Osteoporosis Flashcards by Aniqa Rahman

What are the risk factors for osteoporosis? (10)

Long-term oral corticosteroids
Vitamin D deficiency
Low calcium intake
Lack of physical activity
Low BMI
Cigarette smoking
Excess alcohol intake
Parental history of hip fractures
Previous fracture at a site characteristic of osteoporotic fractures
Early menopause

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Patients at risk of osteoporosis should ensure adequate intake of (?) and (?)

Calcium

Vitamin D

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What lifestyle changes should be encouraged in patients at risk of osteoporosis/fragility fractures?

Increase level of physical activity
Stop smoking
Maintain normal BMI
Reduce alcohol intake

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What is the first line for the treatment of osteoporosis in postmenopausal women?

Oral bisphosphonates

alendronic acid
risedronate sodium

Alternative oral bisphosphonate: ibandronic acid

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What are four alternative options for the treatment of osteoporosis in postmenopausal women in which oral bisphosphonates are not tolerated or unsuitable? (5)

Parenteral bisphosphonates
Denosumab
Raloxifene hydrochloride
Strontium ranelate
Hormone replacement therapy (HRT)

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The use of HRT for the management of osteoporosis is restricted to (?) women with menopausal symptoms who are at high risk of fractures

younger postmenopausal

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The use of HRT for the management of osteoporosis is restricted to younger postmenopausal women with (?) who are at high risk of fractures

menopausal symptoms

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Why is there restricted use of HRT in the management of osteoporosis?

Risk of adverse effects such as cardiovascular disease and cancer in older postmenopausal women and women on long-term HRT

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What osteoporosis treatment is reserved for postmenopausal women with severe osteoporosis at very high risk of fractures, particularly vertebral fractures?

Teriparatide

SIGN (2021) also recommend romosozumab as an option for postmenopausal women with severe osteoporosis who have previously experienced a fragility fracture and are at imminent risk of another (within 24 months).

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What is considered a large dose of glucocorticoids (requires bone-protection treatment)?

Prednisolone >/= 7.5 mg daily or equivalent

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When does the greatest rate of bone loss occur when taking glucocorticoids?

Early after initiation

The rate of bone loss also increases with the dose and duration of threapy

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What are the first-line treatment options for glucocorticoid-induced osteoporosis?

Oral bisphosphonates

alendronic acid
risedronate sodium

Alternatives

zoledronic acid
denosumab
teriparatide

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

Oral bisphosphonates

alendronic acid
risedronate sodium

Alternatives:

zoledronic acid
denosumab

Additional alternatives:

teriparatide
strontium ranelate

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What therapy for prostate cancer increases the fracture risk in men?

Androgen deprivation therapy

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After how many years of bisphosphonate treatment with alendronic acid should treatment be reviewed?

5 years

Bisphosphonate treatment should be reviewed after 5 years of treatment with alendronic acid, risedronate sodium or ibandronic acid, and after 3 years of treatment with zoledronic acid.

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After how many years of bisphosphonate treatment with risedronate sodium should treatment be reviewed?

5 years

Bisphosphonate treatment should be reviewed after 5 years of treatment with alendronic acid, risedronate sodium or ibandronic acid, and after 3 years of treatment with zoledronic acid.

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After how many years of bisphosphonate treatment with ibandronic acid should treatment be reviewed?

5 years

Bisphosphonate treatment should be reviewed after 5 years of treatment with alendronic acid, risedronate sodium or ibandronic acid, and after 3 years of treatment with zoledronic acid.

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After how many years of bisphosphonate treatment with zoledronic acid should treatment be reviewed?

3 years

Bisphosphonate treatment should be reviewed after 5 years of treatment with alendronic acid, risedronate sodium or ibandronic acid, and after 3 years of treatment with zoledronic acid.

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Which patients are generally recommended (based on fracture-risk assessment) to continue bisphosphonate treatment beyond the review at 5 years?

Aged > 75 years
History of previous hip or vertebral fracture
One or more fragility fractures during treatment
Taking long-term glucocorticoid treatment

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(?) are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover.

Bisphosphonates

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Bisphosphonates are adsorbed onto hydroxyapatite crystals in (?), slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover.

bone

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Bisphosphonates are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore (?) the rate of bone turnover.

reducing

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What is the indication for the use of alendronic acid?

Osteoporosis

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What is the dose of alendronic acid for the treatment of osteoporosis?

10 mg daily

Alternatively 70 mg once weekly (only an option for treatment of postmenopausal osteoporosis in BNF)

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Why should patients be advised to report any thigh, hip or groin pain during the treatment with a bisphosphonate?

Atypical femoral fractures have been reported rarely with bisphosphonate treatment Mainly in patients receiving long-term treatment for osteoporosis

The risk of (?) of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease.

osteonecrosis

The risk of osteonecrosis of the (?) is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease.

jaw

The risk of osteonecrosis of the jaw is substantially greater for patients receiving (?) bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease.

Which bisphosphonate has the highest risk of developing osteonecrosis of the jaw?

Zoledronate

Which patients need a dental check-up before bisphosphonate treatment or as soon as possible after starting treatment? (2)

1. Patients with cancer | 2. Patients with poor dental status

What are the risk factors for developing osteonecrosis of the jaw when taking a bisphosphonate? (8)

1. Potency of bisphosphonate (highest for zoledronate) 2. Route of administration (IV) 3. Cumulative dose 4. Duration and type of malignant disease 5. Concomitant treatment 6. Smoking 7. Comorbid conditions 8. History of dental disease

Osteonecrosis has been reported in which two body parts in patients taking bisphosphonates?

Jaw | External auditory canal

A patient taking bisphosphonate presents with ear symptoms such as chronic ear infection or suspected cholesteatoma. What very rare complication of bisphosphonate treatment do you need to consider?

Benign ideopathic osteonecrosis of the external auditory canal Benign idiopathic osteonecrosis of the external auditory canal has been reported very rarely with bisphosphonate treatment, mainly in patients receiving long-term therapy (2 years or longer).

What are the risk factors for developing osteonecrosis of the external canal in patients taking bisphosphonates?

1. Steroid use 2. Chemotherapy 3. Infection 4. An ear operation 5. Cotton-bud use

What are the contraindications for the use of alendronic acid?

1. Abnormalities of oesophagus 2. Hypocalcaemia 3. Other factors which delay emptying (e.g. stricture or achalasia)

Which electrolyte abnormality is a contraindication to the use of alendronic acid?

Hypocalcaemia

When is a prescription of bisphosphonate potentially inappropriate (STOPP criteria) in an elderly patient?

Current or recent history of GI disease or bleeding (risk of relapse/exacerbation of oesophagitis, oesophageal ulcer or oesophageal stricture)

Bisphosphonates should be avoided if creatinine clearance is less an (?) mL/minute

35 mL/minute

What needs to be corrected before starting treatment with bisphosphonate?

Disturbances of calcium and mineral metabolism (e.g. vitamin D deficiency, hypocalcaemia)

What should be monitored during treatment with bisphosphonate?

Serum-calcium concentration

What are the directions for administration for oral bisphosphonates? (4 steps)

1. Swallow whole (if solution in a single dose) 2. Taken with plenty of water while sitting or standing 3. On an empty stomach at least 30 minutes before breakfast (or another oral medicine) 4. Stand or sit upright for at least 30 minutes after administration (1 hour for ibandronic acid)

(?) is a human monoclonal antibody that inhibits osteoclast formation, function, and survival, thereby decreasing bone resorption.

Denosumab

Denosumab is a human monoclonal antibody that inhibits (?) formation, function, and survival, thereby decreasing bone resorption.

osteoclast

Denosumab is a human monoclonal antibody that inhibits osteoclast formation, function, and survival, thereby (?) bone resorption.

decreasing

Denosumab is a human monoclonal antibody that inhibits osteoclast formation, function, and survival, thereby decreasing bone (?).

resorption

Why should patients report any new or unusual thigh, hip, or groin pain during treatment with denosumab?

Atypical femoral fractures Atypical femoral fractures have been reported rarely in patients receiving denosumab for the long-term treatment (2.5 or more years) of postmenopausal osteoporosis.

Osteonecrosis of the jaw is a well-known and common side-effect in patients receiving denosumab (?)mg for cancer

120 mg

(?) is a well-known and common side-effect in patients receiving denosumab 120 mg for cancer

Osteonecrosis of the jaw

What are the risk factors of developing osteonecrosis of the jaw when receiving treatment with denosumab?

1. Smoking 2. Old age 3. Poor oral hygiene 4. Invasive dental procedures 5. Comorbidity (dental disease, anaemia, coagulopathy, infection) 6. Advanced cancer 7. Previous treatment with bisphosphonates 8. Concomitant treatments (chemotherapy, anti-angiogenic biologics, corticosteroids, radiotherapy to the head and neck)

Which electrolyte abnormality is associated with denosumab?

Hypocalcaemia Hypocalcaemia usually occurs in the first weeks of denosumab treatment, but it can also occur later in treatment.

What increases the risk of hypocalcaemia in patients taking denosumab?

Renal impairment

All patients receiving denosumab should be advised to report symptoms of hypocalcemia. What are these symptoms?

Muscle spasms, twitches, cramps | Numbness or tingling in the fingers, toes or around the mouth

What is the contraindication to the use of denosumab?

Hypocalcaemia

What are the common side effects of denosumab?

1. Abdominal discomfort 2. Cataract 3. Constipation 4. Hypocalcaemia 5. Increased risk of infection 6. Pain 7. Sciatica 8. Second primary malignancy 9. Skin reactions

Effective contraception in women of child-bearing potential is essential during treatment with denosumab. For how long after stopping denosumab do the women need to continue contraception?

At least 5 months Ensure effective contraception in women of child-bearing potential, during treatment and for at least 5 months after stopping treatment.

Renal impairment with a creatinince clearance less than 30 mL/minute increases the risk of which side effect of denosumab?

Hypocalcaemia

What needs to be corrected prior to starting treatment with denosumab?

Hypocalcaemia | Vitamin D deficiency

What needs to be monitored during treatment with denosumab?

Plasma-calcium concentration

What are the indications for the use of ibandronic acid? (3)

1. Reduction of bone damage in bone metastases in breast cancer 2. Hypercalcaemia of malignancy 3. Treatment of postmenopausal osteoporosis

What are the side effects of all bisphosphonates? (26)

1. Alopecia 2. Anaemia 3. Arthralgia 4. Asthenia 5. Constipation 6. Diarrhoea 7. Dizziness 8. Dysphagia 9. Electrolyte imbalance 10. Eye inflammation 11. Fever 12. Gastritis 13. GI discomfort 14. Headache 15. Influenza like illness 16. Malaise 17. Myalgia 18. Nausea 19. Oesophageal ulcer 20. Oesophagitis 21. Pain 22. Peripheral oedema 23. Renal impairment 24. Skin reactions 25. Taste altered 26. Vomiting

In addition to the common side effects for all bisphosphonates, what are the additional common side effects for alendronic acid? (3)

GI disorders Joint swelling Vertigo

What class of drug is raloxifene hydrochloride?

Selective oestrogen receptor modulator (SERM)

What are the two indications for the use of raloxifene hydrochloride?

Postmenopausal osteoporosis | Breast cancer [chemoprevention in postmenopausal women at moderate to high risk]

What are the contraindications for the use of raloxifene hydrochloride? (4)

Cholestasis Endometrial cancer History of VTE Undiagnosed uterine bleeding

What are the common side effects of raloxifene hydrochloride? (4)

Influenza Leg cramps Peripheral oedema Vasodilation

What class of drug is alendronic acid?

Bisphosphonate

What class of drug is ibandronic acid?

Bisphosphonate

What class of drug is risedronate sodium?

Bisphosphonate

What are the indications for the use of risedronate sodium? (2)

1. Paget's disease of bone 2. Osteoporosis - postmenopausal osteoporosis - Corticosteroid osteoporosis in postmenopausal women - Osteoporosis in men

What is the contraindication for the use of risedronate sodium?

Hypocalcaemia

What needs to be correct before starting or at the onset of treatment with risedronate sodium?

Hypocalcaemia | Other disturbances of bone and mineral metabolism (e.g. vitamin D deficiency)

What foods, supplements and medications should be avoided for at least 2 hours before or after taking risedronate? (3)

Calcium-containing products (e.g. milk) Iron and mineral supplements Antacids

(?) is a humanised monoclonal antibody that inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption.

Romosozumab

Romosozumab is a humanised monoclonal antibody that inhibits (?), thereby increasing bone formation and decreasing bone resorption.

sclerostin

Romosozumab is a humanised monoclonal antibody that inhibits sclerostin, thereby (?) bone formation and decreasing bone resorption.

increasing

Romosozumab is a humanised monoclonal antibody that inhibits sclerostin, thereby increasing bone formation and (?) bone resorption.

decreasing

Romosozumab is a humanised monoclonal antibody that inhibits sclerostin, thereby increasing bone (1?) and decreasing bone (2?).

1. formation | 2. resorption

What is the indication for the use of romosozumab?

Severe osteoporosis in postmenopausal women at increased risk of fractures (specialist use only) - Subcutaneous injection

Strontium ranelate stimulates bone (1?) and reduces bone (2?).

1. formation | 2. resorption

What is the indication for the use of strontium ranelate?

Severe osteoporosis in men and postmenopausal women at increased risk of fractures (initiated by a specialist)

Teriparatide contains a synthetic form of natural human hormone called (?)

parathyroid hormone (PTH)

(?) contains a synthetic form of natural human hormone called parathyroid hormone (PTH).

Teriparatide

What is the indication for the use of teriparatide?

Osteoporosis | Corticosteroid-induced osteoporosis

What are the contraindications for the use of teriparatide?

1. Bone metastases 2. Hyperparathyroidism 3. Metabolic bone diseases 4. Paget's disease 5. Pre-existing hypercalcaemia 6. Previous radiation therapy to the skeleton 7. Skeletal malignancies 8. Unexplained raised alkaline phosphatase (ALP)

(?) is a synthetic steroid hormone drug, which is mainly non-selective in its binding profile, acting as an agonist primarily at estrogen receptors (ER)

Tibolone

Tibolone is a synthetic steroid hormone drug, which is mainly non-selective in its binding profile, acting as an agonist primarily at (?) receptors (ER)

Oestrogen

What are the 2 indications for the use of tibolone?

1. Short-term treatment of symptoms of oestrogen deficiency 2. Osteoporosis prophylaxis in women at high risk of fractures when other prophylaxis is contraindicated or not tolerated

What are the common side effects of tibolone?

1. Breast abnormalities 2. Cervical dysplasia 3. Endometrial thickening 4. Gi discomfort 5. Genital abnormalities 6. Hair growth abnormal 7. Increased risk of infection 8. Pelvic pain 9. Postmenopausal haemorrhage 10. Vaginal discharge 11. Vaginal haemorrhage 12. Weight increased

What class of drug is zoledronic acid?

Bisphosphonate

What are the indications for the use of zoledronic acid? (5)

1. Prevention of skeletal related events in advanced malignancies involving bone (specialist use only) 2. Tumour-induced hypercalcaemia (specialist use only) 3. Paget's disease of bone (specialist use only) 4. Osteoporosis (including corticosteroid-induced osteoporosis) in men and postmenopausal women 5. Fracture prevention in osteopenia [hip or femoral neck]

Which bisphosphonate is contraindicated in women of child-bearing potential?

Zoledronic acid

Can bisphosphonates be taken during pregnancy?