Metabolic Bone Disease Flashcards
OSTEOPOROSIS
more common in females or males?
RF: SHATTERED
What defines osteoporosis in regards to BMD (bone mineral density)?
how can osteoporosis present?
Ix for osteoporosis is DEXA scan:
- get a T score based on bone mass, what is the score for normal, osteopaenia and osteoporosis?
Tx of Osteoporosis
- conservative?
- supplements?
- medication:
1st line bisphosphonate?
2nd line bisphosphonate? - rule for taking this medication?
- what can we provide for post-menopausal women?
- for those intolerant to bisphosphonates?
- human monoclonal antibody that can be injected every 6 months?
- females
RF:
- S – Steroid use
- H – Hyperthyroidism
- A –Alcohol
- T – Thin (<22 BMI)
- T – Testosterone low
- E –Early menopause
- R – Renal failure
- E – Erosive/inflam bone disease (RA)
- D – Dietary Calcium low
- A BMD value (T score) 2.5 SD below the standard value observed in young healthy adults defines it.
T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Tx:
- Quit smoking and reduce alcohol.
- Calcium and Vit D supplements.
alendronate is first line orally
2nd line = risedronate.
- For bisphosphonates – say to swallow pill with plenty of water whist remaining upright for 30 mins on an empty stomach (before breakfast) and not eat/take other drugs until 30 minutes after.
- Hormone replacement therapy can prevent osteoporosis in post-menopausal women.
- Strontium ranelate – reduce fracture rates – alternative to those intolerant to bisphosphonates
- denosumab
Side effects of bisphosphonates?
Side effects of bisphosphonates – osteonecrosis of jaw, oesophageal ulcers.
OESOPHAGEAL PROBLEMS
Which one of the following is not a risk factor for developing osteoporosis?
smoking obesity sedentary lifestyle premature menopause female sex
obesity
Low body mass, rather than obesity is associated with an increased risk of developing osteoporosis
OSTEOPOROSIS
What is FRAX score?
If someone has a FRAX score of 10% or higher?
indicate a risk of suffering a fragility fracture in the next 10 years.
This value is considered to be the threshold of arranging a DEXA scan for both genders.
A 56-year-old woman attends the rheumatology clinic for follow up of her rheumatoid arthritis after a recent flare-up which was treated with oral prednisolone. When assessing the patient, her fracture risk assessment tool (FRAX) score was found to be 11%.
What is the most appropriate next step of management in regards to her FRAX score?
Prescribe vit d supplement
DEXA scan
Annual review of fracture risk
Prescribe alendronic acid weekly
DEXA scan
A FRAX score of 10% or greater warrants a DEXA scan
OSTEOPOROSIS
IF someone is going to take long term steroids for a certain condition - what action do you need to take?
Bone protection for patients who are going to take long-term steroids should start immediately
give bisphosphonate + calcium and Vit D supplements
A 71-year-old woman is diagnosed with polymyalgia rheumatica. She is started on prednisolone 15mg od. What is the most appropriate approach to bone protection?
arrange DEXA scan
ensure calcium and vit D replete
Reassess fracture risk after 3 months
Do a FRAX assessment
start oral alendronate + ensure calcium and vit D replete
start oral alendronate + ensure calcium and vit D replete
A 83-year-old lady comes to see you with her daughter, who’s wondering if her mum needs to be on something to protect her bones. Her past medical history includes a fracture neck of femur ten months ago, chronic kidney disease stage IV, hypertension and ischaemic heart disease.
After her fractured neck of femur, she was discharged from hospital on alendronic acid. This was stopped by a colleague six months ago due to distressing reflux, which resolved once the tablet was stopped. She was also unable to tolerate risedronate for the same reason. Her DEXA scan after her fractured neck of femur showed a T score of -4.2.
What is the most appropriate action?
repeat DEXA scan
re-introduce alendronate
refer for denosumab
refer for IV zoledronate infusion
refer for denosumab
A 70-year-old woman attends your GP surgery having fallen in her kitchen last week. After the fall, she attended the emergency department and was found to have some bruising, but no fractures. She is worried that she might fall again, and is worried about a fracture occurring in the future. You suggest an assessment of the patient’s fracture risk. Which of the following would be most appropriate in assessing the patient’s fracture risk?
DEXA scan
FRAX tool
Bone scan
FRAX tool
A 55-year-old woman presents for review. Her mother has just been discharged after suffering a hip fracture. She is concerned that she may have ‘inherited’ osteoporosis and is asking what she should do. She has no significant past medical history of note, takes no regular medication and has never sustained any fractures. She smokes around 20 cigarettes per day and drinks about 3-4 units of alcohol per day.
What is the most appropriate course of action?
Arrange DEXA scan
Refer to genetics team
FRAX tool
start bisphosphonates
FRAX tool
A 57-year-old woman with a history of polymyalgia rheumatica has been taking prednisolone 10 mg for the past 5 months. A DEXA scan is reported as follows:
L2 T-score -1.6 SD
Femoral neck T-score -1.7 SD
What is the most suitable management?
no Tx Vit D + Calcium Vit D Vit D + calcium + HRT Vit D + calcium + oral bisphosphonate
Vit D + calcium + oral bisphosphonate
A 78-year-old woman is discharged following a fractured neck of femur. On review she is making good progress but consideration is given to secondary prevention of further fractures. What is the most suitable management?
arrange DEXA + start strontium ranelate if T score < 2.5 SD
start oral bisphosphanate
arrange DEXA + start bisphosphonate if T score < 2.5 SD
stat oral bisphosphanate
NICE guidelines support starting a bisphosphonate without waiting for a DEXA scan in such scenarios
A 75-year-old female was recently started on alendronate for treatment of osteoporosis following a fragility fracture. She returns to your clinic as she has suffered troubling upper gastrointestinal side effects. What is the most appropriate next step in her management?
continue alendronate
change alendronate to strontium ranelate
change alendronate to risedronate
change alendronate to denosumab
change alendronate to risedronate
OSTEOMALACIA
- what is it?
- if it occurs in children what do they get?
- mainly due to deficiency of?
- how do adults present?
- how do children present?
- Tx?
- if resistant to above medication?
- normal bony tissue but reduced mineral content
- rickets
- vit D
- adults: pathological fractures
- children: limb deformities - bow legged
Tx: calcium with Vit D supplements
- give calcitrol
How do you differentiate between osteomalacia and Paget’s disease in investigations?
Osteomalacia = increased ALP, low Calcium, low PO4
Paget’s disease = only raised ALP
