Presented by: Kenneth Saag, MD and Nancy Lane, MD.
Perspective by:Teri Puhalsky, BSN, RN, CRNI

Premenopausal Osteoporosis, Diagnostic Approaches and Management. Presented by: Kenneth Saag, MD

Dr. Saag defined what Osteoporosis looks like in premenopausal women; uncommon, difficult to diagnose by bone mineral density (BMD) alone, diagnosis is more certain when low trauma fractures are present. Premenopausal women should be using Z scores and not T scores to determine their bone density. Women (and men) <50 who have a Z score about -2.0 are within the expected range for age. Z scores below -2.0 are below the expected range for age.

He went on to explain that low BMD in young women may be due to genetics, suboptimal bone mass accrual during adolescence or small stature. Dexa scans measure in 2 dimensions, does not capture the thickness or volume of bone and underestimates BMD in small individuals. The incidence and prevalence of fractures is much lower in PREmenopausal than POSTmenopausal women, even when the BMD is very low. The risk of fracture increases with age.

Dr. Saag described the most common causes of Osteoporosis in PREmenopausal women are:

• Glucocorticoid excess (endogenous or iatrogenic)
• Premenopausal estrogen deficiency-Amenorrhea/eating disorder/athletic triad
• GI disease-Celiac disease, IBD, malabsorption
• Medications-Antiepileptic drugs, cancer chemotherapy
• Alcoholism
• Primary hyperthyroidism
• Osteogenesis imperfecta
• Idiopathic

Laboratory evaluation should include: CBC, Serum calcium and phosphate, electrolytes, renal function, serum albumin, transaminases, total alk phosphatase, serum TSH, and serum 25-hydroxyvitamin D. Urine for calcium and creatinine.

Dr. Saag also discussed that idiopathic osteoporosis (IOP) is defined as premenopausal women and men <50, otherwise healthy, normal gonadal function, with no secondary cause of bone loss. These patients are usually Caucasian, often present in their mid-30s, have one or more low trauma fractures. The osteoporosis may be mild or devastating.

The challenge is to decide whether to treat premenopausal women and how to treat them. General measures like adequate nutrition, calcium, vitamin D and lifestyle changes have minimal effects on BMD. Therapies for secondary causes often provide the large increases in BMD including control of inflammation in inflammatory diseases like RA and IBD. Pharmacologic therapy is rarely justified unless the patient has fractures, ongoing bone loss with conservative Rx, or an extremely low BMD (Z score -3.0. The 2017 ACR GIOP guidelines recommend to treat men and women <40 and 40 at moderate to high fracture risk with oral bisphosphonates, IV bisphosphonate, teriparatide, denosumab or raloxifene. Vitamin D 600-800 IU/d, Calcium 1000-1200 mg/d, weight bearing exercise, optimal nutrition and fall prevention.

BPs (bisphosphonates) or TPTD (teriparatide) improve BMD in premenopausal women with secondary osteoporosis are only FDA approved in premenopausal women taking GCs and do not prevent fractures.

Calcium and Vitamin D supplementation to prevent and manage osteoporosis presented by Dr. Nancy Lane.

Dr. Nancy Lane detailed that peak skeletal mass is achieved by ages 20-30, and the adult skeleton is remodeled and replaced every 10 years. Strategies to prevent fractures are to build peak bone mass early in life and to reduce bone loss later in life.

Dr. Lane went on to describe that vitamin D is important in maintaining serum calcium and phosphorus for metabolic functions, bone health and neuromuscular functions. There are consequences of vitamin D inadequacy, low calcium absorption, increased release of PTH which increases osteoclastic bone resorption, increased osteoclastic bone resorption is associated with increased risk of fracture. Normal 25(OH)D levels are 40-60ng/ml (100-150 nmol/L), inadequacy≤ 30 (mg/mL) and deficiency 9 (mg/mL).

Dr. Lane discussed the recommendations for calcium and vitamin D. 1200 mg calcium (diet and supplement) and 800 IU for PMO women with osteoporosis, 1000 mg calcium (diet and supplement) and 600 IU vitamin D for premenopausal women and men. She explained the data does not support an annual dose of vitamin D 500,000 IU or that there is any benefit for exceeding the recommendation for calcium intake.

Two important determinants of skeletal fracture are skeletal fragility due to low bone mass and micro-architectural deterioration and propensity for falls due to low muscle mass and vitamin D has a role in the etiology for both of those.

Dr. Lane shared that recent studies have reduced the concern for CVD with calcium supplementation in women. She also explained that up to 14 days after denosumab patients, especially elderly women, are hypocalcemic and to make sure they have sufficient calcium and vitamin D intake during that time.

Teri Puhalsky, BSN, RN, CRNI
Membership Development Chair Registered Nurse
Medstar Orthopaedic Institute
Brandywine, MD

Teri Puhalsky currently resides in Maryland, where she works as an infusion RN at Medstar Orthopaedic Institute. She studied nursing at Excelsior College School of Nursing and has been practicing rheumatology since 2011. Teri received the Outstanding Clinical Performance Award as an LPN, obtained her CRNI in 2012, and is a member of Sigma Theta Tau International PhiPi Chapter. She strives for positive patient outcomes and firmly believes that collaboration with the healthcare team is critical for chronic disease management. With a patient-focused and evidence-based nursing practice, she knows all patients can receive quality, safe, and effective care.