Osteoporosis with Dr. Leila Khan

Question 1:

(Dr. Wardrop): I can ask the first question to Dr. Khan. So for the internal medicine residents, medical students, and PCPs, what is osteoporosis and how is it diagnosed? Answer: (Dr. Khan):

Case (Dania): Thank you for sharing that Dr Khan. I wanted to start off by presenting a case that I recently encountered in the primary care clinic. So this was a 57-year-old lady with past medical history of hypertension, type 2 diabetes, premature menopause, and celiac disease presented to the primary care clinic for a routine physical exam visit. She reports historical height loss of 3 inches, but she never had a fracture before. She takes calcium, vitamin D. She reports that her father broke his hip in his 80s. She does not smoke or drink alcohol.

Question 3 (Dania): Would you order a DXA scan to screen for osteoporosis in this patient? Answer: (Dr. Khan) : Yes, 3-inch height loss is very significant. I usually order DXA scans:

Question 2 (Dania): So, given the patient’s history of height loss and other risk factors, her PCP orders a screening DXA scan which revealed a lowest T-score of -2.5 at the spine. What additional work-up would you order for this patient? Answer: (Dr. Khan) :

Question 3 (Dania): The PCP decides to calculate her patient’s 10-year risk of fracture using the online FRAX calculator, which results in a 7.5% 10-year risk of major osteoporotic fracture and 0.8% 10-year risk of hip fracture. How do you decide whether to initiate pharmacologic treatment? Answer: (Dr. Khan) : I usually try to risk-stratify patients to decide on treatment strategies.

Question 4 (Arjun): What are some medical options for osteoporosis?
Answer: (Dr. Khan):

I usually start everyone on IV zoledronic acid (reclast) or denosumab (prolia) because the oral bisphosphonates are associated with significant reflux symptoms. But if a patient prefers oral medications, we can either do a once daily, once weekly, or once monthly regimen of oral bisphosphonates.

For patients who have severe osteoporosis, are unable to tolerate bisphosphonates, or have an eGFR<30, other potential alternatives include anabolic agents like teriparatide and romosozumab.

A recent clinical practice article was published in NEJM which nicely summarizes all the pharmacological treatments available[1].

Question 5 (Arjun): What is the general monitoring for these patients?
Answer: (Dr. Khan):

Question 6 (Dania): How long do you generally treat patients with osteoporosis? Answer : (Dr. Khan)

Question 7 (Dania): How does osteoporosis in male patients differ than in females? Answer : (Dr. Khan): Osteoporosis is generally much less prevalent among men compared to women, primarily because they have higher peak bone mass, larger bone size, and do not experience the abrupt drop in estrogen that women experience around menopause. Men have a more gradual decrease in their estrogen levels, and this is usually more pronounced after the age of 70. This is why the screening guidelines are usually slightly different for men than for women, as we discussed previously. But once osteoporosis is diagnosed in a male patient, treatment and monitoring guidelines are pretty similar to those followed for women. But unfortunately, males to be undertreated as compared to females. In fact, a recent study showed that males were less likely to be treated with osteoporosis medications following a hip fracture, and had higher rates of all-cause mortality[2].

Wrap-up:

(Dr. Wardrop) What are your final take home points for all the generalists and PCPs for osteoporosis screening and treatment? Answer: (Dr. Khan):

Closing (Dr. Wardrop)

References: