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MB2: Endocrinology > Bone and calcium endocrinology > Flashcards

Bone and calcium endocrinology Flashcards

1
Q

describe bone microarchitecture in middle age

A

decreased trabecular thickness in non-load bearing horizontal trabeculae

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2
Q

describe bone microarchitecture in older age

A

decreased number of connections between vertical trabecular and so decrease in strength

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3
Q

factors affecting bone mass

A 
age 
sex hormones 
diet 
exercise 
weight
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4
Q

factors affecting bone loss

A 
sex hormone deficiency 
age 
weight 
genetics 
diet 
immobility 
disease 
aromatase inhibitor/glucocorticoids
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5
Q

describe bone mass over lifetime in men

A

increases up to age of 30, higher tha that of women then plateau and slow decline linerarly after 50

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6
Q

describe bone mass over lifetime in women

A

increases up to age of 30, less than that of men, sudden drop at menopause

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7
Q

common osteoporotic fracture sites

A

distal radius
vertebral body
neck of humerus
neck of femur

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8
Q

what is the fracture domino effect

A

one fracture leads to another and leading to progressive disability and lost independence

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9
Q

modifiable risk factors ofr fragility fracture

A 
diet 
BMD 
alcohol
smoking 
weight 
pharmacological risk factors 
physical activity
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10
Q

non-modifiable factors for fragility fracture

A 
age 
ethnicity 
gender 
FHx
pre-existing fracture 
co-existant disease 
menopause <45
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11
Q

who to assess for fragility fractures?

A

<50 with strong risk factors like exogenous steroids or early menopause
>50 with risk factors

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12
Q

who to refer for risk of fragility fracture

A

anyone with 10 year risk assessment >10%

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13
Q

normal DEXA scan?

A

within 1SD of young adult ref range

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14
Q

osteopaenia on DEXA?

A

1-2.5SD of normal ref range young adult

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15
Q

osteoporosis on DEXA?

A

> 2.5SD of normal young adult ref range

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16
Q

severe osteoporosis on DEXA?

A

> 2.5SD of normal young adult ref range and a fragility fracture

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17
Q

causes of secondary osteoporosis

A

steroid use
IBD, malabsorption, coeliac diseas, chronic liver disease, chronic pancreatitis
cushings, hyperthyroidism, hyperparathyroidism
CKD
CF, COPD

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18
Q

lifestyle management of osteoporosis

A 
high intensity strength training 
low impact weight bearing exercises 
avoid excess alcohol 
avoid smoking 
fall prevention 
calcium in supplement or diet
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19
Q

when should calcium and vitamin D supplements not be taken

A

within 2 hours of oral bisphosphonates

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20
Q

name and mechanism of action of 2 bisphosphonates

A

alendronate, risedronate

uptake by osteoclasts leading to cell death to inhibit bone resorption

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21
Q

indication for bisphosphonates and cautions/side effects

A

osteonecrosis of the jaw, oesophageal malignancy, atypical fractures
T score >2.5SD or >1.5SD in steroid treatment >3m or pre existing fracture

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22
Q

mechanism of action of denosumab and cautions

A

binds to RANKL and prevents activation of RANK receptor so inhibits osteoclastic activity
hypocalcaemia, eczema, cellulitis

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23
Q

mechanism of action of teriparatide

A

recombinant PTH so stimulates bone growth

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24
Q

indication for teriparatide

A

recommended over bisphosphonate in postmenopausal women with 2 moderate/1 severe or low trauma vertebral fracture

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25
Q

mechanism of action of romosozumab

A

binds to and inhibit sclerosin, substance formed be osteoclasts, to inhibit bone resorption

26
Q

indication/contraindication for romosozumab

A

postmenopausal women with severe osteoporosis who are at imminent risk of fragility fracture
contraindicated in previous cerebrovascular accident and MI

27
Q

what is osteogenesis imperfecta associated with

A

dentinogenesis imperfecta

blue sclerae

28
Q

management of osteogenesis imperfecta

A

fracture fixation, surgery for deformity and bisphosphonates

29
Q

inheritance of osteogenesis imperfecta?

A

mostly autosomal dominant

30
Q

what is pagets disease, where does it affect and who is it more common in

A

abnormal osteoclastic activity followed by abnormal osteoblastic activity
long bones, skull, lumbar spine, pelvis
usually people >40

31
Q

presentation of pagets disease

A

deafness
bone pain
deformity
compression neuropathy

32
Q

diagnosis of pagets disease

A

raised alk phos
x ray
isotope bone scan

33
Q

management of pagets disease

A

bisphosphonates and analgesia

34
Q

complication of pagets disease

A

osteosarcoma

35
Q

describe the basic uptake and metabolism of vitamin D

A

vitamin D from sun and diet undergoes reaction with 25-hydroxylase in liver and 1-OHase in kidney - PTH stimulated and increases calcium and phosphate absorption

36
Q

how does PTH work on the body to increase serum calcium

A

stimulates 1-OHase to increase active vitD and increase Ca and PO4
causes calcium resorption from bone

37
Q

what is the action of calcitonin

A

lowers osteoclast resorption and so lowers Ca and PO4

38
Q

what is the calcium sensing receptor and where is it founds

A

found in PTH gland and stimulation acts as -ve feedback on parathyroid hormone secretion

39
Q

acute symptoms of hypercalcaemia

A 
Bones 
Stones 
Thrones 
Groans 
Psychiatric overtones
40
Q

chronic features of hypercalcaemia

A 
myopathy 
fracture 
oesteopenia 
depression 
hypertension 
pancreatitis 
DU
renal calculi
FHH
41
Q

causes of hypercalcaemia

A 
primary hyperparathyroidism 
malignancy 
vitamin D, thiazide diuretics 
sarcoidosis, TB
thyrotoxicosis, pagets disease 
tertiary hyperparathyroidism
42
Q

Low PTH with raised ALP is suggestive of

A

bone pathology

mets, sarcoid, thyrotoxicosis

43
Q

Low PTH with low ALP is suggestive of

A

bone pathology
vitamin D toxicity
myeloma

44
Q

high PTH with high urine calcium excretion is suggestive of

A

primary/tertiary hyperparathyroidism

45
Q

high PTH with low urinary calcium excretion

A

FHH

46
Q

investigation of metastatic hypercalcaemia

A

PTHrp
calcium and alk phos
XR, CT, MRI, PET
isotope bone scan

47
Q

initial management of hypercalcaemia

A

0.9% saline 4-6L in 24 hours
consider loop diuretics
single dose bisphosphonates
steroids for sarcoid

48
Q

definitive management of hyperparathyroidism

A

surgery

cinacalcet for tertiary hyperparathyroidism or parathyroid carcinoma

49
Q

indication for parathyroidectomy

A 
bone disease
gastric ulcers 
renal stones 
osteoporosis 
serum Ca >2.85mmol/L
under 50 
eGFR<60mL/min
50
Q

genetic causes of hyperparathyroidism

A

MEN1/2 - parathyroid adenoma with hypercalcaemia at a young age
familial isolated hyperparathyroidism

51
Q

what is FHH

A

familial hypercalcuric hypercalcaemia
dysfunctional calcium sensing receptor so elevated PTH, elevated serum Ca but low urine Ca
autosomal dominant and usually benign

52
Q

diagnosis of FHH

A

mild hypercalcaemia
reduced urine Ca excretion
marginally elevated PTH
genetic screen

53
Q

features of hypocalcemia

A 
paraesthesia in fingers, toes, perioral 
fatigue 
muscle weakness, cramps, tetany
bronchospasm /laryngospasm 
fits 
chovsteks sign trousseau sign 
prolonged QT on ECG
54
Q

acute management of hypocalcaemia

A

emergency
IV calcium gluconate 10ml 10% over 10 mins
infuse 10ml 10% in 100ml infusate at 50ml/h

55
Q

chronic management of hypocalcaemia

A

calcium supplements

vitamin D

56
Q

causes of hypocalcaemia

A 
digeorge syndromew 
malignancy, radiotherapy, surgery
autoimmune 
hypomagnesaemia 
idiopathic
57
Q

describe why hypomagnesaemia causes hypocalcaemia

A

calcium release from cells is dependent on magnesium so in deficiency intracellular Ca is high

58
Q

causes of hypomagnesaemia

A 
PPI
GI illness
pancreatitis 
alcohol 
thiazide diuretics
59
Q

what is pseudohypoparathyroidism and features

A

GNAS1
low calcium but high PTH due to resistance
causes bone abnormality, obesity, s/c calcification, learning disability, bradydactyly of 4th metacarpal

60
Q

causes of osteomalacia/rickets

A

gastric surgery, coeliac disease, liver disease, pancreatic failure
chronic renal failure/disease
lack of sunlight
anticonvulsant drugs

61
Q

clinical features of osteomalacia/rickets

A 
low calcium 
prox myopathy 
dental defects
bone tenderness
rib/limb deformity
62
Q

management of osteomalacia/rickets

A

vitamin D3 - loading dose over 12 weeks
calcitriol
combined Ca and vitamin D
alfacalcidol

MB2: Endocrinology (13 decks)

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