Management of Osteoporosis - Introduction to General Medicine - Lecture Slides, Slides of Medicine

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History of hip or vertebral fracture.

Other prior fractures and T-score between -1.0 and -2.5 at the femoral neck, total hip, or spine, as measured by dual-energy X-ray absorptiometry (DXA).

T-score -2.5 (DXA) at the femoral neck, total hip, or spine, after appropriate evaluation to exclude secondary causes.

T-score between -1.0 and -2.5 at the femoral neck, total hip, or spine and secondary causes associated with high risk of fracture, such as glucocorticoid use or total immobilization.

T-score between -1 and -2.5 at the femoral neck, total hip, or spine, and a 10-year probability of hip fracture 3 percent or a 10-year probability of any major osteoporosis-related fracture 20 percent based upon the US-adapted WHO algorithm.

• Rosen C. N Engl J Med 2005;353:595-
• Ebeling P. N Engl J Med 2008;358:1474-
• Rosen C. N Engl J Med 2005;353:595-

 ISCD : recommends follow-up BMD testing (DXA spine and hip) when the expected

change in BMD equals or exceeds the least significant change (LSC), which is typically one

year after initiation or change of therapy, with longer intervals once therapeutic effect is

established. In conditions associated with rapid bone loss, such as glucocorticoid therapy,

testing more frequently is appropriate 43

 AACE : recommends annual DXA of the LS and proximal femur until stability is achieved,

and every two years thereafter. 44

 NAMS : recommends DXA of the total hip every two years. 45

 Others:

 Conservative approach - takes the position that monitoring for efficacy of antiresorptive

therapy is unnecessary, as only a minority of patients continue to lose bone on therapy.46,47,

 Bone turnover markers- if DXA cannot be performed at one year then measure fasting

urinary NTX or serum CTX before and three to six months after starting antiresorptive

therapy. 48,49^ If the marker has fallen significantly (by 50 percent), the patient can be

reassured that the next BMD measurement will likely be stable or improved. Repeat DXA

can be done in 2 yrs.

 12/15-lipoxygenase inhibitors: coded by the Alox15 gene which is up regulated in IL mediated bone resorption.^20

 Oral calcium sensing receptor antagonists : Administration leads to a transient rise in endogenous parathyroid hormone, similar to intermittently administered exogenous parathyroid hormone 21

 Sclerostin inhibitors : Sclerostin is produced by osteocytes and inhibits bone formation (^22). Antagonism of sclerostin might be associated with anabolic effects on bone. Monoclonal antibodies against sclerostin, for example, prevent its binding to Wnt coreceptors, enhancing Wnt signaling and increasing bone mass in rodents and nonhuman primates.^23

 Integrin antagonists : Integrins mediate the adhesion of osteoclasts to the bone surface, an important initial step for bone resorption 24

 Cathepsin-K inhibitors — Cathepsin K is a protease that may play a role in osteoclast- mediated bone resorption.^25