Osteoporosis Flashcards
what is osteoporosis?
Osteoporosis is a disease characterized by
low bone mass and structural deterioration
of bone tissue, with a consequent increase in
bone fragility
what are the risk factors for osteoporosis?
alcohol use
cigarette smoking
low cal/ vit d
medication
menopause
what is the most serious fracture? why?
- Hip fracture is the most serious consequence of falls among older people
– Reduced function, loss of independence, loss of confidence, high mortality rate (10% at 1 month, 30% die within a year of hip fracture)
what are some interventions to try and prevent further fracture?
- Prevent further fracture
“secondary prevention” (see
later) - If already on treatment check
adherence and administration - Lifestyle advice
- Falls assessment
- Including medication
review - Prevention of venous
thromboembolism with LMWH - Appropriate pain management
what is characteristic of spin: compressions fractures? what interventions can be made?
– Acute and chronic back pain
– Height loss, kyphosis
interventions …
* Secondary fracture(#) prevention
* Lifestyle advice
* Pain control and analgesia review
* Physiotherapy
* Surgical management
who do we give primary prevention to?
People who have never had a fracture but are at increased risk of fracture (All women aged 65 years and over, and all men aged 75 years and over.)
who do we give secondary prevention to?
People who have already had a fracture and need to reduce the risk of further fracture
Fracture liaison services have an important role here- pick up over 50s with fragility fracture
and offer DXA scan
what i FRAX?
- FRAX is an online tool that can be used to assess fracture risk (40-90 yrs)
- Gives a result as:
- 10 year risk of osteoporotic fracture
and 10 yr risk of hip fracture (%)
what action should be done following assessment?
Depending on fracture risk one or more of the
following options may be employed:-
* Lifestyle advice (smoking, alcohol, vit D, calcium, exercise)
* Referral for a DXA scan +/- specialist review
* Initiation of treatment (for “very high” fracture
risk also consider refer to specialist)
how do we treat?
- Bisphosphonates
- Oral (alendronic acid, risedronate, ibandronic acid)
- Parenteral (zoledronic acid, ibandronic acid)
- Denosumab (subcutaneous injection)
- Less commonly used:
– HRT (early menopause)
– Raloxifene (specialist only)
– Teriparatide (daily injections-expensive)
– Strontium- discontinued by manufacturer in 2017-
increased CV risk- brought by to the market 2019 - Romosozumab
why is patient information essential? what information do we give?
- Prophylactic treatment requires motivation
- Patients must be involved in treatment decision
- Explain
– Why they have been prescribed their medication
– How it works
– Benefits
– How to take correctly
– Side effects & what to do if they occur
– Length of treatment
what is first line ?
oral BPs
for prevention and treatment
what are the main drug interactions with BPs? what should be done to prevent?
(absorption)
– Avoid any other medicines for at least 30 mins
– Avoid calcium supplements for at least 2 hours (preferably 4hrs)
what are the main cautions and contraindications with BPs?
– eGFR <35ml/min/1.73m2 Alendronic acid
– eGFR <30ml/min/1.73m2 Risedronate (however note that some
clinicians will use below this)
– Known hypocalcaemia
– Dysphagia/swallowing difficulties
– (Recent) GI bleed
– Note that Risedronate may cause fewer GI side-effects
when should you review BPs?
Review after 5 years (continue vs. stop vs. pause in treatment ‘drug holiday’)
what counselling should be given for oral BPs?
- This medication will help to reduce chance of breaking a bone (by up to 50%);
you only need to take it once a week. - Take at least 30 minutes before breakfast, with a full glass of water, then
remain upright for 30 mins after (because…) - If you take calcium supplements take at a completely different time or miss
the morning dose on that day. - The most common side effect with this medication is heartburn/indigestion,
though not everybody gets this. If it happens to you and it is severe, stop
taking the medicine and go to see your GP. They may be able to switch you to
an alternative [i.e. some people may tolerate risedronate better from GI point
of view] - Maintain good dental hygiene, report any thigh/hip/groin pain…
- Usually we would review your treatment after 5 years, to check that you still
need it and to reduce the risk of any longer term side effects
when is zolendronic acid given? what is its doe?
- Given in secondary care
- Dose:
– 5mg annual IV infusion over 15 minute
what are the side effects of zolendronic acid?
– Flu-like symptoms common
– Hypocalcaemia
– Rarely atypical #, osteonecrosis of jaw (all antiresorptives)
when should you review zolendronic acid?
Review after 3 years (consider ‘drug holiday’)
what is important to check before initiating zolendronic acid?
– RENAL function
– CALCIUM and
– VITAMIN D before each infusion (correct first)
* Regular dental check-ups + ONJ reminder card
who is denosumab licensed for?
postmenopausal women, also licensed for men
when is the denosumab given/ what dose?
- First dose in hospital; after that via GP
- Dose: 60 mg SC injection 6 monthly
what should be checked prior to each injection?
Check bloods before each injection (renal, calcium, vitamin D); hypocalcaemia
risk
* Correct calcium deficiency, vitamin D loading if D low.
* Not renally excreted but caution in renal impairment due to increased risk of
hypocalcaemia (deaths and hospital admissions reported)
what does denosumab increase the risk of?
?Increased risk of UTI/chest infection, rash/cellulitis
what are the rare side effects of denosumab?
Rare atypical fracture/osteonecrosis of jaw (good dental hygiene, report hip/thigh/groin pain)
when is strontium ranelate aristo indicated?
- For ‘severe’ osteoporosis where other medications not suitable or not tolerated, initiated by a specialist
what should you monitor in strontium?
- Monitor for skin reactions (SJS, DRESS)- highest early in treatment
- Review cardiovascular risk every 6-12m
who is strontium c/i in?
C/I in IHD, PAD, CVD, VTE, uncontrolled HTN,
temporary/permanent immobilisation
– Withhold post-surgery, for example
– Caution if cardiovascular risk factors e.g. diabetes, smokin
what is teriparatide? when is it given?
Recombinant fragment of PTH
Expensive, daily SC injection, 2 yr course
* Evidence base for reduction vertebral #
Only anabolic agent currently on the UK market
what are the side effects of teriparatide?
Limb pain, nausea, headache dizziness (esp. at start of therapy), depression
what is the risk of when using teriparatide?
Risk HYPER calcaemia (unlike antiresorptives)
what is romosozumab?
- Humanised monoclonal antibody that inhibits
sclerostin, first-in-class - Stimulates osteoblasts AND reduces osteoclast function
what is the potential side effect of romosuzumab?
Significant potential cardiac adverse events
* Prescribed for 12 months (injections twice a
month) then followed by other tx
what are the rare side effects with treatment?
Atypical Fracture
* Very rare but increasing risk with
increased duration
* Usually thigh bone often atraumatic
* Can be bilateral
* Report thigh, hip and groin pain (X-ray
to rule out)
* Benefits of treatment generally
outweigh risks
BRONJ - MRONJ
* Osteonecrosis – death of bone
* Case reports (2003) – BRONJ
* Associated with other medications –
MRONJ e.g. Denosumab
* Usually associated with invasive dental
procedures
how do you treat MRONJ?
- Radical surgical management to remove large segments
of necrotic bone. - Patient safety alerts – EMA/MHRA
when should you give calcium and vit D?
- Most osteoporosis treatments licensed to be used
alongside calcium/vitamin D- always consider - Consider for all patients on osteoporosis medication (other than teriparatide)
Recommended particularly if dietary calcium intake poor/ housebound or institutionalised
how can steroids induce osteoporosis?
- Steroids increase bone resorption (early, transient) decrease bone
formation (long-term) - Bone loss v. rapid in 1st 3months of steroid treatment
– some features of dose responsive effect, particularly at the spine - Increase # risk independently of BMD
- Oral steroids- # risk higher on >7.5mg/day, all doses increase # risk
significantly at the spine
– Increased risk of vertebral and non-vertebral (including hip) #,
Spine # more common than hip #
– Could also be due in part to disease itself
– # risk declines after d/c and on continued therapy
– Interventions need to be started early!
when should you review medication?
r bisphosphonates periodically,
particularly after 5 or more years of use (3yr zoledronicacid)
– can decide to continue or drug holiday at this point – weigh up the risks and benefits
* Drug holiday = Stop bisphosphonate, usually for 1-2 years
* Increasingly used in practice with bisphosphonate medications
* After 10 years, usually drug holiday if not already
* REVIEW IS ESSENTIAL – EFFECT NOT RETAINED
INDEFINITELY
what happens when you stop BPS?
- Gradual in BMD, in BTM
- # risk remains reduced for period of time?
why is denosumab not suitable for a drug holiday?
” as not retained in the bone
* On cessation of denosumab increased bone
resorption, rapid decline in BMD
what are the general rules with osteoporosis drugs?
- If intolerant of Alendronic try Risedronate
(depending on reason not tolerated) - If not tolerated oral therapy (generally BPs), consider
parenteral therapy - Note- drug substitution rather than addition
- Parenteral treatment
– KIDNEY function very important
– CALCIUM and VITAMIN D level need to be checked before
Zoledronic IV/Ibandronic IV/Denosumab SC
– MHRA: Risk of hypocalcaemia
– Higher risk of atypical fracture and ONJ
