IC18 Management of osteoporosis Flashcards
What is osteoporosis?
It is a metabolic bone disease characterised by:
1. Low bone density
2. Decreased bone strength
3. Increased risk of fracture
What are the 2 ways that can cause a decrease in bone mass?
- Excessive bone resorption
- Decreased bone formation
What are possible primary causes for ↓ in bone mass?
- Age
- Menopause
- Alcohol consumption
- Smoking
- Low sr Ca
- Physical inactivity
- Medication use
- Other diseases
What medications can contribute to drug-induced osteoporosis?
- *Glucocorticoid
- Immunosuppressants
- Antiseizure medications
- Heparin
- Cancer chemotherapy
- GnRH agonists and antagonists
Are there any symptoms in early stages of osteoporosis?
No.
Osteoporosis is often undiagnosed until presented w fragility fracture.
What is fragility fracture?
Fragility fracture is a type of fracture caused by low trauma that normally doesn’t cause fractures.
What are the goals of therapy of osteoporosis?
- Prevention of fractures* [most impt]
- Improve QoL
- Reduce economic burden
What are the 2 main risk factors for osteoporosis?
- Post-menopausal women
- Men ≥ 65yo
Other risk factors:
- Low body weight
- Low Ca intake
- Smoking
- Excessive alcohol intake
- etc.
What is the T score for:
- Osteoporosis
- Osteopenia
- Normal bone density?
Osteoporosis: ≤ -2.5 SD
Osteopenia: -1 to -2.5 SD
Normal bone density: ≥ -1 SD
Z-score is another score that tells us if there are other co-existing problems that can contribute to osteoporosis.
What is the Z-score value that tells us that the osteoporosis caused by other co-existing problems?
Z-score ≤ -2 SD
This indicates that other co-existing problems - such as alcoholism or glucocorticoid therapy can contribute to osteoporosis.
FRAX score is another assessment tool to measure a pt’s risk of fracture.
What is the FRAX score for:
- Pt at risk of major osteoporotic fracture?
- Pt at risk of hip fracture?
- Pt at risk of major osteoporotic fracture - risk score of ≥ 20%
- Pt at risk of hip fracture - risk score of ≥ 3%
What is the process of diagnosing a pt with osteoporosis and initiating treatment?
- Check pt for risk factors
- Check DXA score of pt (see if T-score is ≤2.5)
- Check FRAX score
- Diagnose pt with osteoporosis
- Start treatment
When do we initiate treatment for osteoporosis?
- Pt presents with fragility fracture
- Pt has a T score ≤2.5
- Pt w T score <-1 to >-2.5, & high risk of fracture (FRAX >3% for hip fracture OR FRAX ≥ 20% major osteoporotic fracture)
What are the treatments available for osteoporosis?
- Oral bisphosphonates - Alendronate, Risendronate
- IV bisphosphonates - Zoledronic acid
- SC Denosumab - RANKL inhibitor
- Raloxifene - oestrogen receptor modulator
What are the contraindications of oral bisphosphonates?
Oral bisphosphonates are contraindicated in:
- CrCL < 30ml/min
- Hypocalcaemia
- Oesophageal or gastric abnormalities
- Pt w inability to stand/sit upright ≥30mins
- Aspiration risk
What are the contraindications in IV bisphosphonates?
IV bisphosphonates are contraindicated in:
- CrCL <35ml/min
- Hypocalcaemia
Note: Oral bisphosphonate is CI in CrCL <30ml/min, while IV Oral bisphosphonates is CI in CrCL<35ml/min
What are the ADR of both Oral & IV bisphosphonates?
- Osteonecrosis of the jaw (ONJ)
- Atypical femoral fracture
How long should treatment be for oral and IV bisphosphonates?
Length of therapy:
Oral bisphosphonates - 5 years
IV bisphosphonates - 3 years
When will we consider using denosumab?
Denosumab is only considered if pt is renally impaired + unable to take oral bisphosphonates.
What is the contraindication of Denosumab?
Hypocalcaemia
What are the ADRs of denosumab?
Similar to oral & IV bisphosphonates.
- ONJ
- Atypical femoral fracture
- Increased risk of infections
If a pt is on bisphosphonates, which medical professional must they inform?
Dentists.
Pt on bisphosphonates must inform their dentist as there is risk of ONJ.
What is considered atypical fractures?
Example of atypical fractures is:
- Shaft fracture
Common fracture area is the hip joint.
What labs must we check before we initiate any treatment for osteoporosis?
We need to check:
1. Serum Ca levels
2. Vitamin D (Vit D ≥ 20-30ng/ml)
What supplements must we give pt if they are on treatment for osteoporosis?
Give Ca and Vit D supplementation during treatment.
Take Ca and Vit D 2hrs apart from oral bisphosphonates.
What are some non-pharmacological treatment for osteoporosis?
- Weight bearing exercises - tai chi, walking, elastic band exercises
- Take high Ca food
- Take Vit D - can ↓ falls
- Smoking cessation
- Limit alcohol intake (<2 units/day)
