Bones 🦴 Flashcards
Poor bone health is commonly associated with menopause. What risk factors are present that increase the risk of osteoporosis and what considerations should be made about improving bone health and preventing fractures for TY?
Risk factors:
Female sex
Increasing age
Smoking
Alcohol
Previous fracture
Oral corticosteroids
Rheumatoid arthritis
Parental history of hip fracture
BMI over 18.5
Reduce bone mineral density(BMD):
Endocrine disease
Diabetes mellitus, Hyperthyroidism, and hyperparathyroidism
Gastrointestinal conditions that cause malabsorption
Crohn’s disease, Ulcerative colitis, Coeliac disease, and Pancreatitis - chronic.
Chronic kidney disease
Chronic liver disease
Chronic obstructive pulmonary disease
Menopause
Immobility
Body mass index of less than 18.5 kg/m²
Do not reduce BMD:
Increased age
Oral corticosteroids
Smoking
Alcohol
Previous fragility fracture
Rheumatological conditions
Rheumatoid arthritis, other inflammatory arthropathies
Genetic
Parental history of hip fracture
Other:
Selective serotonin reuptake inhibitors
Proton pump inhibitors
Anticonvulsant drugs, in particular enzyme-inducing drugs(carbamazepine)
To improve bone health and prevent fractures:
Bone density testing (DEXA scan)
Hormone replacement therapy(menopause-oestrogen deficiency): e.g. oestrogel
Bisphosphonates (bone-sparing treatment)
Increase level of calcium and vitamin D via diet or supplements
Regular weight bearing exercise to strengthen bones
Keep smoking cessation
Limit alcohol
What are Noreen’s risk factors for a fragility fracture? Calculate her FRAX score and consider how this score can be used to discuss treatment options holistically?
Age and postmenopausal
At 65 and postmenopausal, naturally higher risk of osteoporosis and fragility fractures due to decreased oestrogen, which affects bone density. Decreased bone density .
BMI
18.4 is underweight, which means a higher risk of fractures due to lower bone density.
DEXA Scan T-Scores:
Her T-scores indicate osteoporosis:
Hip T-score: -3.0 (indicates osteoporosis)
Spine T-score: -1.0 (borderline osteopenia/normal)
The hip T-score of -3.0 is particularly concerning for fracture risk.
History of Fragility Fracture:
Already had a hip fracture from a fall, so she has experienced a fragility fracture. This is one of the most significant risks of future fractures.
Postural hypotension? - risk of falls
Sitting BP 110/80 mmHg
Standing BP 90/75 mmHg
BP drops when she stands which increases risk of falls → postural hypotension?
Lives alone (increased risk of falls)
Alcohol (increased risk of falls)
Steroids negatively impact bone health
FRAX SCORE:
10 year possibility (%) of major osteoporotic fracture ( hip, spine, forearm, and shoulder) and another one specifically for hips
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Calculating:
Age (40–90 years).
Sex.
Body mass index (BMI).
Clinical Risk Factors:
Previous fracture (after age 50).
Parental history of hip fracture.
Current smoking.
Glucocorticoid use (e.g., prednisone for ≥3 months at ≥5 mg/day).
Rheumatoid arthritis.
Secondary causes of osteoporosis (e.g., diabetes, hyperthyroidism, premature menopause).
Alcohol intake (≥3 units/day).
Bone Mineral Density (BMD) (Optional):
Specifically, femoral neck BMD can be entered to enhance accuracy.
Geographic and Population Data:
Country-specific fracture and mortality data are incorporated to adjust risk predictions.
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Lifestyle Factors:
Eat a well-balanced diet containing a variety of foods, including grains, fruits and vegetables, nonfat or low-fat dairy products or other calcium-rich foods, and meat or beans each day.
→ currently eats a dairy-free diet - so suggest dairy-free alternatives that are rich in calcium (chia, sunflower seeds, soy milk, tofu, etc)
Lives alone so can be difficult to keep up with eating well
Choose weight-bearing activities such as brisk walking, jogging, tennis, netball or dance.
Reduce alcohol consumption (6 units/week (not over limit but can increase risk regardless)), already stopped smoking
What further pharmacological and non-pharmacological treatments could be offered to Noreen to reduce her risk of future fractures? Make sure you consider the appropriate patient advice.
Pharmalogical
First line - bisphosphonate: alendronate 10mg daily / 70mg once weekly or Risendronate 5mg OD or 35mg once weekly
Take it at same time each time to remember
Calcium and vit D supplements (already on vit D, increase calcium in diet)
Calcium supplements taste chalky so give advice for how it important it is
Non-pharmacological
Take regular exercise (tailored to person) to improve muscle strength.
Encourage:
Walking, especially outdoors, will increase exposure to sunlight, increasing vitamin D production.
Strength training (such as weight training) of different muscle groups (for example hip, wrist, and spine).
A combination of exercise types, for example balance, flexibility, stretching, endurance, and progressive strengthening exercises.
Cognitive ability
Check continence
Monitor Codeine
Eat a balanced diet. Calcium-rich foods, protein. (Eggs fish lean meats leafy greens almonds)
Drink alcohol within recommended limits, as alcohol is a dose-dependent risk factor for fragility fracture.
Look at tripping hazards in house. Ensure her bungalow is fall-proof by reducing tripping hazards, adding grab bars, and ensuring proper lighting.
Falls assessment
Encourage regular vision and hearing checks
Hydration
Small frequent meals
Get up slowly from standing
What chemical properties of bisphosphonates potentially contribute towards their extremely poor oral bioavailability? What formulations are available and what are their respective advantages for both administration and delivery, and the patient
extremely poor oral bioavailability, generally less than 1%, very little of drug taken orally actually reaches systemic circulation.
Absorption Challenges:
Highly Polar and Hydrophilic:
Bisphosphonates have two phosphonate groups, making them poorly absorbed through lipid-rich GI membranes. They are really big and polar (negative change) and highly hydrophilic which is the opposite needed for good absorption.
Charge and pKa:
Strongly negatively charged at physiological pH, limiting passive diffusion across cell membranes.
Affinity for Divalent Cations:
Bind to calcium, magnesium, and iron in food, forming insoluble complexes that reduce absorption.
Patients are advised to take bisphosphonates on an empty stomach and avoid supplements or certain foods during administration.
Poor Permeability:
High molecular weight and hydrophilicity prevent effective passive or active transport across the GI tract.
Available Formulations and Their Advantages:
Oral Tablets (Standard Formulations):
Examples: Alendronate, Risedronate, Ibandronate.
Advantages: Non-invasive, convenient, and traditional.
Challenges:
Low bioavailability despite taking on an empty stomach.
Requires remaining upright for 30–60 minutes to minimize GI irritation.
Common GI side effects.
Delayed-Release Oral Formulations:
Example: Delayed-release Risedronate.
Advantages:
Reduces GI irritation by releasing the drug in distal GI sections.
Can be taken with food, improving patient adherence.
Challenges: Bioavailability is still limited by the drug’s chemical properties.
Intravenous (IV) Formulations:
Examples: Zoledronate, Ibandronate, Pamidronate.
Advantages:
100% bioavailability by bypassing the GI tract.
Eliminates absorption issues and GI side effects.
Less frequent dosing (e.g., annually for zoledronate), improving adherence.
Challenges:
Invasive and requires healthcare facilities.
Higher costs and reduced patient convenience.
Bisphosphonates instructions
Empty stomach. 30 -60 minutes before food / other meds
Swallow whole with water
30mins sit / stand up right to prevent irritation
Eat calcium and vitamin D and iron and protein rich foods
Side effects
Upper gi effects: swallowing difficulty, nause, discomfort, oesophageal ulcers
Atypical fractures
Osteonicrosis of jaw
The patient returns in 12 months for their annual medication review. On reviewing their recent blood results, you note their renal function has deteriorated such that creatinine clearance is 34 mL/min. You also note a recent acute issue for her codeine and paracetamol. What adjustments need to be made to her treatment?
Codeine: reduce the dose or replace by low dose oxycodone or hydromorphone
Codeine is metabolised in the liver while the active metabolites are excreted by the kidney. The accumulation of their metabolites may cause neurotoxic symptoms.
Oxycodone and hydromorphone are safe in renal impairment patients but need dose adjustment and monitoring.
Bisphosphate: replace by Denosumab
Bisphosphate is excreted by the kidney and has potential nephrotoxicity. BNF recommends: avoid if creatinine clearance less than 35 ml/minute.
Denosumab is not metabolised or excreted by the kidneys, and does not accumulate in kidneys. Denosumab is given by s.c. injection twice per year. So denosumab is more suitable for patients with severe renal impairment.
Monitor: hypokalemia
Paracetamol: adjust dosing interval
Paracetamol is generally safe in renal impairment. But we can extend the dosing interval to 6-8 hours in severe renal impairment.
Adcal D3: continue with caution
Periodic check plasma calcium levels and urinary calcium excretion.
Calcium and vitamin D3 is beneficial for the patient of osteoporosis
But reduced renal function increased the risk of hypercalcaemia.
