no significant past medical history. She takes either an H2 blocker or a proton pump inhibitor for occasional GERD. Her mother had a hip fracture when she was 70. The patient smokes one-half pack of cigarettes per day. Her physical exam shows that she is 5'3" tall and weighs 111 lbs. with BMI 19.7 kg/m2.
a) Since she is not 65, screening for osteoporosis is not indicated.
b) H2 blockers and proton pump inhibitors are medications that increase the risk of osteoporosis in this patient.
c) Due to her family history of hip fracture, she should begin pharmacotherapy for osteoporosis.
d) Risk factors for osteoporosis in this woman include family history of osteoporosis, tobacco use, Caucasian heritage, and thin habitus. Bone density testing should be obtained now.

10. A 50-year-old perimenopausal Caucasian woman presents to your office for a physical examination. Her last menses was 2 years ago. She has no significant past medical history. She takes either an H2 blocker or a proton pump inhibitor for occasional GERD. Her mother had a hip fracture when she was 70. The patient smokes one-half pack of cigarettes per day. Her physical exam shows that she is 5'3" tall and weighs 111 lbs. with BMI 19.7 kg/m2.
a) Since she is not 65, screening for osteoporosis is not indicated.
b) H2 blockers and proton pump inhibitors are medications that increase the risk of osteoporosis in this patient.
c) Due to her family history of hip fracture, she should begin pharmacotherapy for osteoporosis.
d) Risk factors for osteoporosis in this woman include family history of osteoporosis, tobacco use, Caucasian heritage, and thin habitus. Bone density testing should be obtained now.

11. Risk Factors for Osteoporosis
Strongest Risk Factor is Age, followed by Female Sex
⅔ Men Diagnosed found to have precipitating factor
Heavy EtOH Use, Glucocorticoid Use or Hypogonadism
Men w/ Osteoporosis should be tested for Testosterone
Race: African Americans show less fractures than Whites and Asians
Family Hx of Hip Fracture or Personal Hx Fractures
Lifestyle Risk Factors
Tobacco Use
Low Body Weight (<127 lbs)
Sedentary Lifestyle
>3 Alcoholic Beverages a day

12. Osteoporosis Risk Factors

13. Medications that increase risk for Osteoporosis

14. Should she undergo screening for osteoporosis with a DXA scan?
A 40-year-old African American woman on 15 mg/day of prednisone for systemic lupus erythematosus for the last 6 months presents for follow up. Her main clinical manifestations of lupus have been arthralgias and nephropathy. Attempts to wean the dose below 7.5 mg/day have resulted in flares and have been unsuccessful.
Should she undergo screening for osteoporosis with a DXA scan?
a) No, her dose of prednisone is not high enough to put her at risk for osteoporosis.
b) No, she has not been on glucocorticoids long enough to affect bone density.
c) Yes, any patient likely to be on glucocorticoids longer than 2 years should be screened.
d) Yes, any patient likely to be on glucocorticoids longer than 3 months should be screened.

15. Should she undergo screening for osteoporosis with a DXA scan?
A 40-year-old African American woman on 15 mg/day of prednisone for systemic lupus erythematosus for the last 6 months presents for follow up. Her main clinical manifestations of lupus have been arthralgias and nephropathy. Attempts to wean the dose below 7.5 mg/day have resulted in flares and have been unsuccessful.
Should she undergo screening for osteoporosis with a DXA scan?
a) No, her dose of prednisone is not high enough to put her at risk for osteoporosis.
b) No, she has not been on glucocorticoids long enough to affect bone density.
c) Yes, any patient likely to be on glucocorticoids longer than 2 years should be screened.
d) Yes, any patient likely to be on glucocorticoids longer than 3 months should be screened.

16. Glucocorticoids and Osteoporosis
Most common cause of 20 Osteoporosis
Bone loss starts at 3 months, and peaks at 6
Prednisone >5mg/day for >3 months at increased risk
Baseline DEXA Scan at 3 Mo
Lifestyle Modifications
Tobacco, Exercise, Alcohol
Vitamin Supplementation
mg Vitamin D
mg Calcium

17. Young Pts ( Age <50) Chronic Glucocorticoid Therapy
If no history of Fragility Frax No Indication for Treatment
Counsel on Lifestyle Modifications
Short Term Therapy (1-3 Mo)
>5mg Alendronate or Risedronate
>7.5mg Zoledronic Acid
Longterm Therapy (>3 Mo)
Same as above w/ addition of Teriparatide as option
Treat childbearing women >7.5mg

18. Mature Pts (Age >50) Chronic Glucocorticoid Therapy

19. Which ONE of the following statements is true?
A 72-year-old Asian American woman comes to see you for an initial health assessment. She experienced menopause at age 51 and never took hormone replacement. She is on no medications. Her mother was "hunched over" later in life, and the patient doesn't want this to happen to her. Physical exam reveals a thin woman, and the remainder of the exam is normal. You order a bone density scan that shows the following results:
Which ONE of the following statements is true?
a) This patient has osteopenia, as her Z-scores are between -1.0 and -2.5.
b) The Z-score is a better measure of risk, as it compares patients to age-matched controls.
c) This patient has osteoporosis, as her femoral neck T-score is below –2.5.
d) This patient has osteopenia but not osteoporosis; none of her T-scores are lower than

20. Which ONE of the following statements is true?
A 72-year-old Asian American woman comes to see you for an initial health assessment. She experienced menopause at age 51 and never took hormone replacement. She is on no medications. Her mother was "hunched over" later in life, and the patient doesn't want this to happen to her. Physical exam reveals a thin woman, and the remainder of the exam is normal. You order a bone density scan that shows the following results:
Which ONE of the following statements is true?
a) This patient has osteopenia, as her Z-scores are between -1.0 and -2.5.
b) The Z-score is a better measure of risk, as it compares patients to age-matched controls.
c) This patient has osteoporosis, as her femoral neck T-score is below –2.5.
d) This patient has osteopenia but not osteoporosis; none of her T-scores are lower than

21. Dual Energy Xray Absorption Scan
Non-Invasive, Inexpensive Test
Assesses Bone Mineral density of Pt’s bone and compares it to controls
T-Score: Standard deviation from Peak Bone Mass (Used Pts >50)
Z-Score: Age-Matched Controls (Pts <50)
Sites Interpreted: Femoral Neck, L-Spine, and Total Hip
Only one needs to be abnormal to be considered positive

22. DEXA Diagnostic Criteria
Z Score < -2.0 Considered Osteoporosis in Pts <50
Incorrect Positioning and Osteophytes can cause false positives
Fragility Fracture = Osteoporosis
Primary Hyperparathyroidism Wrist DEXA

23. You are seeing a 67-year-old woman for follow up after a DXA scan showed a T-score of -2.3 in her spine and femoral neck. She has no family history of osteoporosis and is a non-smoker. She is otherwise healthy, and surprised at the result. Appropriate management at this point would be:
a) Follow up in 6 months; address lifestyle management to improve bone mineral density.
b) Assess 10-year fracture risk; treat only if total fracture risk is >3%.
c) Assess 10-year fracture risk; treat only if hip fracture risk is >20%.
d) Assess 10-year fracture risk; treat if hip fracture risk is >3% or total fracture risk is >20%.

24. You are seeing a 67-year-old woman for follow up after a DXA scan showed a T-score of -2.3 in her spine and femoral neck. She has no family history of osteoporosis and is a non-smoker. She is otherwise healthy, and surprised at the result. Appropriate management at this point would be:
a) Follow up in 6 months; address lifestyle management to improve bone mineral density.
b) Assess 10-year fracture risk; treat only if total fracture risk is >3%.
c) Assess 10-year fracture risk; treat only if hip fracture risk is >20%.
d) Assess 10-year fracture risk; treat if hip fracture risk is >3% or total fracture risk is >20%.

26. Fragility Fracture Risk

27. A 52-year-old perimenopausal Caucasian woman visits you in the office and has several risk factors for osteoporosis. Because of these risk factors, she is screened for osteoporosis, with results below:
Does this patient meet criteria for Osteoporosis?

28. Evaluating the Osteoporosis Patient
Lab Work Should be done in All Confirmed Cases
Careful History and Physical to Eliminate Secondary Causes

29. Osteoporosis Risk Factors

30. Evaluating the Osteoporosis Patient
Additional Lab Work if indicated by H&P.

31. A 68-year-old woman is diagnosed with osteoporosis after a screening DXA scan showed a T-score of -2.7 in her hip and -2.5 in her lumbar spine. She smokes and has GERD, treated with a proton pump inhibitor. She does not drink alcohol. She admits she doesn’t like vegetables and avoids dairy due to lactose intolerance. She exercises by going to the neighborhood YMCA, using their pool for water aerobics three times weekly. You begin management of her osteoporosis by addressing lifestyle modification. Which recommendation is appropriate for this patient?
a) Since she has osteoporosis, she should take 2000mg of calcium daily, and 1000IU of vit D.
b) She should stop smoking, not because it affects bone mineral density, but because of the risk of cardiovascular disease.
c) She should either change her swimming to weight-bearing exercise, or add weight-bearing exercise to her weekly routine.
d) Because of the risk of nephrolithiasis, calcium and vitamin D supplementation are no longer recommended.

32. A 68-year-old woman is diagnosed with osteoporosis after a screening DXA scan showed a T-score of -2.7 in her hip and -2.5 in her lumbar spine. She smokes and has GERD, treated with a proton pump inhibitor. She does not drink alcohol. She admits she doesn’t like vegetables and avoids dairy due to lactose intolerance. She exercises by going to the neighborhood YMCA, using their pool for water aerobics three times weekly. You begin management of her osteoporosis by addressing lifestyle modification. Which recommendation is appropriate for this patient?
a) Since she has osteoporosis, she should take 2000mg of calcium daily, and 1000IU of vit D.
b) She should stop smoking, not because it affects bone mineral density, but because of the risk of cardiovascular disease.
c) She should either change her swimming to weight-bearing exercise, or add weight- bearing exercise to her weekly routine.
d) Because of the risk of nephrolithiasis, calcium and vitamin D supplementation are no longer recommended.

33. Lifestyle Modifications
Weight Bearing Exercises
1000 mg Ca Women <50 and Men < for older Patients
Calcium Citrate > Calcium Carbonate
Vitamin D Recommendations Treat Vit D <20 ng/ml
Symptomatic Pts: Ergocaliceferol U 2-3 Times Weekly until stores repleted
Assymptomatic Pts: Ergocaliceferol 50,000 U Once Weekly 8-12 weeks
Once Repleted Daily mg Supplements
Decrease Fall Risk

34. A 67-year-old woman with Crohn disease treated with glucocorticoids for three weeks earlier this year is now well-controlled on low doses of sulfasalazine. She returns for follow up to review the results of her screening bone density test. She has never experienced a fracture and has no family history of fracture. She missed her last appointment, as she was caring for her older sister, who was recently diagnosed with breast cancer. Her bone density test shows a lumbar spine T-score of -2.9, a femoral neck T-score of -2.1, and a total hip T-score of Based on these results, what should this patient be advised regarding pharmacologic therapy?
a) Therapy with lifestyle modification is adequate for this patient.
b) Raloxifene would be reasonable therapy in this patient.
c) Because of the family history of breast cancer, bisphosphonates are contraindicated.
d) Calcitonin is not a good option for this patient, as its main action is to increase hip bone density.

35. A 67-year-old woman with Crohn disease treated with glucocorticoids for three weeks earlier this year is now well-controlled on low doses of sulfasalazine. She returns for follow up to review the results of her screening bone density test. She has never experienced a fracture and has no family history of fracture. She missed her last appointment, as she was caring for her older sister, who was recently diagnosed with breast cancer. Her bone density test shows a lumbar spine T-score of -2.9, a femoral neck T-score of -2.1, and a total hip T-score of Based on these results, what should this patient be advised regarding pharmacologic therapy?
a) Therapy with lifestyle modification is adequate for this patient.
b) Raloxifene would be reasonable therapy in this patient.
c) Because of the family history of breast cancer, bisphosphonates are contraindicated.
d) Calcitonin is not a good option for this patient, as its main action is to increase hip bone density.

36. Pharmacotherapy in Osteoporosis
Estrogen Replacement Effective in Reducing Fractures however dangerous
VTE, Breast Cancer
Selective Estrogen Receptor Modulators (Ex Raloxifene)
Approved Both Osteoporosis prevention and treatment
Shown only effective for spinal fractures, not hip
Decreases Breast Cancer risk, Increases risk of VTE
Calcitonin
Decreases Osteoclast Activity
Decreases fracture risk, increases Bone Density
Also decreases pain

37. Your next patient is a 75-year-old Caucasian woman who had a screening DXA scan that showed a T-score of -2.6 in the lumbar spine, -2.3 in the femoral neck, and –2.6 in the total hip.
After screening her for secondary causes of osteoporosis, which of the following would you recommend?
a) Begin pharmacotherapy with a bisphosphonate and repeat her DXA scan in 2 years.
b) Begin pharmacotherapy with a bisphosphonate and repeat her DXA scan in 6 months.
c) Begin pharmacotherapy with calcitonin and reassess bone density in 1 year.
d) Begin pharmacotherapy with raloxifene because of osteoporosis in the lumbar spine.

38. Your next patient is a 75-year-old Caucasian woman who had a screening DXA scan that showed a T-score of -2.6 in the lumbar spine, -2.3 in the femoral neck, and –2.6 in the total hip.
After screening her for secondary causes of osteoporosis, which of the following would you recommend?
a) Begin pharmacotherapy with a bisphosphonate and repeat her DXA scan in 2 years.
b) Begin pharmacotherapy with a bisphosphonate and repeat her DXA scan in 6 months.
c) Begin pharmacotherapy with calcitonin and reassess bone density in 1 year.
d) Begin pharmacotherapy with raloxifene because of osteoporosis in the lumbar spine.

39. Pharmacotherapy in Osteoporosis - Bisphosphonates
Bisphosphonates: Inhibits osteoclastic activity preventing resporption
Dosed either weekly or monthly
Important dosing Details
Early morning empty stomach - wait minutes before any other food or meds
Drink full 8 oz of water
Contraindicated in CKD patients w/ GFR <35
Osteonecrosis of Jaw (more common in IV Formulation)
Usually in patients undergoing dental work

41. Pharmacotherapy
Denosumab: Monoclonal Antibody that targets an activator of osteoclasts
Decreases bone resorption and increases bone density
Decreases Vertebral and Hip Fractures
Teriparatide: Human recombinant PTH, promotes bone formation
Approved for patients at high risk for bone fracture
Only medication that works by increasing bone formation