Osteoporosis

Question 1

What is osteoporosis?

Answer 1

progressive bone disease characterised by low bone mass measured by bone mineral density (BMD)

bone reservoir - calcium and phosphate
osteoclasts - bone resorption/breakdown
osteoblasts - bone formation

Question 2

What are the risk factors for osteoporosis?

Answer 2

non-modifiable
- increasing age
- female sex
- early menopause
- white race

modifiable
- slender habitus = low body weight
- smoking
- excessive alcohol
- lack of exercise
- drugs = corticosteroids, PPIs, heparin, ciclosporin
- endocrine disease = Cushing’s syndrome, hyperparathyroidism, gonadal failure

Question 3

What are the symptoms of osteoporosis?

Answer 3

is not typically symptomatic until a fracture occurs
- thoracic and lumbar vertebrae (spine), neck of the femur (hip), distal radius (wrist)

Question 4

What investigations should be osteoporosis? When should they be done for people?

Answer 4

Dual energy X-ray absorptiometry (DEXA)
- measures bone mineral density = < -2.5 SD is low

Bindex

all women aged 65 and over should be assessed
all men aged 75 and over should be assessed
- depends on age and sex

Question 5

What is FRAX and Qfracture?

Answer 5

risk of fracture assessment tools
- estimate 10 year predicted absolute fracture risk

Question 6

What are non-drug treatments for osteoporosis?

Answer 6

exercise
- weight bearing
smoking cessation
reduce alcohol intake
maintain normal BMI

adequate calcium intake
- 700-1200mg per day

adequate vitamin D intake
- 400-800 iu (10-20mcg) of cholecalciferol

Question 7

What are the pharmacological treatments of osteoporosis for women and men?

Answer 7

women
- oral bisphosphonate = alendronic acid, risedronate sodium
- i.v bisphosphonate = ibandronic acid, zoledronic acid
- denosumab
- raloxifene
- strontium ranelate
- hormone replacement therapy
- tibolone
- teriparatide
- romosozumab

men
- alendronic acid
- risedronate sodium
= where these are contraindicated or not tolerated, zoledronic acid or denosumab

Question 8

How do bisphosphonates work? What are the types? What counselling is needed? What are their side effects?

Answer 8

inhibit bone resorption via inhibition of osteoclast activity

alendronic acid
- 10mg daily or 70mg weekly
counselling
- take on an empty stomach and with water whilst standing and remain standing for 30 mins
side effects
- oesophageal reactions (oesophagitis/oesophageal ulcers)

risedronate sodium
- 5mg daily or 35mg weekly
counselling
- take on an empty stomach or 2 hrs after meals with water
- avoid Ca containing products (milk), antacids, iron and mineral supplements

Question 9

What are the serious side effects of bisphosphonates? How can it be prevented?

Answer 9

osteonecrosis of the jaw
- greater risk for patients receiving i.v bisphosphonates
- must have regular dental checks

atypical femoral fractures
- should report any thigh, hip or groin pain during treatment

osteonecrosis of the external auditory canal
- should report any ear pain, ear discharge or infections

Question 10

What is treatment holiday?

Answer 10

treatment should be reviewed
- after 5 years for oral bisphosphonate
- after 3 years of i.v zoledronic acid
- if taking long term corticosteroid therapy
- if aged >75 years

Question 11

How does denosumab work? What counselling is needed? What are their side effects?

Answer 11

monoclonal antibody that inhibits osteoclast formation, function and survival

60mg subcutaneous injections every 6 months
- supplement with vitamin D and calcium

associated with
- osteonecrosis of the jaw
- risk of hypocalcaemia = muscle spasms, cramps, numbness or tingling of the toes/fingers/mouth

require dental checks
- report any pain, swelling or non-healing sores

Question 12

What is raloxifene? When is it used?

What is strontium ranelate?

Answer 12

raloxifene
- activates oestrogen receptors on the bone but has no stimulatory effect on the endometrium
- is used after treatment failure with bisphosphonates
- 60mg daily

strontium ranelate
- stimulates bone formation and reduces bone resorption
- 2g once daily in water
- avoid food before and after taking
- avoid Ca containing products and antacids

Question 13

What is DRESS?

Answer 13

drug rash with eosinophilia and systemic symptoms (DRESS)
- severe allergic reactions seen in people taking strontium ranelate

• starts with rash, fever, swollen glands, and increased white cell count, and it can affect the liver, kidneys and lungs
• stop taking strontium ranelate and consult their doctor immediately if skin rash develops.

can be fatal

Question 14

When should hormone replacement therapy be used? What are the side effects?

Answer 14

used for prophylaxis of postmenopausal osteoporosis if started early in menopause and continued for up to 5 years, but bone loss resumes on stopping HRT

increases the risk of
- venous thromboembolism,
- stroke
- endometrial cancer (reduced by a progestogen)
- breast cancer

Question 15

What are risk factors for osteonecrosis of the jaw (ONJ)?

Answer 15

smoking,
old age,
poor oral hygiene,
invasive dental procedures
comorbidity
advanced cancer,
previous treatment with bisphosphonates
concomitant treatments
- e.g. chemotherapy, anti-angiogenic biologics, corticosteroids

Question 16

What are the symptoms of hypocalcaemia?

Answer 16

muscle spasms
twitches
cramps
numbness or tingling in the fingers, toes, or around the mouth

Question 17

What is tibolone?
What is teriparatide?

Answer 17

tibolone
- potent agonist of the estrogen receptor (ER)

teriparatide
- is a recombinant fragment of parathyroid hormone (primary regulator of calcium and phosphate metabolism in bone and kidney)
- limited treatment period due to risk of osteosarcoma

Question 18

What is romosozumab? What are the risks associated?

Answer 18

is a humanized monoclonal antibody that binds and inhibits sclerostin, a glycoprotein produced in osteocytes
- the main function of sclerostin isto stop (inhibit) bone formation

210 mg once a month for 12 months, supplement with calcium and vitamin D

risks
- osteonecrosis of jaw
- atypical femoral fracture
- hypocalcaemia

Question 19

What is corticosteroid-induced osteoporosis? How should it be treated?

Answer 19

is the most common form of secondary osteoporosis
- corticosteroids tend to both reduce the body’s ability to absorb calcium and increase how fast bone is broken down

bone-protective treatment should be started at the onset of glucocorticoid therapy in individuals at high risk of fracture.
- alendronate and risedronate are first line treatment options
- denosumab or teriparatide are alternative options

Question 20

How is osteoporosis treated in men?

Answer 20

alendronate and risedronate (bisphosphonates) are first line treatments in men.
- where these are contraindicated or not tolerated, zoledronic acid or denosumab provide the most appropriate alternatives
- strontium ranelate or teriparatide are additional options.