Osteoporosis

Question 1

Osteoporosis: Dx

Answer 1

• Skeletal condition characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture leading to compromised bone strength
• Increases the risk of fragility (i.e. non-traumatic) fractures.

Question 2

Osteoporosis: risk factors

Answer 2

• Non-modifiable
  
  • Advanced age (>65 years)
  • Female gender
  • Caucasian or south Asians
  • Family history of osteoporosis-genetic
  • History of low trauma fracture
• Modifiable
  
  • Low body weight (58 kg or body mass index [BMI] <21)
  • Premature menopause (age<45)
  • Sedentary lifestyle
  • Calcium/vitamin D deficiency
  • Rheumatoid Arthritis
  • Cigarette smoking
  • Excessive alcohol intake (>3 drinks/day)
  • Iatrogenic: e.g. corticosteroids, aromatase inhibitors
  • Other than steroids: SSRIs, Antiepileptics, PPI, Glitazones, Long term heparin
  • Endocrine disorders: hyperthyroidism, hypogonadism, GH deficiency, hyperparathyroidism, diabetes mellitus
  • Multiple myeloma, lymphoma
  • History of parental hip fracture
  • Gastrointestinal disorders: IBD, malabsorption (e.g. Coeliac’s), gastrectomy, liver disease
  • Chronic kidney disease
  • Osteogenesis imperfecta, homocystinuria

Question 3

Osteoporosis: Screening tools

Answer 3

• FRAX
• QFracture Risk

Question 4

Osteoporosis: Gold Standard Diagnostic Ix

Answer 4

• Gold Standard: Dual energy x-ray absorptiometry (DEXA) of the lumbar spine and hip
• T-score is the number of SDs from the mean bone density of persons of same gender at age of peak density (25 years)
  
  • T-score minus 2.5 or less = Osteoporosis
  • Normal BMD = T-score ≥ −1
  • Osteopenia = T-score between −1 and −2.5

Question 5

Osteopenia: Mx

Answer 5

• Weight-bearing exercise
• Vitamin D3 supplementation (800-2000 IU/day)
• Limiting alcohol
• Smoking cessation
• Dietary advice regarding calcium intake; supplements if needed.

Question 6

Osteoporosis: Mx

Answer 6

• Vitamin D ± calcium supplementation plus:
  
  • 1st line: Oral bisphosphonates, or IV if oral not tolerated.
    
    • Alendronate but Risedronate or Etidronate if not tolerated
  • 2nd line: Raloxifene or Strontium or Denosumab or teriparatide

Question 7

Osteoporosis: Blood Ix

Answer 7

• Full blood count
• Urea and Electrolytes
• Liver function tests
• Bone profile
• CRP
• Thyroid function tests

Question 8

Why are Bloods done for Osteoporosis?

Answer 8

1. Exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma)
2. Identify the cause of osteoporosis and contributory factors
3. Assess the risk of subsequent fractures
4. Select the most appropriate form of treatment

Question 9

Glucocorticoid-induced Osteoporosis: causes

Answer 9

• Risk of osteoporosis is thought to rise significantly once a patient is taking the equivalent of prednisolone 7.5mg a day for 3 or more months.
• Treat anticipating if patient on it for more than 3 months

Question 10

Glucocorticoid-induced Osteoporosis: Mx

Answer 10

• Patients over the age of 65 years or those who’ve previously had a fragility fracture should be offered bone protection.
• Patients under the age of 65 years should be offered a bone density scan, with further management dependent:
  
  • Greater than 0 = Reassure
  • Between 0 and -1.5 = Repeat bone density scan in 1-3 years
  • Less than -1.5 = Offer bone protection

Question 11

Glucocorticoid-induced Osteoporosis: medications

Answer 11

1st line treatment is Alendronate + Calcium + Vitamin D