Disorders of Bone Health including Osteoporosis

Question 1

What is osteoporosis

Answer 1

Progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture

Question 2

How common is osteoporosis

Answer 2

One in two women
one in six men
All over the age of 50 will develop osteoporosis

Question 3

Where are the common fracture sites for osteoporosis

Answer 3

Neck of femur
Vertebral body
Distal radius
Humeral neck

Question 4

How much of the adult skeleton is remodelled each year

Answer 4

10%

Question 5

What does osteoporotic bone look like

Answer 5

Loss of bone

large spaces and breaks in the microscopic architecture

Question 6

What contributes to peak bone mass

Answer 6

Genetics 
Body weight 
sex hormones
diet
exercise

Question 7

What contributes to bone loss

Answer 7

Sex hormone deficiency 
Body weight 
Genetics
Diet
Immobility 
Diseases
Drugs. e.g. steroids, aromatase inhibitors

Question 8

What are the modifiable factors for reducing the risk of fragility fractures

Answer 8

BMD 
Alcohol
weight
smoking 
physical inactivity

Question 9

What are the non-modifiable factors or reducing the risk of fragility fractures

Answer 9

Age 
gender
ethnicity
preious fracutre
family history 
early menopause (

Question 10

What is involved in the WHO fracture risk calculator

Answer 10

Allows calculation of absolute risk for incorporating additional risk factors rather than just BMD
Prediction of 10 year fracture risk of major osteoporotic fracture or hip fracture
Some limitations

Question 11

What are some of the pros of FRAX

Answer 11

Freely available

calculates 10 year absolute risk of hip or major OP fracture

Question 12

What are some of the cons of FRAX

Answer 12

Underestimates vertebral fracture risk
Same level of risk assigned to all secondary causes
Dichotomised variable smoking/ alcohol

Question 13

What can bone mineral density predict

Answer 13

risk independently of other risk factors

Question 14

What type of scans are used to measure BMD

Answer 14

DEXA

Question 15

What BMD result diagnoses osteopenia

Answer 15

BMD >1 SD below the young adult mean

Question 16

What BMD result diagnosis osteoporosis

Answer 16

BMD >2.5 SD below the young adult mean

Question 17

What BMD result diagnosis severe osteoporosis

Answer 17

BMD >2.5 SD below the young adult mean with fragility fracture

Question 18

To assess someone with suspected bone disease, what should we investigate

Answer 18

U&E
LFT
Bone biochemistry 
FBC
PV 
TSH

Question 19

What other factors should be considered when investigating someone with suspected bone disease

Answer 19

Protein electrophoresis 
Coeliac antibodies
Testosterone
Vitamin D 
PTH

Question 20

What is a endocrine causes of bone disease

Answer 20

hyperthyroidism, hyperparathyroidism, Cushing’s

Question 21

What are some GI causes of bone disease

Answer 21

Coeliac disease
IBD
chronic liver disease
chronic pancreatitis

Question 22

What are some Resp causes of bone disease

Answer 22

CF

COPD

Question 23

What are 5 bits of lifestyle advice that are recommended in managing a patient with osteoporosis

Answer 23

High intensity strength training 
Low impact weight bearing exercise 
Avoidance of excess alcohol
Avoid smoking
Fall prevention

Question 24

How much calcium should be taken in from the diet

Answer 24

700mg calcium or 1000mg for postmenopausal women

Question 25

What are some non-dairy sources of calcium

Answer 25

``` Bread and cereals fish with bones nuts green veg beans ```

Question 26

What are the drug treatment options for bone disease

Answer 26

``` calcium and vitamin D supplementation bisphosphonates denosumab teriparatide strontium ranelate HRT testosterone ```

Question 27

What are bisphosphonates

Answer 27

Antiresorptive agents

Question 28

What do bisphophonates do

Answer 28

Prevent bone loss at all sites vulnerable to osteoporosis | Reduce risk of hip and spine fractures

Question 29

Where do bisphosphonates work

Answer 29

Ingested by osteoclasts leading to cell death thereby inhibiting bone resorption

Question 30

What are some long term concerns of bisphosphonates

Answer 30

Osteonecrosis of the jaw, oesophageal Ca, atypical fractures

Question 31

How is Zoledronic Acid given

Answer 31

Once year IV infusion for 3 years | 5mg in 100mls NaCl over 15 mins

Question 32

What is the success rate of using Zoledronic acid

Answer 32

Around 70% reduction in vertebral fracture and 40% reduction rate in hip fractures

Question 33

How does Denosumab work

Answer 33

Targets and binds with high affinity and specificity to RANKL This prevents activation of its receptor RANK, inhibiting development and activity of osteoclasts, decreasing bone reposition and increasing bone density

Question 34

How is denosumab given

Answer 34

SC injection 6 months

Question 35

What is the 3rd line agent for osteoporosis

Answer 35

Strontium Ranelate

Question 36

What are the contraindications of Strontium Ranelate

Answer 36

History of thromboembolic disease IHD peripheral arterial disease uncontrolled hypertension

Question 37

How does Teriparatide work

Answer 37

Recombinant parathyroid hormone | stimulates bone growth rather than reducing bone loss

Question 38

When should treatment be started for those with bone disease

Answer 38

When the T score is

Question 39

What are the direct affects of corticosteroids and bone

Answer 39

reduction of osteoblast activity and lifespan suppression of replication of osteoblast precursors reduction in calcium absorption

Question 40

What are the indirect effects of corticosteroids and bone

Answer 40

Inhibition of gonadal and adrenal steroid production

Question 41

Biochemically, how do glucocorticoids affect calcium metabolism

Answer 41

Increase PTH and decrease bone mass

Question 42

What is Paget's disease of bone

Answer 42

Abnormal osteoclastic activity followed by increased osteoblastic activity Abnormal bone structure with reduced strength and increased fracture risk

Question 43

What is the aetiology of Paget's disease

Answer 43

Uncertain Viral encironmental biomechanical trigger in genetically predisposed individual

Question 44

What bones are affected in Paget's disease

Answer 44

long bones, pelvis, lumbar spine and skull

Question 45

How does Paget's disease present

Answer 45

bone pain, deformity (bowed legs) deafness or compression neuropathies

Question 46

What is a rare complication of Paget's disease

Answer 46

osteosarcoma

Question 47

What is used to diagnose Paget's disease

Answer 47

XR isotope bone scan shows distribution raised alkaline phosphatase with normal LFT

Question 48

What can be used to treat Paget's disease

Answer 48

Analgesia | if not responding bisphosphonates

Question 49

What type of condition is Osteogenesis Imperfecta

Answer 49

Rare group of genetic disorders mainly affecting bone | Autosomal dominant inheritance

Question 50

What might also be seen in osteogenesis imperfecta

Answer 50

blue sclerae and dentinogenesis imperfect

Question 51

How do severe forms of osteogenesis imperfecta present

Answer 51

Fractures in childhood (could be mistaken for non-accidental injury)

Question 52

What is the treatment for osteogenesis imperfecta

Answer 52

no cure - fracture fixation, surgery to correct deformities, bisphosphonates