Loading summary
Transcript29 lines
- [00:00]
A
Welcome back to Run the List, a medical education podcast in internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only and should not be understood as medical advice under any circumstances. Before we get to the show, a quick word on the sponsors for today's episode.
- [00:16]
B
Open Evidence is the premier AI powered medical information platform for physicians and medical students. It's like ChatGPT for anyone who practices clinical medicine. Whether you have a clinical question, a question that comes up during your literature review, if you have a question that comes up when you're trying to synthesize a topic you're going to teach, you can just go to openevidence.com enter your question and it'll synthesize the answer for you while also linking to those actual articles. It's an outstanding resource. Welcome back to Run the List. This is your host, Walker Red, and I'm here with a really special guest today, Brooke Madsen, who's an endocrinologist here at University of North Carolina, Chapel Hill. Fun fact is that Brooke and I actually grew up together and went to high school together. And so here we are from high school biology class together to both being at the University of North Carolina. And I'm thrilled to have her on here to talk about a really important endocrinology topic, which is osteoporosis. This is such a common disorder, it's something we want all of you to feel comfortable screening for, working up and managing as well. So, Brooke, thank you so much for being here.
- [01:30]
C
It's great to be here. Thank you so much for having me.
- [01:32]
B
Awesome. All right, so to introduce our case today, Brooke, let's imagine we're seeing a 65 year old woman with a history of hypothyroidism, which is well controlled on levothyroxine. And she's coming into our primary care clinic to review some test results from her Medicare wellness visit. This includes a review of her DEXA scan results. So I know that you've taught me previously. Often patients just from a practical, real world standpoint end up getting a DEXA scan at some point before age 65, whether it be through their OB GYN or their PCP. But what are the actual USP STF recommendations for who should undergo screening?
- [02:07]
C
The USPSTF recommends that women age 65 years and older be screened for osteoporosis by DEXA. If they do have additional risk factors for osteoporosis, which I think we'll get to in a little bit, then you can screen them earlier But I typically think of 65 as being the time where we start screening people.
- [02:25]
B
Awesome. So with that in mind, you know, DEXA results have always been a little bit confusing to me. You get different numbers back. So talk a little bit about what your approach is to, like, going through those numbers and how you interpret them. And I guess as well, like how you define osteopenia and osteoporosis.
- [02:40]
C
Sure. DEXA is an X ray based imaging test. And typically there are two images taken with three different sites measured. One image at the lumbar spine, and there are typically measurements from L1 to L4, and then another image at one of the hips with measurements of bone mineral density at the total hip and at the femoral neck as well. This may vary based on center institution, but this is a pretty standard DEXA approach. And you're right, the results do come back with a lot of numbers, including actual measurements of bone mineral density. You may see T scores, you may see Z scores. In postmenopausal women, we are almost always looking at the T score, which actually reflects the number of standard deviations either above or below bone mineral density is compared to a woman who's at peak bone mineral density. So this is a woman around age 30. And this provides us with a proxy for fracture risk. It's not perfect, but it gives us an idea of people's fracture risk. So as far as the T scores go, a T score between -1 and -2.4 would be considered in the osteopenia range, and a score of -2.5 and below, meaning more negative, would be considered in osteoporosis range. So a T score of -2.6, for example, and below that would be diagnostic of osteoporosis. Or you can throw all the T scores out the window and diagnose someone with osteoporosis if they've had a fragility fracture, which is a fracture typically low trauma, in which the average person might not break a bone. But if you fall and break a hip while playing pickleball, we would consider that to be a fragility fracture.
- [04:15]
B
So just to review that quickly, we would define osteopenia by T score of minus 1 to minus 2.4. And then osteoporosis would be a T score of minus 2.5 or more negative, or just as you mentioned, the fragility fracture. That's a really important point to keep in mind too. So let's just imagine the patient who we're following up with in clinic has not had one of those fragility fractures, and we get a results back and her lowest T score is minus 2.3 in the left femoral neck. How do you, from a practical standpoint, how do you kind of review these results with a patient when you're in the clinic? Brooke?
- [04:47]
C
I really like to pull up the DEXA images themselves and show the patient where bone marrow density is being measured. People always really like to look at their own images, so they usually think that's kind of fun. And then I explained that the DEXA scan allows us to measure bone mineral density in each of these areas that I'm showing them in the images, and that these measurements or the T scores are compared to a woman who's at peak bone density, which is, which is kind of an unfair comparison. But that's usually how I describe it. And then I'll go through the definitions of osteopenia and osteoporosis by T score, as we just talked about.
- [05:18]
B
And then so, you know, the next thing is, where do we go from here? And I know that the FRAX calculator y' all often use is actually a free and accessible tool that you can find just by googling it. And so when you sort of pull that up, like, what is the frax calculator giving you? What goes into it? Can you just tell us more about and what that entails?
- [05:36]
C
You know, the patient's next question is, well, what do these T scores mean? What does that mean about my long term risk for a fracture? And so the Franks calculator helps us quantify this and put a number to someone's 10 year risk of fracture. And it also helps us decide on treatment. So, as you mentioned, I will very frequently Google this in the room with the patient. You know, I turn the screen around so they can look at the calculator with me, and we go through the questions that the calculator asks. And by going through these questions, you're also getting a lot of the history that you need to sort of assess someone's risk for fracture. So some of these history questions that the FRAX calculator prompts you to ask include a history of prior fractures, specifically of fragility fractures like we talked about, a history of parental hip fracture, tobacco and alcohol use, steroid use, or whether they have other chronic diseases that are associated with osteoporosis. And these include things like type 1 diabetes, hyperthyroidism, hypogonadism, malnutrition or absorptive issues or chronic liver disease, in addition to some of the questions that the FRAX calculator prompts you to ask, I also ask about lifetime estrogen exposure. And I get at this by asking people about their age at menarche or when they had their first period, how many pregnancies they had and their age at menopause, as well as whether they received any hormone replacement therapy after menopause. And finally, I do ask whether people have had any height loss over time and if they have, it could signal that they may have occult vertebral compression fractures that they didn't know about. And so that might prompt me to get spine films or spine X rays to screen for those.
- [07:11]
B
Thank you for walking us through that. And so after we, you know, are with our patient, we plug all this data into the FRAX calculator, We basically see that since the patient has a 10 year risk of major osteoporotic fracture of 20%, she does meet criteria for treating her osteoporosis to help prevent fractures.
- [07:30]
C
That's right. And the FRAX calculator will give you actually two different outputs as far as the 10 year fracture risk goes. One is of major osteoporotic fracture and one is of hip fracture. Specifically, as you mentioned, our patient has a 10 year risk of a major osteoporotic fracture of 20%. And so she meets criteria for treatment for fracture prevention.
- [07:52]
B
Okay, perfect. Thanks for helping clarify that. And so once we're thinking about treatment, treatment, what goes into like initial choice and then we can talk about it by kind of risk of fracture.
- [08:01]
C
Absolutely. So the choice of initial therapy is dictated by a combination of things. I do like to think about their overall fracture risk. And this is based on the history that they told you, the T scores that they have on their dexa, any fracture history, and your overall clinical judgment based on putting all these factors together. And then as we'll talk about, a lot of the medications come in a lot of different forms. And so many times patients have strong preferences about what route of administration they'd like to receive their medication. So that helps us decide together too how to move forward with treatment.
- [08:32]
B
And so for patients that are at higher fracture risk, what are the, what's kind of standard of care for those patients?
- [08:38]
C
So these are patients that I would consider anabolic therapy for bone building therapy, as I think about it, or explain it to patients. Some of these, including teriparatide and Obama paratide, are self administered daily subcutaneous injections that people will take for 18 months or up to two years. Whereas another medicine called ramosuzumab, or avenad, is a monthly subcutaneous injection that's administered in clinic for 12 months. And the most important thing to remember is that all of these medications that I've just mentioned need to be followed by antiresorptive therapy, which we'll talk about as well, to prevent loss of bone that was built while people were on these agents. So it's important to think about the sequence of therapy and of medications that you're prescribing.
- [09:23]
B
Yeah, Brooke, that's a great pearl. Just so that doesn't get lost in the mix. When you are managing a patient and you gotten them on anabolic therapy, you need to know that you're going to be then transitioning and following up immediately with antiresorptive therapy as well. So for patients who, you know, you judge to be at lower risk overall, what sort of therapy do you use for those patients?
- [09:41]
C
For patients who are at lower risk, and, of course, they're at some risk because we're deciding to treat them. Sure. But if they're overall at lower risk, we typically consider antiresorptive therapy with either oral or IV bisphosphonates. This includes things like alendronate, which is a weekly pill, or zoledronic acid, or reclast, which is an annual infusion, or denosumab or Prolia. This is a subcutaneous injection that's administered every six months in clinic. And like the anabolic agents that we were talking about, one thing that's really important to remember with denosumab or prolia is that this has to be followed with a bisphosphonate as well. And this is to mitigate against the risk of rebound vertebral fractures with missed Prolia doses. So you just can't stop Prolia cold turkey. You always have to follow this with a bisphosphonate to consolidate that therapy.
- [10:29]
B
I know that some of these drugs do have rare side effects. Could you just speak to those? Because I'm sure patients ask you about them and how you kind of summarize that.
- [10:37]
C
Yeah, these are. These are really common questions that patients come to clinic with. You know, you read things on the Internet about things like osteonecrosis of the jaw and atypical femur fracture. These are really common questions that. That patients bring up. These are side effects that many of these drugs carry, but they are very rare. So. So I often reassure patients that they are very rare side effects and they're unlikely to experience.
- [10:59]
B
Thanks, Brooke. So we talked about treatment. We have we're comfortable with that. How do we think about monitoring? I know you want to be keeping in mind when you're going to get the next DEXA scan and how you're going to potentially get to to a holiday from therapy, that sort of thing. Could you summarize your approach to that?
- [11:15]
C
We typically monitor with DXA just like we screened with DEXA every two years. Or you could consider lengthening that time interval if it's not. If an updated DEXA is not going to change anything about your treatment plan or what you're doing in the immediate future. But many people are very interested in seeing how things are going and checking in on their DECA and their T scores. And people tend to get very caught up in these T scores. And of course, while we look at these and they're important and they're providing us with a proxy for fracture risk, I do like to emphasize that as long as we're not fracturing, that is the ultimate goal and generally we're doing okay. The ultimate goal of all of this is to prevent fracture. If people do happen to fracture while they're on therapy, that might prompt you to consider escalating to a more aggressive therapy than the one that they were currently on. And it's always important to remind patients that the goal is to get to a holiday or a break from medication. No one's on these medications indefinitely, forever. So we're always trying to get to a break. And this is to decrease the risk of these rare side effects that we talked about earlier.
- [12:14]
B
Sure. And I think it's such an important point for us in medicine, first of all, to keep in mind we're trying to treat something, but really what are we practically trying to do, which is prevent fractures and helping remind patients of that and contextualize it for them is probably really reassuring and helpful. And so before we finish up with some take home points, I just want to ask you kind of what are the keys for just lifestyle and maybe less sophisticated medications, but what are things that you need to make sure patients are doing in terms of their lifestyle and sort of from a prevention perspective as well?
- [12:41]
C
These are really common questions from patients too. And first I think about calcium and vitamin D intake. The recommendation for calcium intake is 1200 milligrams per day for postmenopausal women. And it's best if you can get all of this in your diet, but if you can't get it all in diet, you can supplement up to 1200mg daily. I like to share The International Osteoporosis Foundation's calcium calculator with people. It's a free tool online. There's a really nice website where people can go through and estimate how many servings of each of these different types of food they're getting throughout the week and spits out a number that gives you an idea of your average daily calcium intake. As far as vitamin D goes, we aim for a vitamin D level between 30 and 50 and not a medication, but making sure we're doing everything we can to prevent falls. So thinking about the usual primary care fall prevention things. Getting rid of throw rugs or things that might increase risk of falls at home, eliminating medications as able that can increase fall risk. So. So doing everything you can to prevent the fall. And then finally, we always emphasize the importance of strength training and of exercise. Many people when asked, they'll say, oh, I walk five miles a day and that that's great. I'm not in the business of telling people not to walk, but it's really important that people are doing strength training and weightlifting as well. One of my favorite resources to share with patients is a physical therapist on YouTube named Margaret Martin. She has a fabulous YouTube channel that I like to share with people to give them ideas of how to start with some of the strength training.
- [14:05]
B
So helpful. So calcium, vitamin D, all the fall prevention things and not just exercise, but even sharing some specific resources for patients to give them ideas of how they can get some strength training in as well. Let's go ahead and just have you summarize what the three most important takeaways are for our listeners.
- [14:21]
C
First, in in treatment naive patients, the FRAX calculator can be used to estimate someone's 10 year risk of fracture as well as to help you decide whether treatment is indicated if the T scores are in the osteopenia range. Second, endocrinology is always available for help for evaluation of secondary causes of osteoporosis as well as consideration for some of these anabolic therapies that are not typically prescribed in primary care settings, such as the ones I mentioned earlier. And then last but not least, part of preventing the fracture is preventing the fall in the first place. And you can do this by engaging in resistance training and strength training to build strength and improve balance.
- [14:57]
B
Excellent. Thank you so much for summarizing all that and thank you to our listeners for tuning in. We're gonna have Brooke back for another endocrine related episode soon, so join us then. Thanks for listening.
- [15:18]
A
Some content from this episode was generated with the assistance of artificial intelligence.