Updated: 1/2/2022

Osteopenia & Osteoporosis

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  • Summary
    • Osteopenia & Osteoporosis represent a continuum of conditions that present with a decrease in bone mass and disrupted bone microarchitecture most commonly as a result of increased age, menopause, and metabolic abnormalities.
    • Diagnosis is made with a lumbar-based DEXA scan with osteopenia having a T-score of 1 to 2.5 standard deviations below the peak bone mass of a 25-year-old individual, and osteoporosis having a T-score >2.5 standard of deviations below the peak bone mass of a 25-year-old individual.
    • Treatment involves a multidisciplinary approach with medical management and physical activity to increase bone mineral density and to help prevent fractures.
  • Epidemiology
    • Incidence
      • 10 million Americans and 200 million people worldwide have osteoporosis
      • 34 million Americans have osteopenia
      • 1.5 million osteoporotic fractures occur each year
        • 700,000 are vertebral fractures
        • 300,000 are hip fractures
        • 200,000 are wrist fractures
    • Demographics
      • male: female ratio is 1:4
        • men have a higher prevalence of secondary osteoporosis (60%) including
          • hypogonadism
          • glucocorticoid excess
          • alcoholism
      • age bracket
        • osteoporosis
          • postmenopausal osteoporosis is highest in women aged 50-70 years
          • senile osteoporosis begins after 70 years
          • secondary osteoporosis begins at any age
        • fractures
          • wrist fractures occur most commonly at age 50-60 years
          • vertebral fractures occur most commonly at age 60-70 years
          • hip fractures occur most commonly at age 70-80 years
    • Anatomic location
      • vertebral body > peritrochanter femur > distal radius
    • Risk factors
      • table of risk factors
  • Etiology
    • Pathophysiology
      • quantitative, not qualitative, disorder of bone mineralization
      • factors
        • failure to build peak bone mass as a young adult
        • bone loss in later life
    • Genetics
      • Polymorphisms in the genes for the calcitonin receptor, estrogen receptor-1, type I collagen alpha-1 chain, or the vitamin D receptor have been shown to be associated with osteoporosis
    • Associated conditions
      • fragility fractures
        • direct relationship between degree of bone loss and fractures
        • kyphotic deformity can arise from vertebral body fractures
        • pelvic ring insufficiency fractures most often treated with bed rest and analgesia
        • total hip arthroplasty with constrained components are a risk factor for fragility fractures
    • Associated with 20% increase in mortality
      • men have higher mortality rates following hip fractures than women
    • Associated with increased morbidity
      • reduced quality of life
      • only one-third of patients with hip fractures return to their previous level of function
    • History of 1 hip fracture results in up to 10 fold increased risk of 2nd hip fracture
  • Classification
      • Type I vs. Type II Osteoporosis
      • Type I
      • (Post menopausal)
      • Type II
      • (Senile)
      • Age group
      • Postmenopausal (highest incidence in 50-70 years old)
      • >70 years old
      • Bone affected
      • Almost exclusively trabecular
      • Trabecular > cortical
      • Bones fractured
      • Distal radius and vertebral
      • Hip and pelvis
      • Effect on calcium
      • Net negative change in calcium levels because of decreased intestinal absorption and increased urinary excretion of calcium.
      • Poor calcium absorption
      • Effect on Vit D
      • Reduced circulating levels of total (but not free) 1,25 dihydroxyvitamin D.
  • Imaging
    • Radiographs
      • indications
        • suspicion of fracture
        • loss of height
        • pain in thoracic or lumbar spine
      • recommended views
        • lateral spine radiograph
        • AP pelvis or hip
      • findings
        • thinned cortices
        • loss of trabecular bone
        • kyphosis
        • codfish vertebra
      • sensitivity and specificity
        • usually not helpful unless > 30% bone loss
    • DEXA Scan (Dual Energy Xray Absorptiometry)
      • usually performed in
        • lumbar spine: measures BMD from L2 to L4 and compiles scores
        • hip: measure BMD from femoral neck, trochanter, and intertrochanter region and compiles scores
      • sensitivity and specificity
        • most accurate with the least radiation exposure
      • DEXA Scan definitions
      • BMD
      • Absolute, patient-specific score determined from certain anatomic areas
      • T-Score
      • BMD relative to normal young matched controls (30-year-old women)
      • Z-Score
      • BMD relative to similar-aged patients
      • L2-4 lumbar density of 1 to 2.5 standard of deviations (T score -1 to -2.5) below the peak bone mass of a 25-year-old individual
      • Osteoporosis
      • L2-4 lumbar density > 2.5 standard of deviations (T score <-2.5) below the peak bone mass of a 25-year-old individual
  • Studies
    • Labs
      • 25 hydroxyvitamin D level
        • low 25 hydroxy cholecalciferol levels (25 hydroxy vit D) in patients sustaining low energy fractures
      • Other labs may be drawn to rule out other causes of osteoporosis (endocrine, hematologic, malignancy, etc)
        • labs are generally normal in osteoporosis
    • Biopsy
      • after tetracycline labeling
      • indications
        • may be helpful to rule out osteomalacia
    • Histology
      • thinned trabeculae
      • decreased osteon size
      • enlarged Haversian and marrow spaces
      • osteoclast ruffled border
        • Increases osteoclast ruffled border seen with
          • PTH
          • 1,25 dihydroxy Vit D3
          • Prostaglandin E
        • flattened ruffled border seen with
          • Bisphosphonates
          • Calcitonin
  • Differential
      • Osteoporosis vs. Osteomalacia 
      • Osteroporosis
      • Osteomalacia
      • Defintion
      • Reduced bone mass, normal mineralization
      • Bone mass variable, reduced mineralization
      • Age
      • Postmenopausal (Type I) or elderly (Type II)
      • Any age
      • Etiology
      • Endocrine abnormality, age, idiopathic, inactivity, alcohol, calcium deficiency
      • Vit D deficiency or abnormal vit D pathway, hypophosphatemia, hypophosphatasia, renal tubular acidosis
      • Symptoms and signs
      • Pain and tenderness at fracture site
      • Generalized bone pain and tenderness
      • Xray
      • Axial fracture predominance
      • Appendicular fracture predominance, symmetric, includes pseudofractures (Looser zones)
      • Serum Ca
      • Normal
      • Low or normal
      • Serum PO4
      • Normal
      • Low or normal
      • ALP
      • Normal
      • Elevated (except hypophosphatasia)
      • Urinary Ca
      • High or normal
      • Normal or low (high in hypophosphatasia)
      • Bone biopsy
      • Tetracycline labeling normal
      • Tetracycline labeling abnormal
  • Treatment
    • Nonoperative
      • lifestyle modification & vitamins
        • indications
          • calcium and Vitamin D
      • pharmacologic treatment
        • indications
          • 2008 National Osteoporosis Foundation Guidelines for Pharmacologic Treatment of Osteoporosis suggests that pharmacologic treatment be considered for
          • postmenopausal women and men >= 50yrs old with:
            • hip/vertebral fracture
            • T score between -1.0 and -2.5 at the femoral neck/spine and
              • 10-year risk of hip fracture ≥ 3% or
              • 10-year risk of major osteoporosis-related fracture ≥ 20% by FRAX calculation
            • T score -2.5 or less at the femoral neck/spine.
        • pharmacologic agents
          • calcium and Vitamin D
          • bisphosphonates
          • Conjugated Estrogen-progestin hormone replacement (HRT)
          • Estrogen-only replacement (ERT)
          • Salmon calcitonin (Fortical or Miacalcin)
          • Raloxifene (Evista)
          • Teriparatide (Forteo)
    • Operative
      • osteoporotic vertebral compression fracture
      • femoral neck fracture
      • distal radius fracture
  • Pharmacologic Agents
    • Bisphosphonates
      • 1st line therapy
      • indications for pharmacologic treatment
        • hip or vertebral fracture
        • T-score <2.5 at the femoral neck or spine (after exclusion of secondary causes)
        • low bone mass (T-score between -1.0 and -2.5) and
          • 10-year probability of a hip fracture ≥ 3% or greater or
          • 10-year probability of a major osteoporosis-related fracture ≥ 20% based on WHO algorithm/FRAX
      • mechanism
        • accumulate at sites of bone remodeling and are incorporated into bone matrix
        • are released into acid environment once bone is resorbed, and are then taken up by osteoclasts
        • decrease osteoclastic bone resorption, flattening of osteoclast ruffled border and increased osteoclast apoptosis
        • renal excretion without undergoing metabolism
        • exact mechanism depends on presence of nitrogen on alkyl chain (see table below)
      • technique
        • improved rates of treatment when coordinated by treating orthopedic surgeon and referral to osteoporosis clinic is made
        • DEXA scan and referral to endocrinologist
      • outcomes
        • alendronate reduces the rate of hip, spine, and wrist fractures by 50%
        • risedronate reduces vertebral and nonvertebral fractures by 40% (each) over 3 years
        • IV zoledronic acid reduces the rate of spine fractures by 70% and hip fractures by 40% over 3 years
      • Osteoporosis medications
      • Drug
      • Indications
      • Mechanism
      • Effects
      • Characteristics
      • Contraindications/
      • Adverse Effects
      • Prophylactic in all patients, best for Type II (senile)
      • Calcium reduces fracture risk by 34%.
      • Vit D supplementation reduces hip fracture risk by 10% and nonvertebral fracture risk by 7%.
      • High dose vitamin D (median, 800IU/d) reduces hip fractures by 24% and nonvertebral fractures by 30%
      • Daily calcium requirements are as follows:
      • -Age 1-3yrs - 500mg/d
      • -Age 4-8yrs - 800mg/d
      • -Age 9-18yrs - 1000 to 1500mg/d
      • -Age >50 yrs- 1200 to 1500 mg/d
      • Vitamin D requirement is 800-1,000 IUs
      • Non-nitrogen-containing bisphosphonates
      • T score <-2.5SD, fragility fracture of the hip, in both men and women
      • Produce toxic ATP analog
      • Etidronate, Clodronate, Tiludronate
      • Esophagitis, dysphagia, gastric ulcers, osteonecrosis of the jaw (ONJ), atypical subtrochanteric fractures
      • Nitrogen-containing bisphosphonates
      • T score <-2.5SD, fragility fracture of the hip, in both men and women
      • Inhibit farnesyl pyrophosphate synthase (mevalonate pathway)
      • Alendronate reduces vertebral fractures by 48% and nonvertebral fractures by 47%.
      • Risedronate reduces vertebral fractures by 65% and nonvertebral fractures by 39%.
      • Ibrandronate reduces vetebral fracture risk by 77%, hip fractures by 41%, and nonvertebral fractures by 15%.
      • Pamidronate, Alendronate (Fosamax), Risedronate (Actonel), Zolendronate (Reclast), Ibandronate (Boniva)
      • Esophagitis, dysphagia, gastric ulcers, ONJ, atypical subtrochanteric fractures
      • Conjugated Estrogen-progestin hormone replacement
      • In women with Type I (within 6 years of menopause)
      • Decreases the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, CAD and heart attack, stroke, PE, DVT, and Alzheimer's disease
      • Estrogen-only replacement
      • Indicated for women with prior hysterectomy
      • Estrogen receptors are present on osteoblasts and osteoclasts
      • Taking unconjugated estrogen (alone) increases the risk of endometrial hyperplasia / uterine cancer)
      • Testosterone
      • Men with low levels of testosterone
      • Not yet approved by FDA for osteoporosis
      • Salmon calcitonin
      • (Fortical or Miacalcin)
      • Women >5y postmenopause, decreases pain in acute vertebral compression fractures (acts as a neurotransmitter)
      • Binds membrane receptors on osteoclasts to inhibit resorption
      • Injection or nasal spray (destroyed by gastric acid)
      • Intranasal - Transient rhinitis.
      • Injectable - nausea, vomiting, flushing, hypersensitivity reactions
      • Raloxifene (Evista)
      • Women
      • Agonist on estrogen receptors in bone (reduce osteoclast resorption).
      • Antagonizes estrogen receptor in breast, reducing breast cancer risk.
      • Selective estrogen receptor modulator (SERM), slows bone resorption, and mild increase in bone thickness.
      • Reduces risk of vertebral fractures only (not non-vertebral fractures)
      • Hot flashes, leg cramps.
      • Contraindicated in patients with VTE
      • Severe osteoporosis/high fracture risk
      • Receptors on osteoblasts (activates osteoblasts) and renal tubule cells, also stimulates intestinal absorption Ca and PO4
      • 1-34 amino-terminal residues of parathyroid hormone (1-84) ;given by daily subcutaneous injections (continuous infusion leads to bone resorption)
      •  Transient hypercalcemia, dizziness, nausea, headache.
      •  Contraindicated in Paget's disease due to potential osteosarcoma risk
      • Postmenopausal women at high risk of fracture
      • Monoclonal Ig2 against RANKL (inhibits binding of RANKL to RANK, like osteoprotegerin)
      • Reduced vertebral fractures by 68%, hip fractures by 40%, nonvertebral fractures by 20%.
      • SC injection to arm, thigh, abdomen
      •  Arthralgia, nasopharyngitis, back pain, osteonecrosis of the jaw
      •  Contraindicated in severe hypocalcemia
      • Romosozumab (Evenity)
      • Postmenopausal women with history of osteoporotic fracture, multiple risk factors for fracture, or who have failed or are intolerant to other osteoporosis therapy
      • Humanized monoclonal Ig2 that activates Wnt pathway by binding sclerostin (sclerostin normally inhibits Wnt pathway).
      • Promotes bone formation and inhibits resorption.
      • Reduced new vertebral fracture by 73% through month 12 and by 75% through month 24
      • SC monthly injections
      • Hyperostosis, cardiovascular events, osteoarthritis, and cancer, osteonecrosis of the jaw, atypical femoral fracture
  • Complications
    • Osteonecrosis of the jaw (ONJ) is associated with IV bisphosphonates (but not oral bisphosphonates)
      • incidence
        • rare
      • treatment
        • stop inciting medication such as a bisphosphonate or Denosumab
    • Atypical subtrochanteric transverse stress fractures (in patients on long-term bisphosphonates)
      • incidence
        • rare
      • mechanism
        • extremely low bone turnover rates
        • shown by reduced markers of bone resorption (e.g. urinary collagen type 1 cross-linked N-telopeptide, NTx)
      • treatment
        • operative fixation with an intramedullary nail and stop bisphosphonates
          • Drug holidays are contraindicated in patients with worsening BMD or on chronic corticosteroids 
  • Prognosis
    • Prior fragility fracture is the strongest predictor of a future fracture from low energy trauma
    • Vertebral fractures
      • associated with 15% increase in 5-year mortality
      • associated with increased morbidity
        • back pain
        • loss of height
        • poor balance
        • respiratory compromise
          • restrictive lung disease
          • pneumonia
      • history of 1 vertebral fracture results in 5 fold increased risk of 2nd vertebral fracture and 5 fold increased risk of hip fracture
      • history of 2 vertebral fractures is the strongest indicated for further compression fractures in postmenopausal women
    • Hip fractures
      • associated with 20% increase in mortality
        • men have higher mortality rates following hip fractures than women
      • associated with increased morbidity
        • reduced quality of life
        • only one-third of patients with hip fractures return to their previous level of function
      • history of 1 hip fracture results in up to 10 fold increased risk of 2nd hip fracture
    • FRAX score
      • WHO fracture risk assessment tool that calculates the 10-year risk of hip fracture and 10-year risk of major osteoporosis-related fractures
      • factors include age, sex, personal history of fracture, low BMI, oral steroid use, secondary osteoporosis, parental history of hip fracture, smoking status and alcohol intake
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(OBQ18.242) An 85-year-old woman presents with severe back pain and the CT shown in Figure A. Her history is notable for prior vertebral compression fractures for which she underwent a cement augmentation procedure. She has been on bisphosphonates for the last 5 years, without improvement of her osteoporosis. She has no history of malignancy. What is the mechanism of action of the medication that should be prescribed for her refractory osteoporosis?

QID: 213138
FIGURES:

Calcium supplementation

1%

(25/1837)

Produces toxic adenosine triphosphate analog

2%

(39/1837)

Inhibits farnesyl pyrophosphate synthase

12%

(216/1837)

Vitamin D supplementation

3%

(62/1837)

Recombinant N-terminal parathyroid hormone

80%

(1476/1837)

L 2 A

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(OBQ18.149) Which of the following statements regarding bone mineral density (BMD) is true?

QID: 213045

The Z-score is the BMD relative to normal young matched controls

2%

(35/1918)

The T-score is the BMD relative to similar aged patients

2%

(30/1918)

Osteopenia is defined as a T-score of -1 to -2.5

83%

(1596/1918)

Osteopenia is defined as a Z-score of -1 to -2.5

5%

(103/1918)

Osteoporosis is defined as a Z-score of < -2.5

7%

(131/1918)

L 1 A

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(OBQ18.143) An 83-year-old woman presents complaining of thigh pain. The pain has been progressing over the last few months. She denies any night chills or recent weight loss. She has smoked 1 pack per day for the last 40 years. Her current medications are alendronate and citalopram. Her current imaging is shown in Figure A. What is the next best step in treatment?

QID: 213039
FIGURES:

Cephalomedullary nailing

74%

(1617/2187)

Computed tomography of the chest, abdomen, and pelvis

10%

(213/2187)

Standard antegrade femoral nailing

12%

(260/2187)

Transfer to an orthopaedic oncologist

1%

(26/2187)

Observation

2%

(53/2187)

L 2 A

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(SBQ18BS.4) Which of the following is accurate regarding sclerostin?

QID: 211145

Anti-sclerostin antibodies result in increased bone density

39%

(761/1935)

Sclerostin induces osteoblastic differentiation

24%

(470/1935)

Sclerostin inhibits osteoblast and osteocyte apoptosis

20%

(396/1935)

Sclerostin antagonizes BMP binding to the LRP5/6 receptor

9%

(165/1935)

SOST gene mutations have been linked to hereditary osteoporosis

6%

(122/1935)

L 1 A

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(OBQ13.90) A 55-year-old woman has T-score -2.0 at the femoral neck. According to the World Health Organization Fracture Risk Assessment Tool (FRAX), she has a ten-year probability of sustaining a hip fracture of 1.5% and a ten-year probability of sustaining a major osteoporotic fracture of 8.9%. Which of the following statements is true regarding her antiresorptive therapy management?

QID: 4725

Antiresorptive therapy should be started based on her T-score

17%

(803/4730)

Antiresorptive therapy should be started based on her risk of hip fracture alone

2%

(83/4730)

Antiresorptive therapy should be started based on her risk of major osteoporotic fracture alone

14%

(664/4730)

Antiresorptive therapy should not be started

46%

(2186/4730)

Antiresorptive therapy should be started based on her risks of both hip fracture and major osteoporotic fracture

20%

(964/4730)

L 2 B

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(SBQ12SP.88) A 75-year-old woman presents with acute severe back pain after sustaining a mechanical fall while walking out of her yard. She denies pain in her buttocks or legs. On physical exam she has point tenderness over the L1 spinous process. Figure A depicts her current radiograph. Which of the following statements is true regarding here underlying metabolic condition and associated pathology?

QID: 3786
FIGURES:

Kyphoplasty is indicated within the first week if the pain is severe enough to warrant narcotic medication.

5%

(104/2219)

Her underlying metabolic bone condition leads to decreased bone quantity with normal bone quality.

52%

(1156/2219)

A DEXA T-score of -2.1 in this individual would confirm the diagnosis of osteoporosis according to the WHO.

18%

(393/2219)

A 25-hydroxy Vitamin D level of 16ng/mL in this individual would confirm the diagnosis of osteoporosis according to the WHO.

5%

(113/2219)

The fracture pattern in Figure A is the third most common fragility fracture in the United States

19%

(425/2219)

L 1 B

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(OBQ12.169) A 72-year-old woman presents with severe hip pain after stepping off of a curb. She denies any trauma or prior history of hip pain. Her past medical history is reviewed including a list of her current medications. Which of the following of her medications would place her at increased risk for a non-traumatic hip fracture?

QID: 4529

Phenytoin

87%

(3360/3852)

Cephalexin

1%

(42/3852)

Simvastatin

4%

(142/3852)

Glipizide

4%

(150/3852)

Allopurinol

4%

(138/3852)

L 2 B

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(OBQ12.138) Which of the following pharmacologic treatments for osteoporosis has been associated with the potential risk for osteosarcoma development?

QID: 4498

Ergocalciferol

4%

(138/3280)

Non-nitrogen containing bisphosphonate

4%

(120/3280)

Monoclonal Ig2 against RANKL

16%

(531/3280)

Nitrogen containing bisphosphonates

13%

(433/3280)

Recombinant parathyroid hormone (1-34)

62%

(2031/3280)

L 3 A

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(OBQ11.257) A 55-year-old healthy female presents for a routine physical exam. When discussing bone health and osteoporosis prevention, what dose of calcium and vitamin D should be recommended for daily consumption?

QID: 3680

1,500mg of calcium and 1,000 IUs of vitamin D

80%

(1800/2249)

2,200mg of calcium and 1,000 IUs of vitamin D

5%

(104/2249)

750mg of calcium and 5,000 IUs of vitamin D

10%

(217/2249)

750mg of calcium and 10,000 IUs of vitamin D

3%

(61/2249)

2,200mg of calcium and 5,000 IUs of vitamin D

3%

(58/2249)

L 1 A

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(OBQ11.115) A 58-year-old woman falls down while walking her dog and sustains the low-energy injury shown in Figures A and B. Which of the following lab values is most likely to be abnormal in this patient?

QID: 3538
FIGURES:

Hydroxylproline

3%

(59/2080)

25-hydroxy cholecalciferol (25 OH vitamin D)

91%

(1890/2080)

Parathyroid hormone-related protein (PTHrP)

4%

(83/2080)

Sry-type high-mobility-group box transcription factor-9 (Sox-9)

1%

(21/2080)

LRP5 (low-density lipoprotein receptor-related protein)

1%

(21/2080)

L 1 B

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(OBQ11.36) A 52-year old woman who is not on any hormone replacement therapy (HRT) falls from standing height and sustains the injury seen in Figure A. Review of her medical history reveals that she carries a diagnosis of osteoporosis, and that her latest T-score was -3.0. How much calcium should she have been consuming on a daily basis prior to sustaining her injury?

QID: 3459
FIGURES:

200-400mg

1%

(14/2771)

600-800mg

3%

(78/2771)

800-1000mg

7%

(197/2771)

1000-1500mg

74%

(2042/2771)

>1500mg

15%

(429/2771)

L 2 A

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(OBQ11.33) A 58-year-old female falls and sustains the injury shown in Figures A and B. Following surgical treatment of the fracture, which of the following is the most appropriate additional investigation?

QID: 3456
FIGURES:

MRI of the pelvis

2%

(39/2193)

Urine electrophoresis

2%

(38/2193)

CT scan of the pelvis

3%

(63/2193)

Bone scan

3%

(55/2193)

DEXA scan

91%

(1989/2193)

L 1 B

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(OBQ10.105) You are seeing a 13-year-old girl for asymptomatic flat feet and recommend observation. In educating this patient/family about general bone health, you recommend what amount of daily dietary calcium for your patient?

QID: 3199

250mg - 500mg

2%

(33/2133)

500mg - 750mg

11%

(236/2133)

750mg - 1000mg

20%

(423/2133)

1000mg - 1500mg

64%

(1364/2133)

over 1500mg per day

3%

(68/2133)

L 3 A

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(OBQ10.57) An 80 year-old female undergoes ORIF of her hip fracture without any complications. A hospitalist consult was obtained for medical clearance pre-operatively, and she was diagnosed with osteoporosis. Which of the following treatment scenarios will lead to the best management of the patient's osteoporosis?

QID: 3145

Schedule a follow-up appointment with the patients primary care physician to initiate therapy

4%

(81/2121)

Order a physical therapy consult and initiate an exercise plan

1%

(20/2121)

Have the patient meet with a nutritionist to increase her calcium and vitamin D intake

2%

(37/2121)

Start bisphosphonates, and have the patient follow-up with her primary care physician

11%

(230/2121)

Perform a metabolic work-up as an inpatient, and set-up an appointment in an osteoporosis clinic

82%

(1745/2121)

L 2 C

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(OBQ10.231) Which of the following administered substances leads to net bone resorption?

QID: 3330

Zoledronic acid (Reclast) injection once per year

5%

(137/2600)

Teriparatide (Forteo) injection once daily

9%

(234/2600)

Alendronate (Fosamax) oral once weekly

4%

(93/2600)

Teriparatide (Forteo) continuous infusion for 2 weeks

75%

(1953/2600)

Alendronate (Fosamax) oral once daily

7%

(172/2600)

L 2 A

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(OBQ10.119) Which of the following medications is a recombinant form of parathyroid hormone that has been found to stimulate new bone formation in patients with postmenopausal osteoporosis?

QID: 3213

Risedronate (Actonel)

1%

(34/3271)

Zoledronic acid (Reclast)

4%

(140/3271)

Teriparatide (Forteo)

91%

(2972/3271)

Ibandronate (Boniva)

1%

(49/3271)

Alendronate (Fosamax)

2%

(63/3271)

L 1 A

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(SBQ09SP.5) According to the 2008 National Osteoporosis Foundation Guidelines for Pharmacologic Treatment of Osteoporosis, when are bisphosphonates indicated for the treatment or prevention of osteoporosis?

QID: 3368

DEXA T-score between -1.0 and -2.5

2%

(35/1819)

FRAX calculated 10-year hip fracture risk of >3%

13%

(230/1819)

FRAX calculated 10-year risk of major osteoporosis-related fracture of >10%

35%

(640/1819)

Answers 1 and 2

16%

(289/1819)

Answers 1 and 3

33%

(606/1819)

L 5 C

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(OBQ09.165) Genetic polymorphisms in all of the following genes are associated with osteoporosis EXCEPT?

QID: 2978

Calcitonin receptor

7%

(164/2319)

Estrogen receptor-1

2%

(48/2319)

Vitamin D receptor

3%

(72/2319)

Type I collagen alpha-1 chain

19%

(434/2319)

Cartilage oligomeric matrix protein (COMP)

69%

(1590/2319)

L 3 D

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(OBQ09.33) Risk factors for insufficiency fractures of the pelvic ring include all of the following EXCEPT:

QID: 2846

Osteoporosis

1%

(9/1454)

Corticosteroid treatment

1%

(13/1454)

Total hip replacement with constrained liner

10%

(141/1454)

Rheumatoid arthritis

7%

(104/1454)

Total hip replacement with ceramic bearings

81%

(1183/1454)

L 4 C

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(OBQ08.32) A 45 year-old woman who has not reached menopause yet falls from a standing height and sustains a distal radius fracture. A DEXA scan reveals a T-score of -2.2. Which of the following treatments is indicated in this patient?

QID: 418

1,700 mg of calcium

19%

(503/2590)

1,200 mg of calcium

62%

(1598/2590)

1,700 mg of vitamin D

17%

(431/2590)

1,200 mg of iron

0%

(7/2590)

1,700 mg of PTH

2%

(43/2590)

L 2 C

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(OBQ08.96) With aging, there is a greater loss of mechanical strength in which of the following types of bone?

QID: 482

Cortical bone more than trabecular bone

23%

(243/1057)

Trabecular bone more than cortical bone

68%

(719/1057)

Cortical bone and trabecular bone equally

7%

(78/1057)

Only trabecular bone

1%

(11/1057)

Only cortical bone

0%

(3/1057)

L 1 C

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(OBQ07.261) Which of the following is NOT included in the best management of a elderly female newly diagnosed with a fragility fracture?

QID: 922

Hip and spine densitometry

1%

(14/968)

Laboratory analysis for secondary causes of osteoporosis

2%

(20/968)

Administration of calcium 1,500 mg/day

1%

(11/968)

Administration of Vitamin D 400 to 800 IU/day

1%

(14/968)

Low protein diet

94%

(907/968)

L 2 A

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(OBQ07.170) What effect does intermittent administration of parathyroid hormone have on bone?

QID: 831

Anabolic

75%

(787/1056)

Catabolic

18%

(194/1056)

No effect

3%

(32/1056)

Decreased quantity

2%

(18/1056)

Decreased quality

2%

(22/1056)

L 2 A

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(OBQ07.120) All of the following medications have been associated with an increased risk of osteoporosis EXCEPT:

QID: 781

Selective serotonin reuptake inhibitors (SSRI)

19%

(170/918)

Glucocorticoids

1%

(8/918)

Non-steroidal anti-inflammatories (NSAIDs)

69%

(633/918)

Phenytoin

4%

(39/918)

Protease inhibitors

7%

(67/918)

L 2 C

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(OBQ07.158) A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma?

QID: 819
FIGURES:

Bone mineral density T-score < -2.5

7%

(146/2096)

Low vitamin D levels

0%

(10/2096)

Family history of osteoporosis

0%

(7/2096)

History of a prior fragility fracture

92%

(1919/2096)

Ten year history of oral prednisone use

1%

(11/2096)

L 2 C

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(OBQ06.178) Regarding bone densitometry, a T-score of -3.5 is defined as which of the following?

QID: 364

Normal bone

0%

(1/994)

Osteopenia

2%

(21/994)

Age appropriate bone loss

1%

(7/994)

Osteoporosis

93%

(929/994)

None. One cannot make this diagnosis without further information.

3%

(34/994)

L 1 C

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(OBQ06.58) Which of the following patients are at greatest risk of having a future vertebral fragility fracture?

QID: 169

Elderly female with prior hip fragility fracture

9%

(157/1742)

Elderly female with prior distal radius fragility fracture

6%

(96/1742)

Elderly female with prior T6 compression fragility fracture

78%

(1358/1742)

Elderly female with a T-score of -3.0

6%

(111/1742)

Elderly female currently on hormone replacement therapy

0%

(4/1742)

L 2 C

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Evidence (83)
VIDEOS & PODCASTS (8)
EXPERT COMMENTS (61)
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