Osteoporosis Flashcards
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
Patients at risk of osteoporosis should ensure adequate intake of (?) and (?)
Calcium
Vitamin D
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
What is the first line for the treatment of osteoporosis in postmenopausal women?
Oral bisphosphonates
- alendronic acid
- risedronate sodium
Alternative oral bisphosphonate: ibandronic acid
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)
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
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
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
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).
What is considered a large dose of glucocorticoids (requires bone-protection treatment)?
Prednisolone >/= 7.5 mg daily or equivalent
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
What are the first-line treatment options for glucocorticoid-induced osteoporosis?
Oral bisphosphonates
- alendronic acid
- risedronate sodium
Alternatives
- zoledronic acid
- denosumab
- teriparatide
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
What therapy for prostate cancer increases the fracture risk in men?
Androgen deprivation therapy
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.
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.
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.
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.
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
(?) are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover.
Bisphosphonates
Bisphosphonates are adsorbed onto hydroxyapatite crystals in (?), slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover.
bone
Bisphosphonates are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore (?) the rate of bone turnover.
reducing
What is the indication for the use of alendronic acid?
Osteoporosis
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)
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.
IV
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)
- 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)
- Potency of bisphosphonate (highest for zoledronate)
- Route of administration (IV)
- Cumulative dose
- Duration and type of malignant disease
- Concomitant treatment
- Smoking
- Comorbid conditions
- 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?
- Steroid use
- Chemotherapy
- Infection
- An ear operation
- Cotton-bud use
What are the contraindications for the use of alendronic acid?
- Abnormalities of oesophagus
- Hypocalcaemia
- 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)
- Swallow whole (if solution in a single dose)
- Taken with plenty of water while sitting or standing
- On an empty stomach at least 30 minutes before breakfast (or another oral medicine)
- 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?
- Smoking
- Old age
- Poor oral hygiene
- Invasive dental procedures
- Comorbidity (dental disease, anaemia, coagulopathy, infection)
- Advanced cancer
- Previous treatment with bisphosphonates
- 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?
- Abdominal discomfort
- Cataract
- Constipation
- Hypocalcaemia
- Increased risk of infection
- Pain
- Sciatica
- Second primary malignancy
- 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)
- Reduction of bone damage in bone metastases in breast cancer
- Hypercalcaemia of malignancy
- Treatment of postmenopausal osteoporosis
What are the side effects of all bisphosphonates? (26)
- Alopecia
- Anaemia
- Arthralgia
- Asthenia
- Constipation
- Diarrhoea
- Dizziness
- Dysphagia
- Electrolyte imbalance
- Eye inflammation
- Fever
- Gastritis
- GI discomfort
- Headache
- Influenza like illness
- Malaise
- Myalgia
- Nausea
- Oesophageal ulcer
- Oesophagitis
- Pain
- Peripheral oedema
- Renal impairment
- Skin reactions
- Taste altered
- 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)
- Paget’s disease of bone
- 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?).
- 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?).
- 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?
- Bone metastases
- Hyperparathyroidism
- Metabolic bone diseases
- Paget’s disease
- Pre-existing hypercalcaemia
- Previous radiation therapy to the skeleton
- Skeletal malignancies
- 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?
- Short-term treatment of symptoms of oestrogen deficiency
- 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?
- Breast abnormalities
- Cervical dysplasia
- Endometrial thickening
- Gi discomfort
- Genital abnormalities
- Hair growth abnormal
- Increased risk of infection
- Pelvic pain
- Postmenopausal haemorrhage
- Vaginal discharge
- Vaginal haemorrhage
- Weight increased
What class of drug is zoledronic acid?
Bisphosphonate
What are the indications for the use of zoledronic acid? (5)
- Prevention of skeletal related events in advanced malignancies involving bone (specialist use only)
- Tumour-induced hypercalcaemia (specialist use only)
- Paget’s disease of bone (specialist use only)
- Osteoporosis (including corticosteroid-induced osteoporosis) in men and postmenopausal women
- 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?
NO
