Q.1: What are the risk factors for
osteoporotic fracture? Ans: The risk
factors for osteoporotic fracture include (but are not limited to) 1)
increasing age, 2) female sex, 3) postmenopausal women, 4) hypogonadism
or premature ovarian failure,5) low body
weight,6) history of parental hip fracture, 7) ethnic background (white persons
are at higher risk than black persons), 8) previous clinical or morphometric
vertebral fracture,9) previous fracture
due to minimal trauma (that is, previous osteoporotic fracture), 10) rheumatoid
arthritis, 11) current smoking, 12) alcohol intake (3 or more drinks daily),
15( low bone mineral density (BMD),16)
vitamin D deficiency, 17) low calcium intake, 18) hyperkyphosis,
19) falling, and 20) immobilization .
Another risk factor for osteoporotic fracture is 21) long-term use of certain
medications, the most commonly implicated being glucocorticoids,
anticoagulants, anticonvulsants, aromatase inhibitors, cancer chemotherapeutic
drugs, and gonadotropin-releasing hormone agonists
(Courtsey: CLINICAL
GUIDELINES |9
MAY 2017
;-Treatment of Low Bone Density or Osteoporosis to
Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from
the American College of Physicians FREE
Amir
Qaseem, MD, PhD, MHA; Mary Ann Forciea, MD; Robert M. McLean, MD; Thomas D.
Denberg, MD, PhD; for the Clinical Guidelines Committee of the American College
of Physicians (*))
Osteoporotic fracture: Q.2: How to diagnose osteoporosis??
Osteoporosis can be diagnosed by the occurrence of fragility fracture. In
patients without fragility fracture, osteoporosis is often diagnosed by low
BMD.
Q. 2A: DXA : Method A:--DXA: Dual-energy x-ray absorptiometry (DXA) is the
current gold standard test for diagnosing osteoporosis in people without an
osteoporotic fracture. Results
of DXA are scored as SDs from a young, healthy norm (usually female) and
reported as T scores.
For
example, a T score of –2 indicates a BMD that is 2 SDs below the comparative
norm. The international reference standard for the description of osteoporosis
in postmenopausal women and in men aged 50 years or older is a femoral neck BMD
of 2.5 SD or more below the young female adult mean .
Low BMD as
measured by DXA is an imperfect predictor of fracture risk, identifying less
than one half of the people who go on to have an osteoporotic fracture.
Q. 3: Z score?? Method B:- Bone density can also be
classified according to the Z score, the number of SD above or below
the expected BMD for the patient's age and sex.
A Z score of –2.0 or lower is
defined as either “low BMD for chronological age” or “below the expected range
for age,” and those above –2.0 are “within the expected range for age” .
Q, 4: What is FRAX?? Risk scores that combine clinical risk
factors with BMD testing results, such as FRAX (the World Health
Organization Fracture Risk Assessment Tool), can be used to predict
fracture risk among people with low bone density.
Q. 5. What drug and how long to treat?? ACP recommends that clinicians
offer pharmacologic treatment with A) alendronate, B) risedronate, C)
zoledronic acid, or D) denosumab to reduce the risk for hip and vertebral
fractures in women who have known osteoporosis. (Grade: strong recommendation;
high-quality evidence) ACP recommends that clinicians treat osteoporotic women
with pharmacologic therapy
for 5 year as per American College of Physicians (ACP)
ACP (American
College of Physicians )
This guideline focuses on the comparative benefits and risks
of short- and long-term pharmacologic treatments for low bone density,
including pharmaceutical prescriptions, calcium, vitamin D, and estrogen.
Men and women with low bone density
and osteoporosis. ACP recommends that clinicians should make the decision whether to
treat osteopenic women 65 years of age or older who are at a high risk for
fracture based on a discussion of patient preferences, fracture risk profile,
and benefits, harms, and costs of medications.
Q. 5A: What drugs?? osteoporosis
include A) bisphosphonates (alendronate, risedronate, ibandronate, zoledronic
acid), B) peptide hormones (teriparatide [ 1,3,4 amino acid fragment of parathyroid hormone] and
calcitonin), C) estrogen (in the form of menopausal hormone therapy) for
postmenopausal women, and D) selective estrogen receptor
modulators (SERMs) (raloxifene for postmenopausal
women).
Q. 5B: What is most current and promising agent/ drugs?? Most
of the treatments aim to prevent bone resorption. E) Denosumab
(a new biologic agent), dietary and supplemental calcium, and vitamin D are
also used for treatment. F)
Bazedoxifene, a SERM, has recently been approved by the U.S.
Food and Drug Administration (FDA) with conjugated estrogen for prevention of
osteoporosis.
Q. 6: What is meant
by Osteoporosis?? Osteoporosis is a systemic skeletal disease characterized
by decreasing bone mass and microarchitectural deterioration of bone tissue
that leads to an increased risk for bone fragility and fracture. Although osteoporosis
can be present in any bone, the hip, spine, and wrist are most likely to be
affected.
Q. 7 : Prevalence of osteoprosis: Osteoporosis is found in an estimated 200 million people
worldwide and an estimated 54 million men and women in the United States have
osteoporosis or low bone density .Approximately 50% of Americans older than 50
years are at risk for osteoporotic fracture .
Q. 8: What changes have bn made recently by FDA on
drug treatment of osteoporosis??
Pharmacologic treatments for osteoporosis include bisphosphonates (alendronate,
risedronate, ibandronate, zoledronic acid), peptide hormones (teriparatide [the
1,3,4 amino acid fragment of parathyroid hormone] and calcitonin), estrogen (in
the form of menopausal hormone therapy) for postmenopausal women, and selective
estrogen receptor modulators (SERMs) (raloxifene for postmenopausal women). Most of the treatments aim to
prevent bone resorption.
Denosumab (a new biologic agent), dietary and supplemental calcium, and vitamin D are also
used for treatment. Bazedoxifene,
a SERM, has recently been approved by the U.S. Food and Drug Administration
(FDA) with conjugated estrogen for prevention of osteoporosis.
Q.9:- Do we know that FDA do not approve etidronate and pamidronate ?? “Etidronate and pamidronate,” neither
of which are FDA-approved for the prevention of fractures or treatment of
osteoporosis. This is as per Several therapies included in the 2008
guideline have been excluded
Several therapies included in the 2008 guideline have been excluded from the update, including calcitonin, which is no longer
widely used for osteoporosis treatment, and both etidronate and pamidronate,
neither of which are FDA-approved for the prevention of fractures or treatment
of osteoporosis.
Q.10 what is then the moist premising agent?? One new
biologic, denosumab, a human monoclonal antibody approved by the FDA for
treatment of osteoporosis, has been added since publication of the 2008
guideline. Different medications for the
treatment of osteoporosis may affect various parts of the skeletal system
differently. This guideline is endorsed by the American Academy of Family
Physicians.
Q.11. Who helpful is Bisphosphonates (alendronate , risedronate , and zoledronic acid) ? ,
High-quality evidence showed that bisphosphonates, including
alendronate , risedronate , and zoledronic acid , reduce vertebral,
nonvertebral, and hip fractures compared with placebo in postmenopausal
osteoporotic women. High-quality evidence also showed that ibandronate reduces
the risk for radiographic vertebral fractures, although evidence is
insufficient to determine the effect of ibandronate on hip fractures .Moderate-quality
evidence showed that zoledronic acid reduces radiographic vertebral fractures
in osteoporotic men
Q.12: How useful is Denosumab???
High-quality evidence showed that treatment with denosumab
reduces radiographic vertebral, nonvertebral, and hip fractures compared with
placebo in postmenopausal osteoporotic women (96–108). One Japanese trial and
its 1-year open-label extension study included postmenopausal osteoporotic
women with prevalent radiographic vertebral fractures and showed that denosumab
protected against radiographic vertebral fractures (101, 109).
Q.12: How useful is Teriparatide??
High-quality evidence showed that treatment with
teriparatide reduces radiographic vertebral and nonvertebral fractures compared
with placebo in postmenopausal osteoporotic women
Q.12: How useful is SERMs??
High-quality evidence showed that raloxifene reduces
vertebral fractures in osteoporotic women; however, it did not statistically
significantly decrease the risk for nonvertebral or hip fractures compared with
placebo
How useful is Bazedoxifene?? Bazedoxifene is FDA-approved in combination with conjugated
estrogens for the prevention of osteoporosis (20 mg, with 0.45 mg conjugated
estrogen). The systematic review did not find any randomized controlled trials
(RCTs) with this combination that had primary fracture outcomes.
Q. 13. How useful is Estrogen Therapy for Postmenopausal Women in
fracture prevention??
Moderate-quality evidence showed no difference in reduced
fracture with estrogen treatment in postmenopausal women with established
osteoporosis This differs from the 2008 guideline, which reported high-quality
evidence that estrogen therapy was associated with reduced risk for vertebral,
nonvertebral, and hip fractures in postmenopausal women Studies included in the
2008 guideline focused on postmenopausal women or those with low bone density
as opposed to the newer data, which focused on postmenopausal women with
established osteoporosis.
Q.14:
How useful is Calcium or Vitamin D??
Moderate-quality evidence showed that the overall effect of
calcium or vitamin D alone on fracture risk is uncertain. Studies showed no
difference between calcium alone and placebo for reduced vertebral and
nonvertebral fracture risk although adherence was low. Data on the efficacy of
vitamin D alone for reducing fracture risk are mixed, and the overall effect is
uncertain .
Q.15: How useful is Physical
Activity??
Evidence is insufficient to conclusively show the effect of
physical activity on fracture risk There are no studies that evaluated the
comparative effectiveness of physical activity with that of other
interventions.
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