Osteoperosis

Question 1

What is Osteoperosis?

Answer 1

Osteoperosis is a type of metabolic bone disease characterised by reduced bone mass

Question 2

How is Osteoperosis defined?

Answer 2

Bone density more than 2.5 SD below the mean young adult bone density

Question 3

What parts of the bone can Osteoperosis affect?

Answer 3

=> Trabecular bone - crush fractures

=> Corticol bone - long fractures common

Question 4

What are the risk factors of Osteoperosis?

Answer 4

=> 2 major risk factors are age and female gender

=> Other risk factors - use mneumonic SHATTERED

S - Steroid use > 5mg/d
H - Hyperthryoidism, Hyperparathyroidism, Hypercalciuria
A - Alcohol and tobacco use
T - Thin
T - Testosterone low
E - Early menopause
R - Renal or Liver Disease
E - Erosive/ IBD
D - Dietary Ca low

Question 5

What are the causes of Osteoperosis?

Answer 5

=> Drugs:

• Glucocorticoids
• Antiepileptics
• PPIs
• Glitazones
• Long term heparin therapy
• SSRIs
• Aromatase inhibitors

=> Increased bone loss

=> Decreased bone mass

Question 6

What drugs worsen Osteoperosis?

Answer 6

• Glucocorticoids
• SSRIs
• Antiepileptics
• PPIs
• Glitazones
• Long term heparin therapy
• Aromatase inhibitors

Question 7

What are the clinical features of Osteoperosis?

Answer 7

• Impaired vision
• Back pain
• Kyphosis
• Impaired gait, inbalance, lower-extremity weakness
• Vertebral tenderness

Question 8

What are the most common fractures of Osteoperosis?

Answer 8

• Thoracic
• Lumbar
• Proximal femur
• Distal radius

Question 9

What is the differential diagnosis of Osteoperosis?

Answer 9

• Primary hyperparathyroidism
• Osteomalacia
• Metabolic bone malignancy
• Multiple myeloma
• Vertebral deformities

Question 10

What is the pathophysiology of Osteoperosis?

Answer 10

Osteoclast activity > Osteoblast activity

• Post menopausal woman see increased risk of osteoperosis due to drop in oestrogen levels
• Senile osteoperosis involves age related loss of activity of osteoblasts where s osteoclasts remain unaffected

Question 11

What are the investigations in suspected Osteoporosis?

Answer 11

=> FRAX score - can be done with or without DEXA
Without DEXA, FRAX score categorises fracture risk:
low - reassure and lifestyle advice
intermediate - offer DEXA
high - treatment

• FRAX score is considered in all women ≥ 65 and men ≥ 75, and in younger patients with certain risk factors

=> QFracture risk

=> DEXA
- Considered before risk tools if the person is under 40 with major risk factors

Question 12

What is the management of Osteoperosis?

Answer 12

=> Lifestyle measures

• Reduce smoking and alcohol
• Start weight bearing exercises
• Calcium and Vitamin D rich diet
• Home based fall prevention programmes

=> Pharmacological measures

• First line Bisphosphonates - Alendronate
• If Alendronate not tolerated, then selective oestrogen receptor modulator given , Raloxifine
• RANKL antibody - Denosumab
• Teriparatide

=> Calcium and Vitamin D supplementations

=> Bisphosphonates should be taken with plenty of water whilst upright as they cause oesophageal ulcers

Question 13

What is a DEXA scan?

Answer 13

Used to calculate a T and Z score

T score:
> -1 means normal
(-1) - (-2.5) means osteopenia
< (-2.5) osteoporosis

Question 14

What factors are considered in the FRAX tool?

Answer 14

• Age
• Sex
• Weight
• Height
• Current fracture
• Parental fracture
• Smoking
• RA
• Glucocorticoids
• Secondary osteoperosis
• Alcohol intake

Question 15

What is the management of patients who are at risk of glucocorticoid induced osteoperosis?

Answer 15

=> Patients > 65 or those who have had a previous fragility fracture should be started on bone protection

=> Patients < 65 should be offered DEXA:

Score > 0 means reassure
Score 0 to -1.5 means repeat DEXA in 1-3 years
Score < -1.5 means offer bone protection

=> Bone protection:

• First line is bisphosphonate
• Calcium and Vitamin D supplements also given