Osteoporosis

Question 1

when does risk of glucocorticoid-induced osteoporosis increase significantly?

Answer 1

if taking equivalent of prednisolone 7.5mg a day for 3 or more months

so if pt has to take steroids for at least 3mo, start bone protection immediately (e.g. in PMR)

Question 2

mx stratification of pt at risk of glucocorticoid-induced osteoporosis?

Answer 2

pt > 65 or those with hx of fragility #: bone protection

pt < 65: bone density scan
- over 0: reassure
- 0 to -1.5: repeat scan in 1-3 years
- less than 1.5: bone protection

Question 3

what is first-line for bone protect?

Answer 3

alendronate

pt should also be on calcium and vit. d replete

Question 4

what are the main rfs of osteoporosis

Answer 4

history of glucocorticoid use
history of parental hip fracture
RA
low bmi
smoking
alcohol excess

Question 5

what are other rfs of osteoporosis

Answer 5

sedentary lifestyle
premature menopause
caucasians, asians

multiple myeloma, lymphoma
CKD
osteogenesis imperfecta, homocystinuria
gi disorders
endocrine disorders

Question 6

what gi disorders are a/w osteoporosis?

Answer 6

ibd
malabsorption, e.g. coeliac’s
gastrectomy
liver disease

Question 7

what endo disorders are a/w osteoporosis?

Answer 7

hyperthyroidism
hyperparathyroidism
hypogonadism (e.g. turner’s, testosterone deficiency)
growth hormone deficiency
DM

Question 8

what medications may worsen osteoporosis

Answer 8

glucocrticoids
SSRIs
antiepileptics
PPIs
glitazones
long-term heparin
aromatase inhibitors e.g. anastrozole

Question 9

what first-line ix can be done to investigate secondary causes

Answer 9

hx, physical exam
FBC, ESR, CRP, LFTs, serum calcium, albumin, creatinine, phosphate, TFTs
bone profile: densitometry (DEXA)

Question 10

factors a/w reduced risk of osteoporosis?

Answer 10

high impact exercise
late menopause
Black ethnicity

Question 11

why does RA increase risk of osteoporosis?

Answer 11

likely multifactorial

increased use of corticosteroids, immobility due to joint pain, effect of systemic inflammation on bone remodelling

Question 12

when are bisphosphonates CI (renal)?

Answer 12

if eGFR > 35 mL/min/1.73m2
so class 3b, 4 and 5 CKD

Question 13

when is bone protection indicated in postmenopasual women if the pt is not on steroids?

Answer 13

if >75 -> GIVE

if <75 -> DEXA
T < -2.5 (GIVE alendronate)

Question 14

when is bone protection indicated in postmenopasual women if the pt is on steroids?

Answer 14

if > 65 -> GIVE (no need for scan)

if < 65 -> DEXA
T < -1.5 (GIVE alendronate)
T > -1.5 (repeat scan 1-3y)

Question 15

what is incl in 2o prevention of osteoporotic fractures in postmenopausal women?

Answer 15

ALL: vit d + ca unless confident they are replete
SOME: alendronate

Question 16

what is given if pt cannot tolerate alendronate?

Answer 16

risedronate or etidronate

Question 17

what is given if pt cannot tolerate bisphosphonates in secondary prevention of osteoporotic fractures?

Answer 17

strontium ranelate and raloxifene (on strict t-scores, e.g. 60y need t score of < 3.5)

Question 18

what % pt cannot tolerate alendronate and why?

Answer 18

25%
upper gi problems

Question 19

what drug alternative to alendronate has the strictest criteria?

Answer 19

denosumab

Question 20

what bisphosphonates are licensed for prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis?

Answer 20

alendronate
risedronate
etidronate

reduce risk of both vertebral and non-vertebral #

Question 21

what is ibandronate?

Answer 21

once-monthly oral bisphosphonate

Question 22

what is raloxifene?

Answer 22

SERM
- shown to prevent bone loss + reduce risk of vertebral #
- increases bone density in spine and prox femur
- may worsen menopausal sx
- increase risk of thromboembolic events
- decreased risk of breast cancer

Question 23

what is strontium ranelate?

Answer 23

dual action bone agent
- increased deposition of new bone by OB differentiation
- reduced resorption of bone by OC inhibition

poor safety profile - only used last-resort
- CV events
- thromboembolic events
- skin rxr (e.g. stevens-johnson)

Question 24

when is strontium ranelate CI?

Answer 24

if hx of cvd or significant risk of cvd

Question 25

what is denosumab?

Answer 25

human mAb against RANK ligand, in turn inhibiting maturation of OC
given as single sc injection 6-monthly

Question 26

what is teriparatide?

Answer 26

recombinant PTH
good at increasing BMD but unclear role in osteoporosis management

Question 27

is HRT used in osteoporosis mx?

Answer 27

reduces vertebral and non-vertebral # incidence

BUT concerns for increased rate of CVD and breast cancer, so no longer recommended unless woman suffering from vasomotor symptoms

Question 28

what are non-medical approaches to osteoporosis mx?

Answer 28

hip protectors - reduce hip # in nursing home pt
compliance is an issue

Question 29

when should tx be reassessed with ongoing bisphosphonates?

Answer 29

after 5y for oral or 3y for IV zoledronate
should be reassessed with updated FRAX score and DEXA scan

continue indefinitely if high risk
stop if low risk, T score > -2.5, then review in 2 years

Question 30

who is considered high risk for osteoporosis when considering stopping bisphosphonates?

Answer 30

any of the following are true:

Age >75
Glucocorticoid therapy
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score <-2.5 after treatment

Question 31

what does a z score adjust for?

Answer 31

age
gender
ethnic factors

Question 32

what does a t score do?

Answer 32

is bmd compared to a healthy 30 year old

Question 33

how should oral bisphonates be taken?

Answer 33

swallowed with lots of water while sitting or standing on an EMPTY STOMACH at least 30 MINUTES before breakfast/another oral med

pt should stand or sit upright for at least 30 minutes afte taking

Question 34

what are CI for oral bisphosphonate therapy?

Answer 34

oesophageal disorders
unsafe swallow

as bisphosphonates can react with oesophageal lining and increase risk of oesophagitis

Question 35

why should bisphosphonates be taken with water?

Answer 35

minimises risk of oesophageal retention