STUDY GUIDE
WEEK 6: Bone and Joint
📖 Chapter 57 — Osteoporosis
🔹 Risk Factors (Tables 57-1 & 57-2)
Table 57-1: Osteoporosis & Fracture Risk Factors
Non-modifiable:
o Advanced age, female sex, postmenopause
o Caucasian/Asian ethnicity
o Family history (hip fracture in first-degree relative)
o Prior fragility fracture
Modifiable:
o Low body weight, sedentary lifestyle
o Smoking, excessive alcohol
o Poor nutrition (low calcium/vitamin D)
o Falls
Table 57-2: Medical Conditions & Drugs Associated with Low Bone Mass
Conditions: rheumatoid arthritis, hyperthyroidism, hypogonadism, malabsorption (celiac, IBD), CKD, chronic liver
disease
Drugs:
o Glucocorticoids (≥5 mg prednisone equivalent ≥3 months)
o Anticonvulsants (phenytoin, carbamazepine, phenobarbital, valproate)
o PPIs, SSRIs, TZDs (pioglitazone), aromatase inhibitors, androgen deprivation therapy
o Heparin, cyclosporine, tacrolimus
🔹 Calcium & Vitamin D (NOF Recommendations)
Calcium:
o Women <50 & men <70: 1,000 mg/day
o Women ≥50 & men ≥70: 1,200 mg/day
Vitamin D (25-OH target >30 ng/mL): 800–1,000 IU/day for adults ≥50
Dietary supplements:
o Calcium carbonate: 40% elemental Ca, inexpensive, requires acid (take with meals; avoid if on PPIs).
o Calcium citrate: 21% elemental Ca, absorbed without acid (better for elderly, achlorhydria, or PPI/H2RA
use).
o Avoid >500–600 mg per single dose (absorption plateaus).
🔹 Non-Pharmacologic Interventions
Fall prevention: home safety (lighting, remove rugs, grab bars), balance/strength training (Tai Chi), PT referral.
Lifestyle: weight-bearing/resistance exercise, smoking cessation, alcohol moderation.
Nutrition: adequate protein, Ca, vitamin D.
Vision & medication review: address sedatives, antihypertensives, etc.
, 🔹 T-Score Interpretation
Normal: ≥ –1.0
Osteopenia (low bone mass): –1.0 to –2.5
Osteoporosis: ≤ –2.5
Severe osteoporosis: ≤ –2.5 plus fragility fracture
🔹 Drug Therapy (Table 57-6: Prescription Drugs for Osteoporosis)
Drug Class Examples Indications Key Contraindications / Counseling
Cautions
Bisphosphonates Alendronate, Postmenopausal CrCl <30–35; esophageal Take with water AM,
Risedronate, women, men, GIOP stricture, inability to sit empty stomach,
Ibandronate, upright; hypocalcemia upright ≥30–60 min;
Zoledronic acid ONJ/atypical femur
fracture risk (rare)
SERMs Raloxifene Postmenopausal Hx VTE, pregnancy Hot flashes, leg
women, esp. with ↑ cramps; no
breast cancer risk endometrial cancer
risk
HRT (estrogen ± Conjugated Postmenopausal VTE, breast/endometrial Use lowest
progestin) estrogen, women with cancer, stroke, CHD dose/shortest
estradiol menopausal duration; combine
symptoms plus progestin if uterus
osteoporosis risk intact
Calcitonin Salmon calcitonin Last-line; short-term Hypersensitivity; limited Not first-line, possible
(nasal, inj) vertebral fracture efficacy ↑ cancer risk with
pain relief long-term use
Denosumab RANKL inhibitor Postmenopausal Hypocalcemia, Monitor Ca/Mg/PO₄;
(SC q6mo) osteoporosis, men at infections, ONJ, atypical rapid bone loss if
high fracture risk, femur fracture discontinued →
CKD transition to
bisphosphonate
Parathyroid Teriparatide, Severe OP, multiple Hypercalcemia, bone Daily SC; follow with
hormone analogs Abaloparatide fractures, failed other metastases, ↑ risk antiresorptive after
(anabolics) therapy osteosarcoma (avoid >2 stopping
yrs lifetime use)
Sclerostin inhibitor Romosozumab Severe CV risk (MI, stroke); Monthly SC; switch to
postmenopausal OP limited to 1 yr antiresorptive
afterward
✅ High-Yield Pearls
First-line: oral bisphosphonates unless contraindicated.
Denosumab: option for CKD patients (not renally cleared), but requires long-term continuation or transition.
Raloxifene: great if osteoporosis + breast cancer risk, but ↑ VTE.
Teriparatide/abaloparatide/romosozumab: for very high risk (T-score ≤ –3.5, multiple fractures).
HRT: only if menopausal symptoms warrant.
Calcium + vitamin D supplementation is foundational for all patients.
WEEK 6: Bone and Joint
📖 Chapter 57 — Osteoporosis
🔹 Risk Factors (Tables 57-1 & 57-2)
Table 57-1: Osteoporosis & Fracture Risk Factors
Non-modifiable:
o Advanced age, female sex, postmenopause
o Caucasian/Asian ethnicity
o Family history (hip fracture in first-degree relative)
o Prior fragility fracture
Modifiable:
o Low body weight, sedentary lifestyle
o Smoking, excessive alcohol
o Poor nutrition (low calcium/vitamin D)
o Falls
Table 57-2: Medical Conditions & Drugs Associated with Low Bone Mass
Conditions: rheumatoid arthritis, hyperthyroidism, hypogonadism, malabsorption (celiac, IBD), CKD, chronic liver
disease
Drugs:
o Glucocorticoids (≥5 mg prednisone equivalent ≥3 months)
o Anticonvulsants (phenytoin, carbamazepine, phenobarbital, valproate)
o PPIs, SSRIs, TZDs (pioglitazone), aromatase inhibitors, androgen deprivation therapy
o Heparin, cyclosporine, tacrolimus
🔹 Calcium & Vitamin D (NOF Recommendations)
Calcium:
o Women <50 & men <70: 1,000 mg/day
o Women ≥50 & men ≥70: 1,200 mg/day
Vitamin D (25-OH target >30 ng/mL): 800–1,000 IU/day for adults ≥50
Dietary supplements:
o Calcium carbonate: 40% elemental Ca, inexpensive, requires acid (take with meals; avoid if on PPIs).
o Calcium citrate: 21% elemental Ca, absorbed without acid (better for elderly, achlorhydria, or PPI/H2RA
use).
o Avoid >500–600 mg per single dose (absorption plateaus).
🔹 Non-Pharmacologic Interventions
Fall prevention: home safety (lighting, remove rugs, grab bars), balance/strength training (Tai Chi), PT referral.
Lifestyle: weight-bearing/resistance exercise, smoking cessation, alcohol moderation.
Nutrition: adequate protein, Ca, vitamin D.
Vision & medication review: address sedatives, antihypertensives, etc.
, 🔹 T-Score Interpretation
Normal: ≥ –1.0
Osteopenia (low bone mass): –1.0 to –2.5
Osteoporosis: ≤ –2.5
Severe osteoporosis: ≤ –2.5 plus fragility fracture
🔹 Drug Therapy (Table 57-6: Prescription Drugs for Osteoporosis)
Drug Class Examples Indications Key Contraindications / Counseling
Cautions
Bisphosphonates Alendronate, Postmenopausal CrCl <30–35; esophageal Take with water AM,
Risedronate, women, men, GIOP stricture, inability to sit empty stomach,
Ibandronate, upright; hypocalcemia upright ≥30–60 min;
Zoledronic acid ONJ/atypical femur
fracture risk (rare)
SERMs Raloxifene Postmenopausal Hx VTE, pregnancy Hot flashes, leg
women, esp. with ↑ cramps; no
breast cancer risk endometrial cancer
risk
HRT (estrogen ± Conjugated Postmenopausal VTE, breast/endometrial Use lowest
progestin) estrogen, women with cancer, stroke, CHD dose/shortest
estradiol menopausal duration; combine
symptoms plus progestin if uterus
osteoporosis risk intact
Calcitonin Salmon calcitonin Last-line; short-term Hypersensitivity; limited Not first-line, possible
(nasal, inj) vertebral fracture efficacy ↑ cancer risk with
pain relief long-term use
Denosumab RANKL inhibitor Postmenopausal Hypocalcemia, Monitor Ca/Mg/PO₄;
(SC q6mo) osteoporosis, men at infections, ONJ, atypical rapid bone loss if
high fracture risk, femur fracture discontinued →
CKD transition to
bisphosphonate
Parathyroid Teriparatide, Severe OP, multiple Hypercalcemia, bone Daily SC; follow with
hormone analogs Abaloparatide fractures, failed other metastases, ↑ risk antiresorptive after
(anabolics) therapy osteosarcoma (avoid >2 stopping
yrs lifetime use)
Sclerostin inhibitor Romosozumab Severe CV risk (MI, stroke); Monthly SC; switch to
postmenopausal OP limited to 1 yr antiresorptive
afterward
✅ High-Yield Pearls
First-line: oral bisphosphonates unless contraindicated.
Denosumab: option for CKD patients (not renally cleared), but requires long-term continuation or transition.
Raloxifene: great if osteoporosis + breast cancer risk, but ↑ VTE.
Teriparatide/abaloparatide/romosozumab: for very high risk (T-score ≤ –3.5, multiple fractures).
HRT: only if menopausal symptoms warrant.
Calcium + vitamin D supplementation is foundational for all patients.
