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Year 2 > Disorders of bone health including osteoporosis > Flashcards

Disorders of bone health including osteoporosis Flashcards

1
Q

What is osteoporosis?

A

Progressive skeletal disease characterised by low bone mass and microarchitectual deterioration of bone structure

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2
Q

Which sex gets osteoporosis more commonly?

A

Women

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3
Q

How does osteoporosis present?

A

Asymptomatic until fractures

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4
Q

Over which age is osteoporosis frequent?

A

50

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5
Q

What are the common osteoporotic fracture sites?

A

Neck of femur
Vertebral body
Distal radius
Humeral neck

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6
Q

What is the domino effect in relation to osteoporosis?

A

An increasing number of vertebral fractures due to osteoporosis causing progressive curvature of the spine

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7
Q

Where does bone remodelling occur?

A

Bone remodelling units

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8
Q

Describe bone remodelling

A

Osteoclasts begin to reabsorb bone at specific sites >
Osteoclasts replaced by osteoblasts which lay down osteoid >
Osteoid undergoes mineralisation to bone >
Resorptive cavity completely filled with new bone

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9
Q

How is bone remodelling altered in osteoporosis?

A

Reabsorption of bone occurs more than formation

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10
Q

How is osteoporotic bone architecture different from normal bone?

A

Large spaces and breaks

Weakened

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11
Q

Which factors are important in bone density?

A 
Body weight
Genetics
Sex hormones 
Diet 
Exercise
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12
Q

Which factors contribute to bone density loss?

A 
Lowered sex hormones (menopause)
Low body weight
Poor genetics
Calcium deficient diet 
Immobility 
Disease affecting bones
Drugs (e.g steroids)
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13
Q

How does bone density change with age?

A

Bone density increases until around 30
After 40 it begins to decline slowly
During and after menopause bone density loss is rapid and oestrogen deficiency can further perpetuate this

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14
Q

What are the non-modifiable risk factors for fragility fractures?

A 
Age 
Gender
Ethnicity 
Previous fracture
Family history 
Early menopause (
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15
Q

What are the modifiable risk factors for fragility fractures?

A 
Bone mineral density 
Alcohol
Low weight
Inactivity 
Diet 
Smoking 
Pharmacological (steroids)
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16
Q

Which diseases increase the risk factor for an osteoporotic fragility fracture?

A 
Rheumatoid arthritis
Hyperthyroidism
Chronic liver disease
Hypogonadism
Diabetes
Dementia
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17
Q

Who should be risk assessed?

A

Patients over 50 with risk factors

Patients under 50 with serious risk factors (steroids, early menopause)

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18
Q

Who should be referred for a dexa bone scan?

A

High risk patients

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19
Q

How is bone mineral density measured?

A

DEXA bone scan

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20
Q

Is bone mineral density a dependent or independent risk factor for fragility fractures?

A

Independent

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21
Q

What is osteopenia?

A

Low bone density above 1 standard deviation below expected

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22
Q

What is osteoporosis?

A

Low bone density over 2 and a half standard deviations below expected

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23
Q

What is severe osteoporosis?

A

Low bone density over 2 and a half standard deviations below expected + fragility fracture

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24
Q

How can osteoporosis be classified in patients younger than 20?

A

Using the z score

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25
Q

As bone mineral density increases what happens to the risk of fracture?

A

Decreases

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26
Q

How should suspected osteoporosis be investigated?

A 
U&E
LFT
Bone biochemistry 
FBC
PV
TSH
Protein electrophoresis/bence jones proteins (myeloma)
Coeliac antibodies 
Testosterone levels
Vitamin D 
Parathyroid hormone
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27
Q

List some secondary causes of osteoporosis

A 
Hyperthyroidism
Hyperparathyroidism
Cushing's disease 
Coeliac
IBD
Chronic liver disease
Chronic pancreatitis 
Cystic fibrosis
COPD
Chronic kidney disease
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28
Q

What lifestyle changes can be helpful in the management of osteoporosis (not diet)?

A 
Risk assessment for falls and prevention
High intensity strength training
Low intensity weight bearing
Smoking cessation
Avoidance of alcohol excess
29
Q

What diet changes can be helpful in the management of osteoporosis?

A

2-3 portions of milk/dairy per day (700g)
3-4 portions of milk/dairy per day (1000g) post menopausal
Non dairy sources (bread, fortified cereal, fish w/ bones, green veg, beans)

30
Q

When are calcium and/or vitamin D supplements indicated?

A

Considered as risk reduction of non-vertebral fracture in patients at risk of deficiency due to diet or limited sunlight (housebound, cultural garb)

31
Q

When should calcium not be taken?

A

Within two hours of oral biphosphonates

32
Q

When would vitamin D alone be indicated?

A

When oral calcium intake is adequate

33
Q

How do biphosphonates work?

A

Anti-resorptive agents - analogues of pyrophosphate that get absorbed onto bone and eaten by osteoclasts causing cell death and less reabsorption

34
Q

Give two examples of biphosphonates

A

Alendronate

Risedronate

35
Q

What do biphosphonates reduce the risk of?

A

Spine and hip fractures

36
Q

When are biphosphonates indicated?

A

T score less than -2.5

Existing fragility fracture

37
Q

How long should biphosphonates be given for?

A

5 yr +

10 yr + if vertebral fracture

38
Q

What are the risks of long term biphosphonate use?

A

Osteonecrosis of the jaw
Oesophageal carcinoma
Atypical fractures

39
Q

How is zoledronic acid given?

A

Once yearly IV infusion (5mg in 100ml NaCl) for 5 years

40
Q

What is a common side effect of zoledronic acid and how can this be treated?

A

Influenza like symptoms (acute phase reaction)

Paracetamol

41
Q

How does denosumab work?

A

Human monoclonal antibody targeting RANKL - inhibiting activation, development of osteoclasts and decreased reabsorption so increased density

42
Q

How is denosumab administered?

A

Subcutaneous injections 6 monthly

43
Q

Which osteoporosis drug can be administered in severe renal failure?

A

Denosumab

44
Q

What are the side effects of denosumab?

A

Hypocalcaemia
Eczema
Cellulitis

45
Q

What is strontium ranelate?

A

Antireabsorptive agent

46
Q

When is strontium ranelate contraindicated?

A

Thromboembolic disease
Ischaemic heart disease
Peripheral artery disease
Uncontrolled hypertension

47
Q

When is strontium ranelate indicated?

A

When there is no other option

48
Q

What is teriparatide?

A

Recombinant parathyroid hormone

49
Q

How does teriparatide work?

A

Stimulates bone growth

50
Q

When is teriparatide indicated?

A

Over 65 with T score -3.5 plus 2 fragility fractures

55-64 with T score

51
Q

When should patients be treated for osteoporosis?

A

Anti-resorptive therapy T score 7.5 for 3 months or more OR prevalent fracture and T score

52
Q

What are the direct and indirect effects of corticosteroids on bone?

A

Direct - reduced osteoblast activity, suppression of osteoblast growth and reduction in calcium absorption
Indirect - reduced gonadal and adrenal hormones

53
Q

Are the fracture risks of glucocorticoids dose dependent?

A

Yes but no safe dose

54
Q

What is Paget’s disease?

A

Abnormal osteoclast activity followed by increased osteoblast activity resulting in weakened bone and increased fracture risk

55
Q

What is the term for paget’s at a single site? What about at multiple sites?

A

Monostotic

Polystotic

56
Q

What is the aetiology of Paget’s?

A

Unknown

57
Q

Which bones does Paget’s affect?

A

Long bones
Pelvis
Lumbar spine
Skull

58
Q

Which age group is affected by Paget’s?

A

Over 55

59
Q

How does Paget’s disease present?

A

Bone pain
Deformity
Deafness
Compression neuropathies

60
Q

What is a rare complication of Paget’s?

A

Osteosarcoma

61
Q

How can Paget’s be investigated?

A

X-ray
Isotope bone scan
Isolated raise on alkaline phosphate
Normal LFTs

62
Q

How is Paget’s treated?

A

Analgesia +/- biphosphonates if not responding

63
Q

What is osteogenesis imperfecta?

A

Group of autosomal dominant genetic conditions arising from mutations in type 1 collagen

64
Q

How many types of osteogenesis imperfecta are there?

A

8 types
Neonatal lethal - type 2
Very severe - type 3 and 4
Mild - type 1

65
Q

What is osteogenesis imperfecta associated with?

A

Blue sclera

Dentinogenesis imperfecta

66
Q

How do severe forms present?

A

Childhood fractures

67
Q

How is osteogenesis imperfecta treated?

A

Fixation
Surgery for deformity
Biphosphonates

68
Q

What is osteogenesis imperfecta an important differential of?

A

Non-accidental injury

Year 2 (72 decks)

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