INVICTUS LQ#11 INTERNAL MEDICINE: OSTEOPOROSIS

COMMENTS
NO
QUESTION
.
In the Philippines, what is the
prevalence of osteoporosis in
menopausal women?
1 above was estimated to be 160 per 10 000. Based on this
There is a difference between
epidemiology between distal and
hip fractures. The former,
increases in frequency before age
60 and plateauing by age 60, with
2 only modest age-related increase
thereafter. The latter, incidence
rates double every 5 years after
age 70. This is because ____.
CHOICES AND ANSWER RATIO AND
REFERENCE
A. 8% The current population of the Philippines is 96 million. Presently https://www.iofbon
B. 11.23% the number of people over 60 years of age is between 6.0 to 6.7% ehealth.org/sites/d
C. 15% (6 million) of the total population. It is expected to increase to 110 efault/files/PDFs/A
A. 19.8% million by 2020 and 146 million by 2050 and of this, 8.8% (9 udit
million) and 17.9% (26 million) will be more than the age of 60 %20Asia/Asian_re
years. gional_audit_Phili
                                                                            ppines.pdf
The prevalence of hip fractures in individuals over 70 years and
prevalence rate, it is estimated that there were about 28 000 hip
fractures in 2003 and 34 000 in 2005. The numbers are expected
to reach 65 000 by the year 2020 and almost 175 000 by the year
2050.
A recent survey of urban postmenopausal women using
ultrasound showed a 19.8% prevalence of osteoporosis, with
age and lower body weight being major risk factors.
A. Related to the way they fall The epidemiology of fractures follows the trend for loss of bone Harrison’s 19th ed
B. Microstructure of long bones density, with exponential increases in both hip and vertebral p2488
C. fractures with age. Fractures of the distal radius have a
D. Because of physical activities of somewhat different epidemiology, increasing in frequency
older people before age 50 and plateauing by age 60, with only a modest
age-related increase thereafter. In contrast, incidence rates for
hip fractures double every 5 years after age 70 (Fig. 425-1).
This distinct epidemiology may be related to the way the
elderly fall as they age, with fewer falls on an outstretched
hand and more falls directly on the hip.

WHO defined osteoporosis by: A. Fracture Risk WHO defines Osteoporosis as bone density that falls 2.5 SD WHO on
B. Bone Density below the mean for young, healthy adults of the same sex. Osteoporosis
3
C. Bone Strength Also referred to a T-score of -2.5.
D. Bone Architecture
Which of the ff is true of the A. For Bone Maturation In adults, bone remodeling, not modeling, is the principal metabolic Harrison’s 19th ed
function of bone remodeling? B. For linear growth of bone skeletal process. Bone remodeling has two primary functions: (1) Chap 425 p. 2489
C. For adaptability of bone to repair microdamage within the skeleton to maintain skeletal
4
D. For maintenance of serum strength and ensure the relative youth of the skeleton and (2) to
calcium supply calcium from the skeleton to maintain  serum
calcium.
This cytokine is responsible for A. LRP5 The cytokine responsible for communication between the Harrison’s 19th ed
communication between B. PTHrP osteoblasts, other marrow cells, and osteoclasts is RANK ligand p2490
5
osteoblasts, other marrow cells C. RANKL (RANKL; receptor activator of nuclear factor-κB [NF-κB]).
and osteoclasts? D. Sclerostin
6 Activity of this favours bone A. Betacatenin With LRP5 and Wnt activation, beta-catenin is translocated to Harrison’s 19th ed
resorption: B. PTHrP the nucleus, allowing stimulation of osteoblast formation, p2489 - 2490
C. RANKL activation, and life span as well as suppression of osteoclast
D. OPG activity, thereby increasing bone formation.

Total daily calcium intake
detrimental to skeleton:
7 C.
8 Vitamin D deficiency is common
among which of the following
groups?
Proresorptive and calciotropic Anabolic or antiresorptive factors
factors
 1,25(OH)2 vitamin D3  Estrogens
 PTH  calcitonin
 PTHrP  BMP 2/4
 PGE2  TGF-
 IL-1,  TPO
 IL-6  IL-17
 TNF  PDGF
 prolactin  calcium
 corticosteroids
 oncostatin M
 LIF
Bone remodeling also is regulated by several circulating
hormones, including estrogens, androgens, vitamin D, and
parathyroid hormone (PTH), as well as locally produced growth
factors such as IGF-I and immunoreactive growth hormone II (IGH-
II), transforming growth factor β (TGF-β), parathyroid hormone–
related peptide (PTHrP), interleukins (ILs), prostaglandins, and
members of the tumor necrosis factor (TNF) superfamily. These
factors primarily modulate the rate at which new remodeling sites
are activated, a process that results initially in bone resorption by
osteoclasts followed by a period of repair during which new bone
tissue is synthesized by osteoblasts. The cytokine responsible for
communication between the osteoblasts, other marrow cells, and
osteoclasts is RANK ligand (RANKL; receptor activator of nuclear
factor-κB [NF-κB]). RANKL, a member of the TNF family, is
secreted by osteoblasts and certain cells of the immune system
(Chap. 423). The osteoclast receptor for this protein is referred to
as RANK. Activation of RANK by RANKL is a final common
pathway in osteoclast development, activation, and life span.
A humoral decoy for RANKL, also secreted by osteoblasts, is
osteoprotegerin. Modulation of osteoclast recruitment and activity
appears to be related to the interplay among these three factors. It
appears that estrogens are pivotal in modulating secretion of
osteoprotegerin (OPG) and perhaps also RANKL. Additional
influences include nutrition (particularly calcium intake) and
physical activity level.
A. <375 Total daily calcium intakes <400 mg are detrimental to the skeleton, Harrison’s
B. <400 and intakes in the range of 600–800 mg, which is about the
<500 average
D. <1000 intake among adults in the United States, are also probably
suboptimal.
A. Dark-skinned surfers However, there is accumulating evidence that vitamin D Harrisons page
B. Liver cirrhosis patients insufficiency may be more prevalent than previously thought， 2491
C. Those with acute gastroenteritis particularly among individuals at increased risk such as the elderly;
D. Those with UTI those living in northern latitudes; and individuals with poor
nutrition, malabsorption, or chronic liver or renal disease.
 Dark-skinned individuals are also at high risk of vitamin D
deficiency

Which statement is correct? A. Risk fracture is higher in rural
communities
B. Physically active people have
higher bone mass
9 C. More active people are more
likely to fall thus higher fracture
risk
Intermittent high levels of physical
activity is found to be beneficial
A – fracture risk is lower in rural communities Harrisons and
Previous Compi
C – more active individuals are less likely to fall -> better
coordination
D – epidemiologic data supports the beneficial effects on the
skeleton of chronic high levels of activity

Which of the following is true
regarding the effect of cigarette
consumption on the bone:
10
A. Activation Of Osteoclasts The use of cigarettes over a long period has detrimental effects on Harrison’s 19th
B. Decreases Calcium Absorption bone mass. These effects may be mediated directly by toxic Edition, Chapter
C. Increased Renal Calcium Excretion effects on osteoblasts or indirectly by modifying estrogen 425, p. 2493
D. Modify Estrogen Metabolism metabolism. On average, cigarette smokers reach menopause 1–2
years earlier than the general population. Cigarette smoking also
produces secondary effects that can modulate skeletal status,
including intercurrent respiratory and other illnesses, frailty,
decreased exercise, poor nutrition, and the need for additional
medications (e.g., glucocorticoids for lung disease).

The most common medications A. Anti-convulsant Glucocorticoids are the most common cause of medication-induced Harrison’s 19th
that can cause osteoporosis are? B. Anti-cancer drugs osteoporosis Edition, p. 2492
11
C. Glucocorticoids
D. Thyroid hormone

A 50 year old diabetic female A. Atorvastatin More recently a variety of agents have been implicated in Harrison’s 19th
consulted for cessation of menses B. Enalapril increased bone loss and fractures. These include selective edition Chapter
and hot flashes. She is taking C. Metformin serotonin reuptake inhibitors, proton pump inhibitors, and 425 page 2492
Enalapril 10 mg 1x a day, D. Omeprazole Thiazolidinediones (pioglitazone and rosiglitazone) under Medications
Atorvastatin 40 mg 1x a day, A. Statin
12 Metformin 500 mg 2x a day. She is B. ACE inhibitor
often taking Omeprazole 20 mg 1- C. Biguanide class
2x a day for recurrent hyperacidity D. PPI
and bloating. Which of her
medications increases her risk for
osteoporosis?

13 In the above patient, which of the A. Plain radiography A. INCORRECT Not included in the noninvasive techniques Harrison’s 19th Ed
following imaging should be used B. High resolution CT scan for estimating skeletal mass or density. (DXA, SXA, page 2493
to measure the bone mass density C. Magnetic Resonance Imaging quantitative CT and US)
D. Dual energy X-ray absorptiometry B. INCORRECT Used to measure the spine and the hip, but
is rarely used clinically, in part because of higher radiation
exposure and cost.
C. INCORRECT Can be used in research settings to obtain
some architectural information on the forearm and
perhaps the hip.
A. CORRECT A highly accurate x-ray technique that has
become the standard of measuring bone density. She also

Vertebral imaging is used to screen
vertebral fractures in which of the
14 following?
Bone manifestation (mejo not sure
exactly how it was stated) of
osteoporosis with the most
morbidity is
15
Based on the 2014 National
Osteoporosis Foundation
Clinician’s Guide to the prevention
and Treatment of Osteoporosis,
bone density testing is indicated in
16
17 Use of biomarker:
passes for the indications for bone density testing in table
425-2.
A. Any age with T score <1 SD on DXA Ht loss of >2.5-3.8 cm is an indication for VFA by DXA as is the Table 425-3
B. Menopausal women >60 yo presence of kyphosis and back pain harrisons
C. men /women >70 yo
D. 69 yo c loss of height and back
pain
A. Bone cancer Hip fractures are associated with a high incidence of deep vein Harrisons p 2488
B. Hip fracture thrombosis and pulmonary embolism (20–50%) and
C. Fracture of long bone a mortality rate between 5 and 20% during the year after surgery.
A. Vertebral fracture There is also significant morbidity, with about 20–40% of survivors
requiring long-term care, and many who are unable to function as
they
did before the fracture.
A. Adults who have fracture before age A - dapat “after age 50” Harrisons 19ed,
50 B - dapat “65 and older” p.2493
B. Women 60 and above without risk C - POSSIBLE since smoking is a risk factor (p.2489 and table
factors 425-1) and patient is within the category of “men age 50-69 with
C. 50y/o man with 20pack year smoking clinical risk factors” (PLEASE CHECK)
history D - patient with a condition (arthritis) and on chronic steroid. Was
D. 45 y/o arthritic patient on chronic the answer on the previous whis
steroids with T score of 1
Table 425-2 Indications for Bone density Testing
● Women age 65 and older and men age 70 and older,
regardless of clinical risk factors
● Younger menopausal women, women in the menopausal
transition and men age 50-69 with clinical risk factors
for fracture
● Adults who have fracture after age 50
Adults with a condition (e.g. rheumatoid arthritis) or taking a
medication (e.g. glucocorticoids in a daily dose >/=5mg prednisone
or equivalent for >/=3months) associated with low bone mass or
bone loss
A. Detect presence of bone cancer Biochemical markers of bone turnover may: Past question
B. Identify fracture risk independent 1. PREDICT RISK OF FRACTURE INDEPENDENTLY OF
of BMD BONE DENSITY.
C. Determine duration of drug holiday 2. Predict extent of fracture risk reduction when repeated
with accuracy after 3-6 months of treatment with FDA approved
D. Can differentiate bone loss from therapies
osteoporosis &from 3. Predict magnitude of BMD increases with FDA approved
hyperparathyroidism therapies
4. Predict rapidity of bone less
5. Help determine adequacy of patient compliance and
persistence with osteoporosis therapy
 ● Help determine duration of “drug holiday”

Which of the following is true of A. Currently, it is no longer of clinical
Bone Biopsy? value
B. It is a very important diagnostic tool
in the evaluation of other metabolic
disorders
18 C. Determination of the rate of
remodeling is aided with use of radio
iodide labeling
D. Its clinical use has been largely
replaced by the current use of a
combination of non invasive tests
Tetracycline labeling of the skeleton allows determination of the Harrisons 2949
rate of remodeling as well as evaluation for other metabolic bone
diseases. The current use of BMD tests, in combination with
hormonal
evaluation and biochemical markers of bone remodeling, has
largely replaced the clinical use of bone biopsy, although it remains
an important tool in clinical research and assessment of
mechanism
of action of medication for osteoporosis.

Which of the following conditions A. Hypoparathyroidism Hypoparathyroidism, malabsorption, and osteomalacia will manifest Harrisons
with abnormal bone mineral B. Malignancy with low serum and urine calcium
19 density and fracture will manifest C. Malabsorption
with elevated serum and urine
calcium? D. Osteomalacia

In the presence of hypercalcemia, A. Urine Calcium In the presence of hypercalcemia, a serum PTH level Harrisons pg 2494
what other test should be done? B. PTH differentiates between hyperparathyroidism (PTH↑) and malignancy
20 C. TSH (PTH↓), and a high PTHrP level can help document the presence
of humoral hypercalcemia of malignancy
D. Serum magnesium

Which of the following is true
regarding osteoporotic fractures
21
A. Majority of vertebral fracture may be
managed conservatively
B. Majority of vertebral fracture present
with sudden onset of back pain
C. In general complete bed rest is
advocated until severe pain resolves
usually 6-10 weeks
D. Psychotherapy and
antidepressants may be needed
for multiple vertebral fracture
Multiple vertebral fractures often are associated with 2495
psychological symptoms; this is not always appreciated. The
changes in body configuration and back pain can lead to marked Harrisons
loss of self-image and a secondary depression. Altered balance,
precipitated by the kyphosis and the anterior movement of the
body’s center of gravity, leads to a fear of falling, a consequent
tendency to remain indoors, and the onset of social isolation.
These symptoms sometimes can be alleviated by family support
and/or psychotherapy. Medication may be necessary when
depressive features are present.

One of the following is a bone A. Osteogenesis Imperfecta A. The disease osteogenesis imperfecta is caused by https://www.ncbi.nl
disease NOT associated with B. Osteoporosis abnormalities in the collagen molecule that make the matrix m.nih.gov/books/N
bnormal bone matrix formationa C. Mucopolysaccharidosis weak and can lead to multiple fractures. BK45504/
B. osteopetrosis, the bones are too dense because of failure of
D. Osteoid Osteoma osteoclast formation or function.
22 C. Answer. A lysosomal disease. Mucopolysaccharidosis Page 432e-1
type I is an autosomal recessive disorder caused by
deficiency of α-L-iduronidase. Harrison

An osteoid osteoma is a benign bone tumor that arises from

osteoblasts

23 Recommended daily dose of A. 200 IU Institute of Medicine recommends daily intakes of 200 IU for adults Harrison’s pg 2497
 Vitamin D for those with B. 400 IU
osteoporosis or increased risk of C. 600 IU <50 years of age, 400 IU for those 50–70 years, and 600 IU for
osteoporosis is those >70 years
D. ≥1000 IU For those with osteoporosis or those at risk of osteoporosis, 1000–
2000 IU/d can usually maintain serum 25(OH)D above 30 ng/mL.

Which of the following is true A. Weight-bearing exercises results in A. Meta-analyses of studies performed in postmenopausal Harrison’s page
regarding exercise? maximal gain in bone mass women indicate that weight-bearing exercise helps prevent 2497
B. Swimming and water exercises bone loss but does not appear to result in substantial gain
decreases bone loss substantially of bone mass
C. The end-point of exercise is the B. Even women who cannot walk benefit from swimming or water
reduction in the risk of fall exercises, not so much for the effects on bone, which are quite
24
minimal, but because of effects on muscle
D. Exercise allows elderly to attain C. TRUE
maximal genetically determined peak D. Exercise in young individuals increases the likelihood that
in bone mass they will attain the maximal genetically determined peak bone
mass

Which of the following statements is
True regarding estrogens in the
management of patients with
osteoporosis?
25
A. Estrogen is more efficacious when
administered subcutaneously
B. Estrogen increase RANKL and
decreases OPG
C. The beneficial effects of estrogen if
started early is sustained until 10
years after discontinuation
D. The combination Estrogen-
Progestin will increase the risk for
myocardial infarction and stroke
A - Estrogens are efficacious when administered orally or Pg 2498 Harrisons
transdermally.
B - These actions include decreasing RANKL production and
increasing OPG production by osteoblasts.
C - The beneficial effect of estrogen is greatest among those who
start replacement early and continue the treatment; the benefit
declines after discontinuation to the extent that there is no residual
protective effect against fracture by 10 years after discontinuation.
D - the WHI showed that combined estrogen-progestin treatment
increased risk of fatal and nonfatal myocardial infarction by ~29%,
confirming data from the HERS study. Other important relative risks
included a 40% increase in stroke, a 100% increase in venous
thromboembolic disease, and a 26% increase in risk of breast
cancer.

In women, daily progestins or A. Breast ca In women with a uterus, daily progestin or cyclical progestins at
progestin at least 12days per month B. Colon ca least 12 days per month are prescribed in combination with
26 in combination with estrogen is C. Ovarian ca estrogens to reduce the risk of uterine cancer.
prescribed to reduce the risk D. Uterine ca
of_____.

Treatment for menopausal woman A. Raloxifen Ratio:  source: harrisons

complaining of hot flushes B. Tamoxifen A. increases occurence of hot flushes p2499
C. Bazedoxidene/conjugated B. no mention
estrogen  C. bazedoxifene protect uterine tissue from the effect of
27
D. denosumab estrogen and makes it possible to avoid taking progestin,
while using an estrogen primarily for control of menopausal
symptoms
D. no mention
 Which of the ff is true of BMD A. Biomarkers are not indicated and A. BMD may be used Harrisons
monitoring: are, thus, not useful B. Medication induced increments may require several years to
B. BMD should be repeated at >2 produce changes of this magnitude (if they do at all).
years Consequently, it can be argued that BMD should be repeated
C. A change in BMD should prompt a at intervals >2 years.
28
change in Medical Regimen C. Only significant BMD reductions should prompt a change in
D. In BMD, the Spine is preferred medical regimen, because it is expected that many individuals
will not show responses greater than the detection limits of the
current measurement techniques.
D. The Hip is preferred site

Drug used in the treatment of A. Estrogen Calcitonin might have an analgesic effect on bone pain, Pg. 2501
osteoporosis that has value in pain B. Tamoxifen both in the subcutaneous and possibly the nasal form.
29
relief? C. Calcitonin
D. Denosumab

True about steroid use: A. Increased risk of fracture within 1 A. Bone loss is more rapid during the early months Harrisons
year of treatment, and trabecular bone is affected more severely than
B. Topical steroid use does not reduce corticalbone. As a result, fractures have been shown to increase And
bone mass within 3 months of steroid treatment.
C. Affects cortex more than trabecular https://commons.p
bone B. One study of 42 adults found a statistically significant acificu.edu/cgi/vie
30 D. Check urine Calcium for decrease in bone mineral density in patients using wcontent.cgi?
monitoring moderate or high potency topical corticosteroids. article=1518&cont
C. Although it is generally believed that GC affect trabecular ext=pa
bone more than cortical bone.
D. Laboratory evaluation should include an assessment of http://adc.bmj.com
24-h urinary calcium. /content/archdischi
ld/87/2/93.full.pdf

Which of the following is true of A. Acute diseases that increase the risk A. WRONG. Should be chronic diseases Harrison’s
falls? of falling or frailty, including B. WRONG. Women have higher rate of falls than men Chapter 425,
dementia, Parkinson’s disease, and C. CORRECT. pages
multiple sclerosis, also increase
fracture risk. A. WRONG. Less than 50 years old.
31 B. Men have higher rate of falls then
women
C. 5% of falls lead to fracture
D. Colles fracture is more common after
65 y.o

Which of the following is A. Thin individual A (Thin individuals tend to have lower bone mass density), C Harrison’s
associated with the least risk for B. Falling on soft ground (Falling from a standing position results in higher-impact falls), and Chapter 425
falls? C. Falling from a standing position D are associated with increased risk for falls.
32
D. Diabetic with peripheral neuropathy

33 Extremely slow or fast heart rates A. Anxiety attacks or Fear Cardiac arrhythmias produce extremely slow or fast heart rates Functional
 in the elderly is commonly cause that can lead to cerebral hypoperfusion and dizziness. Carotid Performance in
by: B. Antihypertensive medication sinus node disease presents with syncope and is brought on by Older Adults 3rd
C. Carotid sinus node dysfunction such common activities as turning the head to one side as if Ed.
looking over one’s shoulder or hyperextending the neck and head
D. Electrolyte imbalance backward. page 198

Review from Harrisons: Carotid sinus hypersensitivity is one of the

etiologies of sinus node dysfunction causing arrhythmia.

The following environmental A. Bedrails Bedrails may actually increase the risk of falling as a result of Internet :)
factors may increase the risk of B. Rails in the cr attempts by the older adult to leave the bed without lowering the
falling C. Stairs with handrails rails.
34
.
A. Thin carpet

When walking on uneven ground, A. Contrast sensitivity Depth perception is the visual ability to perceive the world in a 3 internet
which visual change is responsible B. Dark Adjustment dimensional plane, the loss of depth perception can lead to
35 for the maintenance of balance C. Depth perception disturbance of balance and coordination
D. Visual Acuity

When walking on uneven ground,
which visual change is responsible
for the maintenance of balance
(Repeat Question)
36
A. Contrast sensitivity The ability of the human eye to see in three dimensions and judge https://www.rebuil
B. Dark Adjustment the distance of an object is called depth perception. It takes both dyourvision.com/bl
C. Depth perception eyes working in sync to look at an object and develop an informed og/interesting-
D. Visual Acuity idea about an object, like its size or how far away it is. Your two vision-facts/depth-
eyes look at the object from different angles and that information is perception-
processed in your brain to form a single image. important/
Depth perception is also responsible for forming an idea of the
length, width and height of an object. The best part of depth
perception is that it takes previous knowledge and uses it to
understand the world around us. It usually occurs unconsciously
and very quickly. It happens thousands of times a day without you
ever realizing that you are using it.

An indication of Bone density A. Men age 70 and older Consider BMD testing in the following individuals Table 425-2 of
testing : B. Post menopausal women  Women age 65 and men age 70 and older regardless of Harrison’s page
C. Adults with osteoporosis clinical risk factors 2493
D. Adults with fractures before 50 y.o  YOUNGER postmenopausal women
37
 Adults who have fractures AFTER age 50
 Adults with a condition or taking a medication
(glucocorticoids >3 months) assoc. With low bone mass or
bone loss

38 In a patient with low bone mass, A. Malignancy ROUTINE LABORATORY EVALUATION Harrisons 19th
lab findings of increased PTH and B. Osteomalacia There is no established algorithm for the evaluation of women who page 2494
hypercalcemia would signify which C. Primary Hyperparathyroidism present with osteoporosis. A general evaluation that includes
 of the following?
39 Which of the ff should avoided in th
mgmt of px with vertebral
compression fractures?
D. Secondary Hyperparathyroidism complete blood count, serum and 24-h urine calcium, renal and
hepatic function tests, and a 25(OH)D level is useful for identifying
selected secondary causes of low bone mass, particularly for
women with fractures or very low Z-scores. An elevated serum
calcium level suggests hyperparathyroidism or malignancy,
whereas a reduced serum calcium level may reflect malnutrition
and osteomalacia. In the presence of hypercalcemia, a serum PTH
level differentiates between hyperparathyroidism (PTH↑) and
malignancy (PTH↓), and a high PTHrP level can help document the
presence of humoral hypercalcemia of malignancy (Chap. 424). A
low urine calcium (<50 mg/24 h) suggests osteomalacia,
malnutrition, or malabsorption; a high urine calcium (>300 mg/24 h)
is indicative of hypercalciuria and must be investigated further.
Hypercalciuria occurs primarily in three situations: (1) a renal
calcium leak, which is more common in males with osteoporosis;
(2) absorptive hypercalciuria, which can be idiopathic or associated
with increased 1,25(OH)2D in granulomatous disease; or (3)
hematologic malignancies or conditions associated with excessive
bone turnover such as Paget’s disease, hyperparathyroidism, and
hyperthyroidism. Renal hypercalciuria is treated with thiazide
diuretics, which lower urine calcium and help improve calcium
economy.
Additional:
Presence of a low bone mass suggests that the hyperparathyroid is
a secondary effect
A. Calcitonin A. Only ~25–30% of vertebral compression fractures present PAge 2495
B. Delayed immobilization with sudden-onset back pain. For acutely symptomatic harrisons IM 19th
C. Soft style brace fractures, treatment with analgesics is required, ed
D. NSAIDs including nonsteroidal antiinflammatory
agents(Choice D) and/or acetaminophen, sometimes
with the addition of a narcotic agent (codeine or
oxycodone). A few small, randomized clinical trials
suggest that calcitonin(Choice A) may reduce pain
related to acute vertebral compression fracture.
Percutaneous injection of artificial cement
(polymethylmethacrylate) into the vertebral body
(vertebroplasty or kyphoplasty) may offer significant
immediate pain relief in patients with severe pain from
acute or subacute vertebral fractures. Safety concerns
include extravasation of cement with neurologic sequelae
and increased risk of fracture in neighboring vertebrae
due to mechanical rigidity of the treated bone. Exactly
which patients are the optimal candidates for this
procedure remains unknown. Short periods of bed rest
may be helpful for pain management, but in general, early
mobilization is recommended(not delayed, Choice B)
because it helps prevent further bone loss associated with
immobilization. Occasionally, use of a soft elastic-style
 brace may facilitate earlier mobilization(Choice C).
Muscle spasms often occur with acute compression
fractures and can be treated with muscle relaxants and
heat treatments.

The usual side effect of calcium A. Diarrhea Although side effects from supplemental calcium are minimal Harrisons
supplementation is: B. Eructation (eructation and constipation mostly with carbonate salts),
40 C. Palpitation individuals with a history of kidney stones should have a 24-h urine
D. D. Urinary stones calcium determination before starting increased calcium to avoid
significant hypercalciuria.

Which of the following will reduce 1. Smoking cessation Answer: A (1,2,3)

the risk for osteoporotic fractures? 2. Adjust timing for nighttime
diuretic use
41 3. Medications review
4. Thyroid hormone replacement

Increased risk for fall due to 1. Dementia Answer: E. all of the above Harrison’s
osteoporosis. 2. Multiple Sclerosis ratio: Elderly patients with neurologic impairment (e.g., stroke, Principle of
3. Poor Eyesight Parkinson’s disease, Alzheimer’s disease) are particularly at risk of Internal Medicine
4. Physical Conditioning falling and require specialized supervision and care
42
Treatment for impaired vision is recommended, particularly a
problem with depth perception, which is specifically associated with
increased risk

True about fracture 1. Hip fractures doesn’t always require Hip fractures almost always require surgical repair if the Harrison’s
surgical repair patient is to become ambulatory again Principle of
2. Vertebral fractures usually needs Internal Medicine:
hospitalization Vertebral fractures rarely require hospitalization but are Chapter 425
3. Osteoporosis fractures usually associated with long-term morbidity and a slight increase in Osteoporosis
secludes humerus mortality rates, primarily related to pulmonary disease. Multiple
4. Thoracic vertebral fracture is vertebral fractures lead to height loss (often of several inches),
associated with restrictive lung kyphosis, and secondary pain and discomfort related to altered
disease biomechanics of the
43
back.

Fractures of other sites, such as pelvis, proximal humerus, and

wrist, would be tantamount to an osteoporosis diagnosis in the
presence of low BMD.

Multiple thoracic vertebral fractures may be associated with

restrictive lung disease symptoms and increased pulmonary
infections.

44 The following conditions increases 1. Rheumatoid arthritis Ans: B (1,3) Source: Harrison’s
the risk of fracture 2. Active lifestyle Ratio: Internal Medicine
3. Malabsorption syndrome Chronic diseases with inflammatory components that increases 19th Edition, page
 4. High fat diet skeletal remodeling such as rheumatoid arthritis, increase the risk 2489
of osteoporosis, as do diseases asociated with malabsorption.

Which of the following 1. Ibandronate- may be given annually Answer: D or B Source:

biphosphanates is correctly
matched with its description:
45
2. Etidronate- not FDA approved for
treatment of osteoporosis
3. Residronate- foos should be avoided
up to 1 hour post dose
4. Zoledronic acid- postdose
symptoms of fever, myalgias,
arthralgias, headache
Ratio: Harrison’s
1. Ibandronate – Wrong, ibandronate doses of 150 mg/month PO principles of
or 3 mg every 3 months IV had greater effects on turnover and internal Medicine
bone mass than did 2.5 mg/d. 19th ed. p 2499
2. Etidronate - Corect, was the first bisphosphonate to be
approved, initially for use in Paget’s disease and
hypercalcemia. This agent has also been used in osteoporosis
trials of smaller magnitude than those performed for
alendronate and risedronate but is not approved by the FDA
for treatment of osteoporosis.
3. Residronate – Wrong, Patients should take risedronate with a
full glass of plain water to facilitate delivery to the stomach and
should not lie down for 30 min after taking the drug. The
incidence of gastrointestinal side effects in trials with
risedronate was similar to that of placebo. A new preparation,
which allows risedronate to be taken with food, was recently
approved.
4. Zoledronic acid -Correct, In the treated population, there was
an increased risk of transient postdose symptoms (acute-
phase reaction) manifested by fever, arthralgia, myalgias, and
headache. The symptoms usually last less than 48 hours.

Osteonecrosis of the jaw (ONJ) is 1. Estrogen-Progesting complex ANS: C Harrisons

seen in 2. Denusomab 1.INCORRECT
3. 2. CORRECT. Through these actions on the osteoclast,
4. Bisphospanates denosumab induces potent antiresorptive action, as assessed
biochemically and histomorphometrically, and may contribute to the
occurrence of ONJ.
46
3. INCORRECT
4.CORRECT. Recently there has been concern about two potential
side effects associated with bisphosphonate use. The first is
osteonecrosis of the jaw (ONJ).

47 Agent associated with increased
risk of cardiovascular events:
1. Strontium An increase in risk of cardiovascular disease has also been Ref: harrisons
2. Alendronate associated with use of strontium, such that the EMA has restricted 19th, page 2503
3. Progestin its use at present. and page 2498
4. Teriparatide
Although earlier observational studies suggested that estrogen
replacement might reduce heart disease, the WHI showed that
combined estrogen-progestin treatment increased risk of fatal and
nonfatal myocardial infarction by ~29%, confirming data from the
HERS study. Other important relative risks included a 40%
increase in stroke, a 100% increase in venous thromboembolic

Which of the ff is true regarding
PTH administration in the
management of osteoporosis?
48
Which of the ff can predict fracture
risk?
49
Indication for vertebral imaging in
postmenopausal women <65 years
old
50
disease, and a 26% increase in risk of breast cancer
1. Therapy Maximum of 2 years 1.CORRECT. Treatment is administered as a single daily injection Harrisons
2. In treatment of naive-patients, it given for a maximum of 2 years.
should be followed by 2. CORRECT. it is best administered as monotherapy and followed
bisphosphonates by an antiresorptive agent such as a bisphosphonate.
3. Exogenous pth can cause bone 3. CORRECT. PTH when given exogenously as a daily injection
formation exerts anabolic effects on bone. Teriparatide (1-34hPTH) is
4. Osteosarcoma is a dreaded side effect approved for the treatment of osteoporosis in both men and women
at high risk for fracture.
4. INCORRECT. Long-term surveillance studies suggest no
association between 2 years of teriparatide administration and
osteosarcoma risk in humans.
A. Ultrasound All of these techniques for measuring BMD have been approved Harrisons
B. CT scan by the U.S. Food and Drug Administration (FDA) on the basis of
C. DXA their capacity to predict fracture risk.
D. SXA
1. History of glucocorticoid use for severe Consider vertebral imaging tests in the following individuals: Harrisons, Ch.
allergic reaction 3 years ago  In all women age 70 and older and all men age 80 and 425, pg 2494,
2. Humeral fracture after vehicular older if bone Table 425-3
accident  mineral density (BMD) T-score is –1.0 or below
3. Chronic back pain  In women age 65–69 and men age 75–79 if BMD T-score
4. Height loss of 4cm is –1.5 or below
 In postmenopausal women age 50–64 and men age 50–
69 with specific
 risk factors:
o Low-trauma fracture
o Historical height loss of 1.5 in. or more (4 cm)
o Prospective height loss of 0.8 in. or more (2 cm)
o Recent or ongoing long-term glucocorticoid
treatment