Management of Osteoporosis

Question 1

What is the difference between osteoblasts & osteoclasts?

Answer 1

Osteoblasts: cells responsible for bone formation
Osteoclasts: cells responsible for bone shedding

Question 2

What happens to the balance of osteoblasts & osteoclasts in osteoporosis?

Answer 2

Osteoclast activity > osteoblast activity.

More bone is shedded then formed.

Question 3

Which specific class of drug can cause osteoporosis?

Answer 3

Corticosteroids, because they increase osteoclast activity.

Question 4

Why are patients with osteoporosis more prone to fractures?

Answer 4

Because the thinning of their bone results in less bone density = more prone to fractures

Question 5

Why are menopausal women more prone to osteoporosis?

Answer 5

Because in menopause you lose oestrogen, which normally helps in maintaining bone function.

Question 6

What are the risk factors of osteporosis?

Answer 6

1. Increasing age
2. Females
3. Early menopause
4. Smoking/alcohol
5. White & Asian people
6. Drugs that increase metabolism of vit. D (phenytoin, PPIs)
7. Fragile, low weight individuals

Question 7

What are the symptoms of osteoporosis?

Answer 7

Symptoms are the result of fractures from osteoporosis. They can occur at 3 sights in the spine.

Question 8

What is a Colles Fracture?

Answer 8

Wrist fracture.

Question 9

What is kyphosis?

Answer 9

Curvature of the spine, making you lose height.

Question 10

What 3 investigations are performed to diagnose osteoporosis?

Answer 10

1. DXA scan (dual energy x-ray) - measures real bone density. It is a negative number.
2. T score - is the measurement of the DXA scan
3. X-ray

Question 11

What is the T score of someone with osteoporosis?

Answer 11

Less than -2.5 = osteoporosis

Question 12

What is Bindex in osteoporosis?

Answer 12

It is a portable ultrasound device used to investigate the density of the bone using sound waves.

Question 13

At what age should someone be assessed for a fracture risk?

Answer 13

Women >65yrs + presence of risk factors

Men >75 yrs + presence of risk factors

Question 14

What main factors should you focus on when assessing a person for osteoporosis?

Answer 14

1. Their gender (females more prone)
2. Age
3. Weight - are they frail?
4. Any medications they are taking
5. Menopause

Question 15

When should you assess a patient <40years old for osteoporosis?

Answer 15

1. If they have premature menopause
2. Taking corticosteroids
3. History of falls/fractures

Question 16

What is FRAX (or Qfracture) in osteoporosis?

Answer 16

It is a tool/questionnaire to assess the risk of a fracture of a person within the next 10 years

• Remember FRAX only screens for osteoporosis, nothing else

Question 17

What risk factors are considered when using FRAX?

Answer 17

1. Age/sex
2. BMI
3. Previous fractures
4. Current glucocorticoid treatment
5. Smoking/alcohol
6. Any secondary causes

Question 18

What is the advantage of having IV bisphosphonate?

Answer 18

It is only given once a year (if the risk of a fracture is >10%)

Question 19

What are some non-drug therapies for osteoporosis?

Answer 19

1. Regular exercise
2. Vitamin D & Ca2+ intake
3. Stop smoking/alcohol
4. Maintain BMI

Question 20

Even if someone has a 1% risk of a fracture, are they still treated?

Answer 20

Yes to prevent future fractures.

Question 21

Which supplement excess can cause osteoporosis?

Answer 21

Ca2+

Question 22

What is the main class of drug given as treatment for osteoporosis?

Answer 22

Bisphosphonates

Question 23

What is the mode of action of bisphosphonates?

Answer 23

1. They bind to the crystal structure of the bone & decrease osteoclast activity
2. This prevents shedding of Ca2+ from the bone
3. Osteoclasts undergo apoptosis

Question 24

Which 2 bisphosphonate drugs are in an IV infusion?

Answer 24

1. Ibandronic acid

2. Zoledronic acid

Question 25

Why cant bisphosphonates (e.g. alendronic acid, or risedronate sodium) be taken with Ca2+ supplements/food/drink?

Answer 25

Because they would bind to the Ca2+ from the tablet/food/drink & not on the bone = no efficacy

Question 26

Why should alendronic acid be taken with a full glass of water, standing up?

Answer 26

Because it can cause oesophageal reactions if the tablet does not go down fully.

Question 27

What is the dose of alendronic acid, and risedronate sodium?

Answer 27

Alendronic acid: 70mg weekly , or 10mg daily Risedronate sodium: 5mg daily, or 35mg weekly

Question 28

What condition are patients taking IV bisphosphonates more prone to?

Answer 28

Osteonecrosis of the jaw. | Good dental/oral hygiene is therefore needed.

Question 29

How many years should a patients bisphosphonate use be reviewed?

Answer 29

Should be reviewed every 5 years. | Zoledronic acid reviewed every 3 years

Question 30

How long is the holiday treatment period for alendronic acid, risedronate sodium, and zolendronic acid?

Answer 30

Alendronic acid: 2 years Risedronate sodium: 1 year Zolendronic acid: 3 years - Remember it like 1R, 2A, 3Z (RAZ)

Question 31

What ear condition can occur due to long-term usage of bisphosphonate?

Answer 31

Osteonecrosis of the external auditory canal.

Question 32

What type of drug is denosumab, & what is its mode of action?

Answer 32

It is a monoclonal antibody. It prevents RANKL from binding to RANK receptors on osteoclasts, so osteoclasts are not activated = no shedding occurs

Question 33

What is the dose for denosumab in osteoporosis?

Answer 33

60mg every 6 months via subcutaneous injection (Prolia)

Question 34

How does estrogen & teriparatide work?

Answer 34

They bind to osteoblasts to increasing bone formation

Question 35

When is denusomab given?

Answer 35

If the patient cannot take any other bisphosphonate, AND have a high risk of fracture.

Question 36

What 4 major things do you have to consider before choosing the right treatment for a patient with osteoporosis?

Answer 36

1. History of hip fractures 2. Alcohol intake 3. Rheumatoid arthritis 4. Age 5. (other risk factors if applicable)

Question 37

What 2 risks can occur while taking denosumab 60mg?

Answer 37

1. Osteonecrosis of the jaw - more common in cancer treatment 2. Hypocalcaemia

Question 38

What risk factors can increase a patients chance of having osteonecrosis of the jaw?

Answer 38

1. Smoking 2. Advanced cancer 3. Poor oral hygiene 4. Previous treatment with bisphosphonates 5. Old age

Question 39

What should always be measured before each administration of denosumab?

Answer 39

Ca2+ levels.

Question 40

What are the symptoms of hypocalcaemia?

Answer 40

1. Muscle spams 2. Tingling in fingers/toes/around mouth 3. Numbness 4. Cramps

Question 41

What is an example of a SERM, and what is its mode of action?

Answer 41

Raloxifene. It activates estrogen receptors on osteoblasts to induce bone formation.

Question 42

What is the mechanism of action of strontium ranelate?

Answer 42

It stimulates bone formation & reduces bone shedding.

Question 43

When is strontium ranelate used?

Answer 43

Only if previous treatments have not worked, & only in specialist care.

Question 44

What is the dosing of strontium ranelate?

Answer 44

2g OD in 30mL water, at bedtime. - Avoid Ca2+ containing products too

Question 45

When should the use of strontium ranelate be stopped immediately?

Answer 45

If a rash/severe allergic reaction occurs. Assess the CV risk of the patient since it can increase CV risk too.

Question 46

When is HRT used as treatment for osteoporosis?

Answer 46

When all other treatments have failed. | It is also only used for premature menopausal women, & stopped at the natural age of menopause (50 years old)

Question 47

What risks increase while taking HRT?

Answer 47

CVD (clotting), stroke, and breast cancer

Question 48

What can HRT also be used for besides treatment?

Answer 48

Prophylaxis of postmenopausal osteoporosis (those with high risk)

Question 49

When is teriparatide given?

Answer 49

As a secondary prevention in fragile women who have osteoporosis to reduce their risk of a fracture. - Used in those very high risk - Use it limited due to costs

Question 50

What is the dosing of teriparatide?

Answer 50

20mcg daily via subcutaneous injection (for 2 years)

Question 51

What makes up teriparatide?

Answer 51

It is a fragment of the parathyroid hormone (inducing growth factors to make new bone)

Question 52

How does romosozumab work?

Answer 52

It is a monoclonal antibody which binds to sclerostin in osteocytes. Sclerostin inhibits bone formation, so blocking this = bone remains

Question 53

What is the dosing of romosozumab?

Answer 53

210mg once a month for 1 year + | vit C/D also taken as 105mg injections

Question 54

Besides osteoporosis, which patients should be considered for bone protective therapy?

Answer 54

Patients >70years old taking high levels of corticosteroids (>7.5mg/day prednisolone)

Question 55

What are the 2 first line treatment options for osteoporosis in men?

Answer 55

Alendronic acid & risedronate

Question 56

What are the alternative treatment options for osteoporosis in men?

Answer 56

Zoledronic acid, or denosumab (can also consider strontium ranelate or teriparatide)