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54 Finals > IC18 Osteoporosis > Flashcards

IC18 Osteoporosis Flashcards

1
Q

metabolic bone disease characterised by

A
  • low bone density
  • microarchitecture disruption (impaired mineralisation)
  • decrease bone strength
  • increased risk of fractures (fragility fractures)
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2
Q

Decrease on bone mass due to:

A
  • Excessive bone resorption
  • Decreased bone formation
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3
Q

Causes for decrease bone mass

A
  • Age
  • Menopause (loss of estrogen function in maintaining metabolism of bone)
  • Low serum Ca (increase bone resorption)
  • Alcohol consumption
  • Smoking
  • Physical inactivity — less anabolic stimulus
  • Medication use
  • Secondary to other diseases
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4
Q

Medications that can cause osteoporosis

A

GC, immunosuppressants (cyclosporin), ASM (esp phenytoin and phenobarbital), aromatase inhibitors, GnRH agonist/ antagonists, heparin, cancer chemotherapy

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5
Q

Clinical manifestation

A
  • Asymptomatic — no pain until suffering a fracture
  • Often undiagnosed until presented with fragility fracture (low trauma)
  • Fractures may give rise to pain and disability → increase healthcare cost, nursing home placement and mortality
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6
Q

Common sites of fractures

A

(weigh bearing): spine (vertebral compression — height loss, kyphosis/bending over), hip (NOF #, IT#), wrist (colles #), humerus (rare), pelvis (rare)

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7
Q

Goals of therapy

A
  • Prevent fractures
  • Improve QOL
  • Reducing economic burden
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8
Q

Risk factors for osteoporosis → pts should be assessed for osteoporosis

A
  • Post-menopausal women
  • Men ≥65yo
  • Family hx of osteoporosis or fragility fractures
  • Previous fractures
  • Ageing
  • Low BW (low bone mass)
  • Height loss (>2cm)
  • Early menopause (≤45yo)
  • Certain meds (eg prolong CS = to >5mg/day prednisolone for >3mths)
  • Low Ca intake (<500mg/day)
  • Excessive alcohol intake (>2 units/day)
  • Smoking
  • Prolonged immobility
  • Hx of falls
  • Presence of diseases that decrease bone density or increase fracture risk (eg DM, inflammatory rheumatic disease)
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9
Q

Diagnosis

A
  1. Hx of fragility fractures → indicate osteoporosis = start tx
  2. Bone mineral density (BMD) measurement using DXA hip and/or spine
  3. Fracture Risk Assessment Tool (FRAX)
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10
Q

Describe fragility fractures and where it occurs

A
  • Locations: vertebral/spine, hip, wrist, humerus, rib, pelvis
  • Occurs spontaneously or from minor trauma that would not usually result in fractures (eg falling from standing height)
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11
Q

BMD scores and when to start tx

A
  • T-score ≤ -2.5 SD → osteoporosis (start tx)
  • T-score -1 to -2.5 SD → osteopenia (look at fracture risk using FRAX score to determine if need to start tx)
  • T-score ≥ -1 SD → normal bone density
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12
Q

T score vs Z score

A
  • T-score: compares BMD against a young adult of ref population
  • Z-score: compares against expected BMD for pt’s age and sex
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13
Q

Z-score ≤-2 SD =

A

coexisting problems/ secondary causes (eg GC use, alcohol) that cause osteoporosis

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14
Q

Clinical hx, PE and labs to exclude secondary causes if Z-score ≤ -2 SD

A
  • Creatine: determine renal function, check for CKD-MBD
  • FBC
  • Corrected Ca
  • 25(OH) vit D
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15
Q

FRAX score and when to start tx

A
  • Consider starting anti-osteoporosis tx if 10year probability is high for: (any one = start tx)
    • major osteoporotic fractures ≥20% (spine, pelvic/hip, wrist, humerus, shoulder #)
    • hip fracture ≥3%
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16
Q

When to start tx?

A
  1. Pt with fragility fractures (start tx after healed ~4weeks after fractures as bisphosphonates can affect bone resorption and healing)
  2. Pt w/o fragility fractures but DXA BMD T score ≤ -2.5 SD (osteoporosis)
  3. Pt w/o fragility fractures but DXA BMD T score -1 to -2.5 SD (osteopenia) + high fracture risk (FRAX >3% hip or ≥20% major osteoporotic fracture)
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17
Q

1st line tx

A

PO bisphosphonates

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18
Q

PO bisphosphonates dosing

A
  1. PO Alendronate 70mg q1week
  2. PO Risedronate 35mg q1week
  3. PO Ibandronate (rare) 150mg q1mth
19
Q

PO bisphosphonates administration

A

Take 0.5-1hr before breakfast with a full glass of water (240mL PLAIN water). Do not lie down after for at least 30mins.

20
Q

PO bisphosphonates PK

A

PO bisphosphonates has poor oral F, absorption impaired by food/ fluids/ other meds

21
Q

PO bisphosphonates SE

A

GI irritation, N, abdominal pain, dyspepsia, hypocalcemia, ONJ (rare, more likely with IV zoledronic acid), AFF

22
Q

PO bisphosphonates CI

A

CrCl <30ml/min, hypocalcemia, GI (gastric ulcer, uncontrolled GERD, erosive esophagitis), unable to stand/sit upright ≥30mins, aspiration risk (eg difficulty swallowing)

23
Q

PO bisphosphonates tx duration

A

5 years → drug holiday (recheck BMD 2 yrs after stopping tx, restart if BMD decr >4-5%)

24
Q

Indication for IV bisphosphonate

A

2nd line if PO not tolerated — GI CI, unable to sit/stand upright ≥30mins, aspiration risk

25
Q

IV zoledronic acid dosing, advice, tx duration

A

IV Zoledronic acid 5mg q1 year (30mins IV infusion)
- adequate hydration before infusion
- Tx duration: 3 years → drug holiday (recheck BMD 2 yrs after stopping tx, restart if BMD decr >4-5%)

26
Q

IV Zoledronic acid SE

A

flu-like sx (fever, malaise, headaches), ONJ, AFF

27
Q

IV Zoledronic acid CI

A

CrCl <35ml/min, hypocalcemia

28
Q

RANKL inhibitor eg and dosing, tx duration

A

SC denosumab q6mths
- Safety data up to 10 years; tx duration: infinite (inc risk of vertebral # if missed dose)

29
Q

SE of denosumab

A

similar to bisphosphonates, hypocalcemia, serious infections (diverticulitis, pneumonia, appendicitis, cellulitis)

30
Q

Recombinant PTH and tx duration

A

SC teriparatide (rare), <2years

31
Q

SERM eg and for which pt

A

PO raloxifene (not favoured)
- Typically used in post-menopausal sx in YOUNG women with post-menopause (usually w/o hot flushes, if hot flushes use HRT)

32
Q

Older women with post-menopause tx

A

PO bisphosphonates/ SC denosumab

33
Q

Sclerostin inhibitor eg

A

SC romosozumab q1mth
SE: similar to bisphosphonates

34
Q

Osteonecrosis of the jaw (ONJ) RF

A

tooth extraction/ invasive dental procedures, hx of cancer/radiotherapy, poor oral hygiene, concomitant therapy (eg angiogenesis inhibitors, bisphosphonates, chemotherapy, CS, denosumab), comorbidities (eg anemia, coagulopathy, infection, dental disease)

35
Q

Advice for ONJ

A
  • Smoking cessation
  • Avoid invasive dental procedures during bisphosphonate tx
  • Maintain good oral hygiene
  • Start bisphosphonates after finishing dental procedures + healed
36
Q

Atypical femur fracture (AFF) monitoring and mx

A

Monitor for unexplained pain in thigh/hip/groin while on tx
- mx: discontinue bisphosphonate tx

37
Q

prior to starting tx what needs to be checked?

A
  • Serum Ca
  • 25(OH) vit D — should be ≥20-30 ng/mL
  • dental procedures
38
Q

During tx supplement with…

A

give adequate Ca and vit D supplementation
- Take Ca supplement at least 2HRS after alendronate

39
Q

Monitoring for tx

A

SCr (renal function), serum Ca, serum 25(OH) vit D

40
Q

Non-pharm

A
  • Appropriate weight bearing, muscle strengthening exercise (eg gym, Taichi, brisk walking) → increase BMD
    • different exercise from OA (low impact exercise)
    • Osteoporosis dont need to reduce weight
  • Smoking cessation, appropriate alcohol intake (≤2 units/day)
  • Appropriate Ca intake (1000mg/day of elemental Ca in diet and supplements)
  • Optimise vit D intake to prevent falls
  • Education on reducing fall risk, home safety and footwear
41
Q

When to give Ca supplements, DDI with Ca supplements

A
  • Consider giving supplementation if dietary intake <700mg/day
  • DDI:
    • PPI & fibre (decr Ca absorption)
    • Ca decr absorption of: iron, tetracyclines, fluroquinolones, bisphosphonates, thyroid supplements
42
Q

Ca in food

A

milk 240ml, nondairy milk 240ml, orange juice 240ml, tofu 0.5 cup, dark leafy green vegetables cooked 0.5 cup, cottage cheese 0.5 cup, almonds 24 whole, orange 1 medium

43
Q

How much vit D to give and DDI

A
  • Give 800IU/day cholecalciferol to pt with vit D insufficiency
  • DDI: rifampicin, ASM (phenytoin, carbamazepine, valproate), cholestyramine, orlistat, Al-containing products
44
Q

How to prevent falls

A
  • switch on lights, dry floor, anti-slip rugs
  • Med review of drugs that increase fall risk (eg drowsiness, OH, anticholinergics)

54 Finals (7 decks)

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