Osteoporosis Flashcards
What is osteoporosis defined by?
Low bone mass
Microarchitectual deterioration of bone tissue
Increase in bone fragility + fracture susceptibility
T score for osteoporosis
<2.5
Common sites fragility fractire
Vertebral bodies
Hip - NOF
Distal fractures
Proximal humerus
Pelvis
Which bone cells are multinucleated?
Osteocalsts
What is the function of osteoblasts?
Secrete osteoid - make bone
What is the function of osteoclasts?
Destroy bone - remodelling
Modelling vs remodelling of bone
Modelling - bone resorption and formation on seperate surafces - growth from birth to adulthood
Remodelling - maintains bone mass and structural integrity, resorption and formation at same site
Mineral depositions in bone
Calcium pyrophosphate
Phosphate
Features of long bones
tubular, cortical layer surrounding spongy trabecular bone
Felxible enogh to absorb stress but strong
What kind of bones are the vertebrae?
Long bones
Pathophysiology osteoporosisn
age → daily remodelling → resorption minerals on insede corticcal layer + in bone cavity → loss trabecular bone and widening of cavity
Fixed risk factors for osteoporosis
- Age
- Female - post menopausal
- Family hisotry
- Caucasian, asian more prone to osteoporosis
- Height loss
- Oestrogen deficiency
- Amenorrhea
- Early menopause
- Hysterectomy
Modifiable risk factors osteoporosis
- CKD → tertiary hyperparathyroidism
- Smoking
- Aclohol
- Low BMI
- Poor nutrition - low dietary calcium intkae
- Vit D deficinecy
- PTH abnormalities
- Eating disorders
- Insufficient exercise
- Frequent falls
- IBD
- Endocrine disorders
- RA
- T1/T2DM - insulin use, longer duration of disease independent of BMD
Medications that increase risk for osteoprorosis
- Corticosteroids
- THyroid hormone excess - medication or pathological
- Aromatase inhibitors - treatnent of breast cancer
- Androgen deprivation for prostate cancer treatment
- Thiazolidinediones
- Antidepressents, antiparkinsonia, antipsychotics, anxiolytics drugs, benzos, sedatices, H3 receptor agonists, PPIs
Scoring for osteoporosis
FRAX - infor about treatment threshold
What medicationand time frame is an indiciation for a DEXA scan?
Corticosteroids - 3 months
What is a DEXA scan? Where are they done?
Dual electron X ray absorptions
Done at lumbar spine, hip or femoral neck
Where does a T score come from?
DEXA scan
What does it mean if the T score is between -1 and -2.5?
Patient has low bone density (osteopenia) but not osteoporosis
Investigations for osteoporosis
Bone mineral density - DEXA scan
Bloods - FBC, bone profile, corrected calcium, magnesium, phosphate, CRP/ESR, RF + CCP, cancer markers
Multiple myeloma testing - immunoglobulins, protein electrophoresis
Urinary benstones proteins
What is considered mild, moderate and severe vertbral fracture based on height loss?
Mild - 20-25%
Moderate - 35 to 40%
Severe = over 40%
What guidelines do you use for osteoporosis?
NOGG
How minimise vit D and calcium low levels with bisphosphonated?
-Normal vit D + calcium levels before start
Give with adcalD3 - calcium and vit D
Why can you not lie down for 30 mins after taking alendronate?
Bisphosphonate - prevent oesophageal eroison
What are contraindications for bisphosphonate treatment?
GORD + GI bleeding
Why is denoximab a better option for dementia patients?
SC injection every 6 months therefore better concordance in elderly
What is osteonecrosis of jaw a side effect of?
Denoximab
What can bisphosphonates cause over time?
Stress femur atypical fractures
Treatments other than bisphosphonates for osteoporosis?
Activated vit D
Denosumab injections
SERMS - selective oestrogen receptor modulator
Strontium ranelate
Risk factors for osteoporosis
- SERMS
- Andonate
- HT
- STEAR
What is a fragility fracture?
Fracture following a fall from standing or less, vertebral may be spontaneous or as a result of routine activities such as bending or lifting
What does presentation age of osteoporosis depend on?
Genetics
Levels of nutrtition - vit D and calcium
Sex hormone levels
Physical acitvity levels
When is peak bone density decline in women?
Accelerates after the menopause for 5 to 10 years
Starts to decline in the 5th decade for women adn men
What hormonal changes cause rate of bone loss to increase?
Oestrogen deficiency
Decreased testosterone
hyperparathyroidism
Risk factors affecting bone mineral density
Endocrine disease - DM. hyperthyroidism, hyperparathyroidism
GI conditions causing malabsorption - Crohns, UC, coeliac, chronic pancreatitis
CKD
Chronic liver disease
COPD
Menopause
Immobility
BMI <18.5kg/m2
Risk factors the decrease bone strength but not bone mineral denstiy?
Age
Oral corticosteroids
Smoking
Alcohol - 3+ units
Prev fragility fracture
Rheumatological conditions eg arthritis, inflam arthropathies
Parental history of hip fracture
Drugs that decrease bone strength over time
SSRIs
PPIs
Anticonvulsant drugs - carbamaxepine
Risk factors for falls
Impaired vision
Neuromucular weakness and incoordination
Cognitive impairment
Use of alcohol and sedative drugs
Risk of fracture who assess in
women over 65 years or 50-64 with risk factors
Men over 75 years - 50-74 with risk factors
Which risk factors mean you do an early fracture risk score for osteoporosis?
Prev osteoporotic fragility fracture
Current ise or requent corticosteroids
Historyh of falls
Low BMI
Smoker
Alcojol intake over 14 units a week
Secondary osteoporosis
Which risk factors mean you do an early fracture risk score for osteoporosis?
Prev osteoporotic fragility fracture
Current ise or requent corticosteroids
Historyh of falls
Low BMI
Smoker
Alcojol intake over 14 units a week
Secondary osteoporosis
Causes of secondary osteoporosis
Hypogonadism in either sex, including untreated premature menopause (menopause before 40 years of age), treatment with aromatase inhibitors (such as exemastane) or gonadotrophin-releasing hormone agonists (such as goserelin).
Endocrine conditions, including diabetes mellitus, Cushing’s disease, hyperthyroidism, hyperparathyroidism, and hyperprolactinaemia.
Conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis.
Rheumatoid arthritis and other inflammatory arthropathies.
Haematological conditions such as multiple myeloma and haemoglobinopathies.
Chronic obstructive pulmonary disease.
Chronic liver failure.
Chronic kidney disease.
Immobility.
When do you assess ppl for risk of osteoporosis when they are under 50?
Current frequent use of oral corticosteroids
Untreated premature menoapyse
Prev fragility fracture
When do you assess ppl for risk of osteoporosis when they are under 50?
Current frequent use of oral corticosteroids
Untreated premature menoapyse
Prev fragility fracture
When assess under40s for their osteoporosis risk?
Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for 3 months or more.
Previous fragility fracture of the spine, hip, forearm, or proximal humerus.
History of multiple fragility fractures.
What medications may make u consider early assessment for osteoporosis?
Selective serotonin reuptake inhibitors.
Antiepileptic medication — particularly enzyme-inducing drugs, such as carbamazepine.
Aromatase inhibitors, such as exemastane.
Gonadotropin-releasing hormone agonists, such as goserelin.
Proton pump inhibitors.
Thiazolidinediones, such as pioglitazone.
Non osteoporotic causes of fragility fractures?
Metastatic bone disease
Multiple myeloma
Osteomalacia
Pagets disease
Symptoms multiple myeloma
Bone pain
Anaemia
Recurrent infections
bleeding
Symptoms of hypercalcemia
Kidney disease
What is multiple myeloma?
Cancer of the plasma cells
What is daily calcium intake risk for fragility fracture?
1000mg/day
What is used to determine whether a DEXA scan is needed?
Qfracture
What is the threshold for a DEXA scan?
10 year risk of 10%
What are the risk levels from the FRAX score?
Against people of same age group
Low = green - Below 10%
Intermediate = orange - close to 10%
High = Red - over 10%
wHAT RISK factors does FRAX underestimate?
Regular use of corticosteroids = or less than 5mg prednisolone daily
OR more thna or = to 7.5mg prednisolone daily for more than 3 months
History multiple fragility fractures
High alcohol intake
Heavy smoking
What to do whne T score is greater than -2.5 (below threshold) but high risk of fragility fracture
Treat underlying conditions, reduce/modify risk factors, repeat DXA at interval appropriate based on risk profile - normally within 2 years
When do you offer bone sparing drug treatment offered for osteoporosis?
When the T score is -2.5 or lower
When do you follow up if someone is low risk of fragility fracture?
5 years
Alendronate dosage (first line bisphophonate)
10mg/day, 70mg a week
Risedronate dosage
5mg once daily, 35mg once weekly
What bisphosphonates are used in postmenopausal women vs men?
Women - all
Men - alendronate, risedronate
Specialist medical treamtent for osteoporosis
zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide.
What protects against fragility farcture in younger postmenopausal women?
HRT
What effects ask about after starting bisphophonates?
Upper GI adverse effects eg dyspepsia, reflux. Often in 1st month then improve
Atypical fracture
Adherence
How long before review need for bisphophonates?
3-5 years
How long can people be on bisphosponates?
alendronate - 10 years
Risedronate - 7 years
How do bisphophonates work?
Inhibitors of bone resorption by altering osteoclast acitvation and fuction
first line treatment for osteoporosis n
Alendronate, risedronate
TYPE 1 vs type 2 primary osteoporosis pathophysiology
Postmenopausal - increase osteoclast activity (distal radius, vertebral fractures)
Senile - age - decreased osteoblast acitvity (NOFs)
What is denusomab and when is it used?
monoclonal antibody - 6 monthly SC injections
Risk factors SHATTERED
+ female sex, FH
Steroid use, smoking
Hyperthyroidism
Age >50, alcohol
thin BMI <22
Testosterone deficiency
Early menopause
Renal failure + liver failure
Erosive bone disease eg RA, myeloma
Deficiency of Ca or vit D, diabetes
Features of vertebral fracture
Back pain
Reduced height
Kyphosis
Respiratory difficulty
What does increased PTH in bloods mean
Hypeparathyroidsim
What does increased PTH in bloods mean
Hypeparathyroidsim
What hormone is increased in menopause
FSH
How much of osteoporotic vertebral fractures are symptomatic
30-50%
Presentation of vertebral osteoporotic fractures
Sudden onset severe well localised dorsal/lumbar pain
Often after effort/trauma
Settles after 6-8 weeks
Loss of height + kyphosis - stooped
Types of fragility fractures
Vertebral fractures
Femoral neck fractures
Colles fracture - FOOSH
How to rule out osteomalacia
Calcium, phosphorous, vit D, alkaline phosphatase and PTH levels
Differentials osteoporosis
Osteomalacia
Hyperparathyroidism
Metastatic carcinoma
Multiple myeloma
Investigations for metastatic carcinoma in vertebrae - where, exam
Thoracic vertebrae more common
Breast exam to rule out as primary site
CT CAP if mets suspected
What is most common priamry deposit in spine
Multiple myeloma
Tests for multiple myeloma + what proteins found
FBC
U+Es
Spine X ray
Bone marrow biopsy
Bence jones proteins in urine and serum
Risk factors osteo
Caucasian and Asian ethnic groups, female sex, increasing age, early menopause, smoking, excess alcohol, corticosteroid use, hypogonadism and rheumatoid arthritis.
Summary of treatment for osteoporosis
bisphosphonates, hormone replacement therapy and raloxifene (a selective oestrogen receptor modulator).
What does electrophoresis look for
Bence jones protein in urine and serum
For myeloma
Mnemonic for osteoporosis
L Ow calcium intake
Seizure meds (anticonvulsants)
Thin build
Ethanol intake
Hyp Ogonadism
Previous fracture
Thyr Oid excess
Race (white, Asian)
Other relatives with osteoporosis
Steroids
Inactivity
Smoking
What are loosers zones/pseudofractures
Osteomalacia
Radiolucent lines thrugh cortex - appearance of non displaced partial fractures
Features of soteoporosis on scans
Cortical thinning and loss of traberculae
Gout on bone scan
y soft tissue gouty tophi, with plain films showing punched-out lesions away from the joint line.
Do you see anything on scans in osteomyelitis
not always
50% - periosteum lifting = subperiosteal abscess formed by + tracking from medullary canal
What is osteomalacia
a disease of reduced bone quality, the mass is normal. It occurs secondary to ineffective mineralization of the bone matrix, which may be due to dietary deficiency, abnormal uptake (gastrointestinal disease), abnormal metabolism (secondary to renal or liver failure) or the actions of certain drugs.
Secondary causes of osteoporosis
Malignancy: myeloma, metastatic carcinoma
Endocrine: Cushing’s disease, thyrotoxicosis, primary hyperparathyroidism, hypogonadism, DM.
Renal disease: reduces vitamin D metabolism and important for absorbing it via PTH.
Drugs: long-term corticosteroids (includes transplant patients), heparin, aromatase inhibitors, androgen deprivation therapy, SSRIs, PPIs, anticonvulsant drugs, in particular enzyme inducing drugs such as carbamazepine.
Rheumatological: RA, AS.
GI: malabsorption syndromes (e.g. coeliac, partial gastrectomy, UC, CD, chronic pancreatitis), chronic liver disease (PBC), anorexia, malnutrition (includes obesity).
Conditions that cause long periods of immobility e.g. stroke
Low levels of oestrogen in women due to anorexia nervosa, early menopause (before age of 45) with removal of ovaries and excessive exercise.
Who can be started on osteoprosis treatment without a DEXA scan
Over 75 + over 2 or more clinical RFs and/or ederly, housebound or care home residents
What does Z score from DEXA scan consider
Age related mean
Patients over 50 who hace fallen with a fracture management
osteoporosis screening and referral for DEXA
falls risk assessment and referral onward to specialist falls teams
alcohol advice and referral onward to alcohol liaison service
bone health education [diet and exercise]
liaison with GP’s with regard to treatment recommendations and follow up.
How to reverse osteoporosis from malabsorption due to coeliac disease
1 year gluten free diet
What can help shorten the period of severe pain from a fracture if given early on
IV bisphosphonates
What is an example of a SERM
Raloxigfene - selective oestrogne receptor modulators
Side effect of SERMs
Hot flushes, leg cramps and potential increased risk of VTE
What replace alendronic acid with if side effects
Risedronate - less side effects
How administer zolendrenic acid
IV infusion
What do if sus metastatic carcinomas
CT CAP spine
