CASE 8 (includes some pharm) Flashcards
what is osteoporosis?
a disease characterised by low bone mass (decreased bone mineral density BMD) and micro-architectual degeneration of bone tissue, leading to enhanced bone fragility and an increase in fracture risk
according to WHO, in osteoporosis the BMD is what below a normal healthy age-matched control?
BMD < 2.5 standard deviations a below a normal healthy age-matched control
what is T score?
patient’s BMD compared to young healthy control
what is Z score?
patient’s BMD compared to age-matched control
what is osteopenia?
defined as between 2.5 and 1 standard deviation below normal heathy control — can go on to develop osteoporosis
osteoporosis affects who?
- affects 1/3 of all UK women
- affects 1/12 of all UK men
what is the cost of osteoporosis to the NHS each year?
over £3 billion a year
name key differences between bone in an 18 year old vs. an 80 year old
18 year old — epiphyseal plate still open, trabeculae, relatively thick cortices of bone
what is the effect of menopause on osteoclasts?
increases the number of osteoclasts
what is the effect of menopause on osteoblasts?
decreases the number of osteoblasts
what are the falling oestrogen levels in menopause associated with? effect of osteoporosis?
increased osteoclasts associated with falling oestrogen levels. however bone secretions from women with osteoporosis show problems with osteoblasts therefore fewer esteoclasts
why is there a deficit in BMD?
- osteoblasts simply no longer “catch up” with the activity of osteoclasts — lower BMD
- menopause, with relatively sudden increase in osteoclast activity accelerates this process
what are the actions of oestrogen on osteoblasts?
- increased alkaline phosphatase expression
- increased collagen type 1 synthesis
- stimulates growth factors synthesis (IGF1, TGF-B, BMPs) — all important for controlling cell division and differentiation
- regulates osteoblast proliferation
- stimulates expression of VDR, marker for osteoblast maturation
what are the actions of oestrogen on osteoclasts?
- increases apoptosis of osteoclasts
- suppresses osteoclast differentiation
- act on osteoclasts via osteoblasts (IL6 or RANK/RANKL, osteoprotegerin)
where are RANK receptors located?
on the surface membrane of osteoclast progenitor cells
what is RANKL?
rank ligand that binds to RANK receptor in osteoclast activation
what secretes RANKL?
osteoblasts
what is the effect of RANKL binding to the RANK receptor?
initiates intracellular signalling and gene expression cascade that results in differentiation and maturation of the precursor cells into osteoclasts
what does osteoprotegerin do?
OPG protects the skeleton from excessive bone resorption by binding to RANKL and preventing it from binding to RANK receptor
what promotes the synthesis of OPG (osteoprotegerin)
oestrogen
what is the overexprexssion of RANKL linked to?
osteoporosis
what bone markers are used for osteoblasts and osteoclasts?
- osteoblasts = alkaline phosphatase
- osteoclasts = collagen breakdown products (teleopeptides)
what is osteoporosis a disease of?
bone remodelling
how long does 1 bone remodelling cycle take?
around 9 months
why is a biochemistry test for osteoporosis disappointing?
in a biochemistry test in a blood sample, the cellular markers will be diluted out and will not change significantly enough to indicate that a disease process is ongoing
is there a higher morbidity and mortality in men or women with osteoporosis?
men
risk factors for osteoporosis
- oestrogen deficiency
- vitamin D insufficiency
- hypocalcaemia (diet or hypoparathyrodism)
- increasing age
- sedentary lifestyle
- asian descent
- family history
- long term use of corticosteroid medications (eg. prednisolone)
- excessive alcohol consumption
why is osteoporosis less common in men than in women?
because men have a higher ‘peak bone mass’ than women
what is corticosteroid therapy used for?
- asthma (inhaled and oral formulations)
- rheumatoid arthritis
- other autoimmune diseases (SLE)
- inflammatory diseases (Chron’s Disease)
what is the most abundant mineral in the human body?
calcium
what is the normal range of Ca conc in the blood and what is said to be average?
normal = 9-10.5 mg/dl or 2.2-2.6 Mmol/L
average = 9.4 mg/dl
how is calcium present in the bones?
present as calcium phosphate
what hormones controls calcium homeostasis?
parathyroid hormone — increases Ca
calcitonin — decreases Ca
where are parathyroid hormone and calcitonin produced?
parathyroid — parathyroid gland
calcitonin — follicular cells in the thyroid gland
factors that increase calcium levels
- parathyroid hormone causes the kidneys to retain Ca ions
- parathyroid hormone (with calcitriol) causes the rate of intestinal absorption to increase
- osteoclasts are stimulated to release stored Ca ions from the bone
factors that decrease calcium levels
- calcitonin causes kidneys to allow calcium loss
- calcitonin doesn’t have a direct effect on the rate of absorption
- decreased parathyroid hormone (or calcitriol) causes a decrease in the rate of intestinal absorption
- osteoclasts are inhibited whilst osteoblasts continue to lock Ca ions in the bone matrix
what do melanosomes in the skin do?
convert a precursor into cholecalciferol (inactive vitamin D3)
what happens to the cholecalciferol?
it is hydroxylated to calcifediol/calcidiol (25-hydroxyvitamin D3) in the liver
what happens to the calcifediol/calcidiol?
it is hydroxylated to calcitriol/calciferol (1,25-dihydroxyvitamin D3) = ACTIVE FORM OF VITAMIN D3 in the kidney
what does calcitriol do?
it increases calcium absorption in the small intestines, kidneys and bones
what else does the activation of calcitriol lead to in the intestines?
leads to the formation of calbindin, a calcium binding protein in the intestinal epithelial cells, which transports calcium into the cell cytoplasm
what is the effect of long term corticosteroids on Ca?
- shuts of Ca resorption through the gut
- stops the 1,25-dihydroxyvitamin D3 having its action on the intestine
what do corticosteroids act on in the bone and what is their effect?
osteoblasts — decrease osteoblast activity (collagen type 1) and possibly osteoblast number.
(complex pathway of osteoblast differentiation from mesenchymal stem cells, in which osteoblasts themselves may have a role — some of this is corticosteroid dependent)
treatment for osteoporosis
- HRT for women with osteoporosis — however bad side effects such as breast cancer so no longer really used
- bisphosphonates (compounds related to bone phosphate, decrease osteoclast activity) — latest developments are IV administration (zolendronic acid once per year and residonate) — but newly recognised side effects of osteonecrosis of the jaw and NOT tolerated in oral formulation by some patients
- SERMs (Selective Estrogen Receptor Modulators, like raloxifene, tissue specific)
- calcium, vit D supplementation
what is menopause? how is it clinically defined?
= the permanent cessation of menstruation that results from the loss of ovarian follicular activity
- clinically defined as when a woman has not had a period for 12 consecutive months
when does menopause typically occur and what is the mean age?
occurs 45–55 years, mean = 51 years
what is peri-menopause and what happens here?
= time leading to menopause
- there is an increase in oestrogen, leading to peak bone mass
- oestrogen levels begin to decline after this surge of oestrogen due to a decrease in ovarian follicles
- this surge in oestrogen prepares the body for the effects of post menopause
what is post-menopause and what happens here?
= the time after menopause
- there is a very high level of FSH, due to decreased levels of oestrogen
what are 2 possible effects of the decreased oestrogen?
- CHD because of increased production of LDL in the liver
- osteoporosis
what are the primary causes of premature menopause?
- chromosomal abnormalities (40%)
- autoimmune disease
- insufficient oestrogen synthesis
- metabolic disorders
what are the secondary causes of premature menopause?
- radiotherapy
- surgery
- hysterectomy
- infection — TB, mumps
what are some symptoms of menopause?
- hot flushes (night sweats)
- changes in period (irregular)
- abnormal bleeding (spotting)
- emotional changes (mood swings, anxiety)
- vaginal changes (dry and thin)
- urinary incontinence
- decrease in sexual drive
- weight gain/gain in body fat
what is HRT?
= hormonal replacement therapy
- possible treatment to menopause
- women with intact uterus — oestrogen + progesterone
- women after hysterectomy — oestrogen
what is the most likely cancer caused by oestrogen?
womb cancer
HRT routes — oestrogen
- transdermal — patch or gel — local skin irritation
2. oral oestrogen — cost effective, acceptable route
HRT routes — vaginal oestrogen
- cream, tablets or vaginal rings
- local delivery
urogenital symptoms — dryness, painful intercourse
HRT routes — progesterone
- micronised progesterone
- oral derivatives
- mineral coil — progesterone released intrauterine coil
use of testosterone supplementation?
used for low sexual drive, if HRT alone is not effective
name some risks of HRT
- breast cancer
- stroke
- venous thromboembolism
- ovarian cancer
HRT after breast and cervical cancer?
breast — avoid systemic HRT. can use topical oestrogen, consider clonidine or paroxetine
cervical — if young, ovarian conservation recommended. systemic HRT can be used
HRT after endometrial and ovarian cancer?
endometrial cancer — if stage 1, can consider ovarian conservation or HRT. if later stage, HRT usually contradicted
ovarian cancer — HRT not usually contradicted, unless tumour has oestrogen receptors
what are 3 types of fractures?
- external appearance (open/closed)
- location (compression/epiphyseal)
- nature of crack or break (incomplete/complete, linear/transverse)
what is a colles fracture?
a break of the distal portion of the radius, and is typically the result of reaching out to cushion a fall
what are the 2 types of treatment for a fracture?
1) surgical
2) conservative : pain relief, immobilisation, stabilisation (all non-surgical)
what are some risk factors for fractures?
- previous fracture
- increasing age
- long term glucocorticoid therapy
- smoking
- falls
how does long term glucocorticoid therapy increase the risk of a fracture?
corticosteroids reduce Ca resorption and decrease osteoblast activity
describe kyphosis and what it may result from
= an exaggerated thoracic curve
- it is a condition of over-curvature of the thoracic vertebrae where it has lost its lordotic profile (inward curvature)
- result from degenerative diseases (such as arthritis). developmental problems, osteoporosis with compression fractures of the vertebrae, or trauma