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35 Cards in this Set
- Front
- Back
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Osteoporosis
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10 Million in US
80% women More common in women in general (5:1) More common in white women and Asian women Black women have more osteoarthritis in the knees Additional 18 Million have osteopenia- Abnormally low bone density 1.5 Million fractures related to osteoporosis a year Hips (15% risk white females > 50, risk doubles Q 10 yrs) Spine Wrists |
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osteoporosis definition
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Systemic skeletal disease characterized by low bone mass and microarchitectural deteriorations of bone, leading to bone fragility and increased risk for fractures
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Pathogenesis
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Calcium is needed for neuromuscular function, and blood clotting and bone formation
A decrease in serum calcium causes the body to: Increase parathyroid hormone release Increase vitamin D synthesis in kidneys and liver Causing… Increased resorption of calcium from bone Increased serum calcium for neuromuscular function Osteoporosis Spinal compression Bone fractures |
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Causes of Osteoporosis
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Decreased calcium concentration in the bone-
Decreased calcium intake Poor nutrition Eating disorders Decreased intestinal absorption of calcium Decreased calcium reabsorbtion in the kidneys Decreased estrogen (menopause, anorexia, depo…) Decreased vitamin D intake or synthesis Decreased physical exercise Prolonged immobility |
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Causes Continued
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Can have genetic causes of osteoporosis
Female athletes Increased exercise Menses changes Aging Menopause |
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Types of Osteoporosis/Differential
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Primary Osteoporosis-
Bone loss due to estrogen deficiency (or male hormone deficiency) |
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Types of Osteoporosis/Differential
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Secondary Osteoporosis-
Bone loss caused by- Disease states- Cancer GI disorders Alcohol abuse Endocrine Medications PPIs Steroids Albuterol Chemotherapy Anticonvulsants Immunosuppressants Long term heparin |
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Risk Factors R/T Osteoporosis
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female polycystic ovary disease
age early menopause family history smoking lack of exercise ethnic group fx hx lack of exercise small-boned frame immobilization late menarche yoyo dieting steroids lactose itolerance anorexia/bolemia excess alcohol carbonated drinks |
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MYTHS
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Pregnancy and breast feeding are not risk factors as previously believed
Calcium is restored to the bones within 6 months of pregnancy and discontinuance of lactation |
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Signs and Symptoms osteoporosis
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Subtle S & S
Fracture is usually first sign (1:2 women in lifetime) Shrinking height (loss > 1.5 inches) Spinal curve Chronic or acute back pain Women should be screened to assess their risk for fractures All women > 65 Women 50-65 who have more than 1 risk factor Younger women and men if indicated |
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Diagnosis of osteoporosis
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Obtain laboratory data to R/O other causes of bone loss-
CBC SED rate Serum calcium Phosphorus and alkaline phosphatase Protein and creatinine Liver function tests Urine calcium Glucose |
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Diagnosis of osteoporosis cont'd
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Test bone mineral density (BMD)
Used to diagnose osteopenia and osteoporosis and predict bone fracture Used to monitor treatment progress of osteoporosis Bone mineral density can be measured using the DEXA (DXA) scan (Gold standard) Measures bone density in heels or forearm, iliac crest Category T Score Normal > -1 SD Osteopenia -1 SD to -2.5 SD Osteoporosis > -2.5 SD (without fracture) Severe Osteoporsis > - 2.5 SD (with fracture) BMD plus risk assessment is better predictor of fracture risk |
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Therapeutic Plan of Osteoporosis
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Prevention/Treatment/Rehabilitation
Early- Identify risks Osteoporosis Risk Assessment Instrument Simple Calculated Osteoporosis Risk Assessment Instrument http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm |
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affecting osteoporosis
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Lifelong
Nutrition Exercise Resistance exercises Smoking Avoid excess alcohol Carbonated beverages Prevent falls Surgery |
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Drug Therapy Guidelines from NOF
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BMD T-score (central DEXA exam)
Below -2 in absence of risk factors Initiate drug Below -1.5 with 1 or more risk factors Initiate drug Women with a prior verterbral or hip fx Initiate drug Also stress need for calcium, vitamin D and exercise http://www.rah.sa.gov.au/nucmed/BMD/bmd_docguide.htm |
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Drugs for Prevention of osteoporosis
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HT
Give estrogen alone if no uterus Give estrogen with progesterone if uterus May use pills or patches May give continuous or cyclic Activella i daily Estraderm patch twice weekly Contraindicated in women with hx breast Ca May give progesterone alone with some benefit |
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Drugs for Prevention of osteoporosis
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Add calcium
Calcium citrate best 500-1500mg day (not more than 2000) 1500mg daily in postmenopausal and not on HT 1000mg-1200mg daily in postmenopausal women on HT Calcium chews (OTC) many flavors-chocolate, vanilla Vitamin D 800 IU > 50 y/o Vitamin D 400-800 IU < 50 y/o (Use vitamin D3 if confined to indoors) http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ |
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D2 vs D3
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Vitamin D3 (cholecalciferol) is the type of vitamin D the body naturally produces in the skin in response to sun exposure. Vitamin D2 is produced naturally when fungi (yeast or mushrooms) are exposed to ultraviolet light from the sun or to artificial UV light.
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Drugs for Prevention & Treatment
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SERMs (selective estrogen receptor modulators)
Decreases bone turnover and bone resorption Raloxifene hydrochloride (Evista)- (oral dosing) Has estrogen like effects on bone and lipids but not uterus or breast Can be used in women with strong Hx of breast or uterine cancer Use in women who are at risk for osteoporosis but are not having menopausal symptoms (give only after menopause) 60mg PO Daily Can cause hot flashes, leg cramps, swelling of feet and legs, rare blood clots Notify NP if post menopausal bleeding or breast tenderness Decreases LDL and increases HDL Do not give concurrently with HT or lipid lowering drugs |
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Bisphosphonates
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Alendronate (Fosamax)- Oral
Decreases bone resorption and prevents bone loss Prevents osteoclast activity Post menopausal osteoporosis 10mg day with 6 oz. H20 ½ hour before 1st meal of day Wait 30 MINUTES (SITTING UP) before eating, drinking or taking other medications For prevention of osteoporosis (if on steroids) give 5 mg day. Side effects nausea and indigestion Do not give to patients with esophageal strictures Cautious use with hiatal hernia, dysphagia, gastritis, peptic ulcers |
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Boniva
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Ibandronate
Decreases bone resorption and prevents bone loss Prevents osteoclast activity Used in postmenopausal women Precautions 2.5mg per day or 150mg per month Take with water 60 minutes before eating. Remain standing or sitting for 1 hour after Cautious use with Upper GI disease Caution with renal dysfunction Baseline creatinine |
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Drugs Continued
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Treatment only…
Calcitonin-Salmon- Has an analgesic effect on osteoporotic fractures Used for severe cases Nasal spray Injection Parathyroid hormone SQ |
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Osteoarthritis
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Most common arthritis disorder
Effects more than 20 Million Americans 46 million clinician visits a year 3.7 million hospitalizations 90% of people > 40 will have radiographic evidence in load bearing joints |
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Osteoarthritis Pathophysiology
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Disorder of the articular cartilage resulting in-
Inability to bare load Deformity of the joint surface Commonly effects- Distal interphalangeal joints Proximal interphalangeal joints Metatarsophalangeal joint of great toe Hip Knee Cervical and Lumbar Spine |
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Risks of osteoarthritis
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Increasing age
Obesity Family history Female Wear and tear Skeletal abnormality |
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Clinical Presentation of osteoarthritis
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Insidious onset of deep localized pain in involved joint
Early morning stiffness lasting less than 30 minutes Pain aggravated by joint use and relieved by periods of rest Crepitus Progression of disease may lead to- Decrease in daily function Muscle atrophy from inactivity Nocturnal pain may interfere with sleep |
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Presentation Continued
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Heberdon’s nodes (DIP)
Bouchards nodes (PIP) Effusion in joints Decreased range of motion in effected joints |
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Differential Diagnosis of osteoarthritis
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Gout/Pseudogout-
Acute onset, nocturnal, monoarticular Septic arthritis- Acute onset, weight bearing joint, large effusion, temperature Osteoporosis- Spontaneous fracture, loss of height Polymyalgia Rheumatica- > 50, pain and stiffness shoulder and pelvis, fever, anemia Systemic Lupus Eryrhematosus- Female, rash, joint symptoms, + ANA Osgood-Schlatter Disease- Young athletes, Prepatellar bursa swelling, tenderness Fractures Malignancies Others??? |
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Diagnosis…of osteoarthritis
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Primarily through physical examination/confirmation by radiologic and laboratory studies
Joint tenderness, creptius, pain on passive ROM Observe walking-may have lurching forward Inspect joints for stiffness, deformity, swelling, occasional warmth, rarely erythemia If joint swelling aspirate and send for analysis Evaluate muscle strength and joint stability |
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diagnosis of osteoarthritis continued
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X-Ray-
Joints show narrowing of joint space Osteophyte formation If signs of inflammation exist order further diagnostic tests- CBC ESR Joint fluid analysis (culture and analysis) |
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Management of osteoarthritis
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No cure, life long treatment
Prevention (start early) Proper diet Nutrition Exercise Weight control Goals- Relieve pain Slow down progression of disease Preserve function |
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Treatment Continued of osteoarthritis
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Life style changes-
Exercise- Muscle strengthing,… Rest- Deceases pain,… Physical and occupational therapy- Appropriate foot wear, appliances,… Heat- Heat packs, paraffin Cold- Ices, sprays, creams Weight reduction- Decrease stress on joints Cognitive Behavioral therapy Braces |
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Pharmacologic Agents osteoarthritis
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Topical treatments 1st line
NSAIDs Capsaicin 5% Lidocaine patches Glucosamin-OTC <120 lbs give 1000mg 120-200 lbs give 1500mg > 200 lbs give 2000mg Helps to rebuild cartilage May raise blood sugar levels (cautious with DM) Do not take if allergic to shell fish, pregnant or breast feeding May affect warfarin levels Drowsiness and headaches Constipation, abdominal pain and diarrhea, heart burn and nausea Rash Anaphylaxis Watch BS if DM Intraarticular injections of steroids- Oral steroids- |
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Pharmacological Agents osteoarthritis Continued
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Medications-
Acetaminophen- Up to 3200mg/day Cautious use in patients who drink/liver disease Do yearly liver function tests NSAIDS- ASA Ibuprofen Cox 2 –Celebrex with caution Ulcers Bleeding CV risk (see previous info on NSAID use) Tramadol Start low and increase dose |
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Complementary Treatment
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Ask patients about complementary treatments-
They don’t always tell clinician They can interfere with treatment They can have side effects Accupuncture Magnets Pulsed Electromagnetic Field Therapy (PEMF) Avoid if pacers, pregnant, metal implants, cancer Copper bracelets Special diets Herbals Yoga |
