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Endocrinology > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Describe the differences in trends between males and females with bone mass density and age.

A

Both males and females have an increase in bone mass density up until the age of 25-30 where they reach skeletal maturity, this then plateaus for around 10 years in females and 20 years in males. Around the age of the menopause there is a significant rate in decline in bone mass density in females for about 20 years (decreases at a decreasing rate), until it reaches the same rate of bone loss as men which gradually decreases at a constant rate from the age of 50. Men generally has a higher bone density at each age.

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2
Q

What are the two factors that determines bone density?

A

Peak bone mass at the age of 30
Rate of bone loss after the fourth decade (after the age of 40)

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3
Q

What is the rate of bone loss determined by?

A

75% is genetically linked, therefore more likely to have osteoporosis if you have a strong family history.

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4
Q

What are some of the genes linked to osteoporosis?

A

Vitamin D receptor gene
Oestrogen receptor gene
Interleukin (IL-6) gene

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5
Q

Aside from the genetic factors, what are some of the environmental factors (lifestyle) that causes osteoporosis?

A

Low calcium intake
Low Vitamin D intake, lack of exposure to sunlight
Physical inactivity
Smoking
Excess alcohol
Having a thin body type

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6
Q

Describe the relationship between alcoholism and osteoporosis.

A

Alcohol interferes with the calcium balance in the body essential for healthy bones, and it also interferes with the production of Vitamin D.
Alcohol also causes hormone deficiencies in both men and females, testosterone (production of osteoblasts) and oestrogen (regulates bone metabolism) deficiencies result as another increasing risk factor for osteoporosis.
May induce raised cortisol levels, cortisol decreases bone formation and promotes bone degradation.
More likely to fall if you have alcoholism.
Also toxic to the bones.

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7
Q

What is the relationship between smoking and osteoporosis?

A

Firstly if you smoke you are more likely going to have some of the other risk factors for osteoporosis such as being thinner, poor diet, drinking more alcohol.
In females, smoking causes abnormal estrogen metabolism, which then increases the risk of osteoporosis.

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8
Q

Define osteoporosis.

A

Osteoporosis is a systemic skeletal disease characterized by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.

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9
Q

Is osteoporosis symptomatic?

A

No, it is asymptomatic and usually only diagnosed after a fracture has occurred.

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10
Q

Where do the characteristic fractures from osteoporosis occur?

A

Wrist, hip (neck of femur) or spine

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11
Q

What is classed as a fragility fracture?

A

If the fracture occurred when falling from standing height or less (would not normally cause a fracture).

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12
Q

What is the T-score?

A

Numerical value used in the definition of osteoporosis by WHO and is calculated by:
The number of standard deviations by
which the individual’s BMD (g/cm2) differs from the mean peak BMD for young adults of the same gender

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13
Q

How does T-score relate to bone fracture risk?

A

WHO defines it as for each standard deviation below the normal age-related bone mass is
associated with a 1.7 to 2.6 times increased risk of fracture at the site tested.

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14
Q

What is the T-score value for osteoporosis?

A

T-score of 2.5 or less
Established osteoporosis 2.5 or less and a fracture

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15
Q

What is the T-score for osteopenia?

A

Between -1 and -2.5

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16
Q

Where does the scan usually occur to calculate the T-score?

A

Clinically relevant sites such as hip or vertebra

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17
Q

How likely is it that an individual will experience an osteoporosis fracture?

A

1 in 2 women
1 in 5 men

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18
Q

How does the risk of osteoporosis change with age in women?

A

At the age of 50, 2% of women are said to have osteoporosis compared to 50% at the age of 80.

Overall 21.9% of women over 50 have osteoporosis

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19
Q

What percentage of men over the age of 50 have osteoporosis?

A

6.7%

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20
Q

Are X-rays a good method for detecting and diagnosing osteoporosis?

A

Normal X-rays are only sufficient for detecting osteoporosis when 30% of the bone mineral density has already been lost. Therefore they are not sufficiently reliable to diagnose
or quantify osteopenia or osteoporosis.

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21
Q

What type of X-ray is used more reliably to detect osteopenia and osteoporosis?

A

DEXA scan which can obtain reproducible measurements of bone mineral density.

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22
Q

What is the most common form of osteoporosis?

A

Primary osteoporosis

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23
Q

What is primary osteoporosis?

A

Diagnosed when the patient has no other
disorders known to cause osteoporosis
present

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24
Q

What are some examples of primary osteoporosis?

A

Postmenopausal osteoporosis
(women within 15-20 years after
menopause)
Age-related, or senile, osteoporosis (elderly)

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25
Q

What are some conditions that would induce secondary osteoporosis?

A

Anorexia nervosa
IBD
Endocrine: E.g. Type 1 DM, Cushing’s
syndrome, hyperthyroidism
Rheumatoid arthritis

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26
Q

What are some of the drugs known to induce osteoporosis?

A

Mainly oral corticosteroids but also
Carbamazepine
Phenytoin
Heparin (anti-coagulants)
Furosemide
PPIs
Ciclosporin (Immuno-suppressants)

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27
Q

What percentage of steroid induced osteoporosis account for the total cases?

A

In secondary osteoporosis:
10% of women, 13% of men

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28
Q

How do steroids reduced bone mineral density?

A

Decrease osteoblast number and activity and life span
Decrease calcium absorption from the
intestine and increase renal calcium loss
causing abnormal PTH and vitamin D
activity
Suppress sex hormone production (no protective effect of oestrogen)

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29
Q

Why do fractures commonly occur with those who have osteoporosis?

A

The amount of bone available for the mechanical support of the skeleton falls below the fracture threshold and therefore the patient may sustain a fracture with little to no trauma.

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30
Q

How does kyphosis occur?

A

Kyphosis is the forward curvature of the spine sustained from multiple fractures to the vertebra eventually resulting in the spine collapsing.

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31
Q

What are the less common sites of fracture?

A

Pelvis
Distal femur
Ribs

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32
Q

After sustaining an initial vertebra fracture what is the likelihood of sustaining additional fractures?

A

Seven fold increase in sustaining another vertebra fracture
13% increase in 5-year risk of hip fractures

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33
Q

What are some of the lifestyle changes that occur after sustaining a hip fracture?

A

50% can’t live independently anymore
Substantial disability due to low impact fractures
20% excess mortality after hip fractures

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34
Q

How much is the cost on the NHS of osteoporosis?

A

£4.4 billion a year, 50% with the care after hip fractures

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35
Q

What are the main three management strategies implemented in osteoporosis?

A

Identifying and treating those who are at risk (through the risk factors)
Managing the risk of falls
Treatment (lifestyle, drug treatment)

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36
Q

Who are the groups of people that should be targeted and assessed for risk of development of osteoporosis?

A

Strong family history (maternal hip fracture before the age of 75)
IBD
Other endocrine conditions (Type 1 DM, Cushing’s syndrome)
Low body mass
Untreated premature menopause (early hysterectomy)
Alcohol and smoking
Prolonged sedentary lifestyle
Oral corticosteroids

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37
Q

When does the greatest loss of bone density occur when taking corticosteroids?

A

Greatest bone mineral density loss is within the first few months of taking the steroids

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38
Q

Which type of fractures are you more prone to with glucocorticoid use?

A

Vertebra and hip fractures

39
Q

Higher risk of fractures when taking steroids or post-menopause?

A

Steroid use

40
Q

Is osteoporosis prophylaxis given to everyone taking oral glucocorticosteroids?

A

No, it is not given unless;
Anyone with prior fragility fracture
Women age ≥70yrs
Postmenopausal women and men ≥50yrs prescribed high dose steroids
Postmenopausal women, and men age ≥50 years, with a high risk FRAX score

41
Q

What is classed as a high dose steroid?

A

≥7.5mg/day of prednisolone or equivalent over 3 months (N.B., this is equivalent to ≥30mg/day of prednisolone for 4 weeks over 3 months)

42
Q

What does FRAX stand for and what it is used to calculate?

A

Fracture risk assessment tool and it is used to determine a patient’s 10 year risk of developing an osteoporotic fracture.

43
Q

If a patient was identified as low risk using the FRAX score what is the management recommendation?

A

Lifestyle + calcium/Vitamin D supplements

44
Q

If a patient was identified as intermediate risk using the FRAX score what is the management recommendation?

A

Assess BMD with DEXA scan

45
Q

If a patient was identified as high risk using the FRAX score what is the management recommendation?

A

Consider starting treatment straight away without the need for DEXA scans

46
Q

What is some of the lifestyle advice that should be provided to a patient with osteoporosis?

A

Limit alcohol intake to at least within the recommended limits
Stop smoking if applicable
Regular exercise to improve muscle strength
Balanced diet

47
Q

Which type of exercises should be recommended to a person at risk of osteoporosis?

A

Walking outside, increasing exposure to sunlight
Weight training of different muscle groups
A combination of exercise types, for example balance, flexibility, stretching, endurance, and progressive strengthening exercises

48
Q

What are the specific dietary requirements for somebody with osteoporosis?

A

Should aim to be eating 3-4 calcium rich foods a day (containing 200-300 mg of calcium per portion) and 700mg minimum a day.

49
Q

What are some examples of calcium rich foods?

A

200ml milk
4 slices white bread
30g hard cheese
125g pot yoghurt
170g cheese and tomato pizza
60g sardines

50
Q

What is the dietary intake of Vitamin D required daily?

A

400 units

51
Q

Which foods contain Vitamin D?

A

Oily fish such as salmon, mackerel
Fortified cereals
Egg yolks

52
Q

Which demographic are given Vitamin D supplements?

A

Residents of a nursing home due to their decreased exposure to sunlight

53
Q

If it is known for a patients dietary intake to be sub-optimal in comparison to what is recommended for those with osteoporosis or at risk what is given?

A

A Calcium / Vitamin D tablet usually containing 1000mg of Calcium and 800 units of Vitamin D.

54
Q

When would altered doses of supplements be given for patients?

A

Depending on their dietary intake
Higher doses for frail or housebound patients

55
Q

What is the recommended intake of Vitamin D supplements?

A

All adults are recommended taking 400 units of Vitamin D for the prevention of Vitamin D deficiency.
Those at risk, take all year round, everybody else just in the autumn and winter months when the exposure to sunlight is reduced.

56
Q

What are some of the medications that increase the risk of falls?

A

Anti-hypertensive medication (become dizzy)
Sedatives and hypnotics
Diuretics (rushing to the toilet, especially at night could trip over things)

57
Q

Aside from medication what are some of the other risk factors for falls?

A

Balance
Poor vision
Environmental factors such as loose carpets Cardiovascular status such as BP and pulse

58
Q

What is the first line treatment (medication) in the treatment of osteoporosis?

A

Bisphosphonates

59
Q

What are examples of some of the bisphosphonates used as the firstline treatment?

A

Alendronic acid (alendronate)
Risedronate sodium

(First line treatment for postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, osteoporosis in men)

60
Q

Aside from the two specific first line bisphosphonates, what are some other examples that can be prescribed?

A

Ibandronic acid
Zoledronic acid

61
Q

How often is the patient review for the bisphosphonates?

A

Alendronic, risedronate, ibandronic acid (oral), review after five years whereas zoledronic acid (IV, and ibandronic acid IV) has a review every 3 years to assess whether continuation of the medication is required.

62
Q

When would you continue treatment for the bisphosphonates beyond the 3 or 5 year period?

A

Over 75 years
History of previous hip or vertebra fracture
Had one or more fragility fractures during treatment
Taking long term oral glucocorticoids

63
Q

What are some second line treatments for treatment of osteoporosis if the bisphosphonates are contraindicated?

A

Denosumab
Raloxifene
Teriparatide
Strontium ranelate
Romosozumab
HRT

64
Q

Alongside prescribing either the bisphosphonates or the second line treatment for HRT what else would you expect to prescribe?

A

Calcium and Vitamin D supplements (1000mg and 400 units)

65
Q

How are ibandronate and zoledronate administered?

A

Ibandronate is taken orally every month or by IV every 3 months.
Zoledronate is given by IV annually

66
Q

What side effects would result in the discontinuation of the oral treatment of bisphosphonates?

A

They are corrosive drugs and therefore can cause dysphagia, heart burn, oesophageal ulcer, oesophagitis

67
Q

What are the main counselling points associated with the bisphosphonates?

A

Swallow whole with a full glass of water
Take in the morning at least 30 minutes before food (60 minutes for ibandronic acid)
Take sitting down or standing up
Ensure you remaining sitting or standing upright for 30 minutes after taking the medication (60 minutes for ibandronic)
Do not lie down until after breakfast
Do not take at bed time or before rising

68
Q

Is it recommended to take the calcium and Vitamin D supplements at the same time as the bisphosphonates?

A

No due to the low bioavailability of the bisphosphonates, calcium and viatmin D supplements should be taken at least two hours afterwards

69
Q

What recommendation would you make if a patient who normally takes bisphosphonates is acutely unwell and can not sit up in bed?

A

Stop oral treatment, these drugs have a long term effect and therefore is not an issue to stop the drugs for a couple of weeks during recover. If this is a long term health condition consider switching to IV bisphosphonates.

70
Q

List the three main rare side effects associated with the bisphosphonates.

A

Osteonecrosis of the jaw
Atypical femoral fractures
Osteonecrosis of the external auditory canal

71
Q

Considering the three main rare side effects associated with the bisphosphonates, which symptoms would you advise patients to look out for?

A

Report any thigh, hip or groin pain
Report any ear pain or discharge

72
Q

What would you advise patients to do, to reduce potential of osteonecrosis of the jaw?

A

Maintaining good oral hygiene
Going for routine dental check ups
In addition to reporting any oral symptoms

73
Q

What is the second line treatment specifically for steroid induced osteoporosis?

A

Zolendronate
Denosumab
Teriparatide

74
Q

How is Vitamin D deficiency detected?

A

Through a routine blood test which detects the serum level of 25-hydroxyvitamin D (25[OH]D).

75
Q

What is consider the deficient and sufficient levels of serum Vitamin D?

A

Less than 25 nmol/L is considered high risk of Vitamin D deficient
Between 25-50 nmol/L is considered perhaps insufficient
Greater than 50 nmol/L us considered sufficient

76
Q

Which drug is specifically used to treat Vitamin D deficiency?

A

Colecalciferol

77
Q

What is the equivalent dose of 400 units of colecalciferol?

A

10mcg

78
Q

What is the loading dose of colecalciferol?

A

Loading dose is normally 300,000 IU across 6-10 weeks.
This can either be:
50,000 units a week for 6 weeks
40,000 units a week for 7 weeks
4000 units daily for 10 weeks

79
Q

When does the maintenance dose of colecalciferol commence?

A

Usually 1 month after after stopping the loading dose

80
Q

What is the maintenance dose of colecalciferol?

A

Normally 800-2000IU daily unless at a severe risk of Vitamin D deficiency in which up to 4000IU can be given.

81
Q

What type of disease is Vitamin D deficiency a complication of?

A

Chronic kidney disease

82
Q

How much calcium and free calcium is found in the plasma and extracellular fluid?

A

2.5mM of total calcium and 1.25mM of free calcium. The concentration of free calcium needs to be tightly controlled.

83
Q

What three main hormones and controlled in calcium homeostasis?

A

Mainly the parathyroid hormone but also
Calcitonin
Vitamin D

84
Q

What is the overall consequence of a loss in calcium homeostasis in the extracellular fluid?

A

Alters the permeability of cells to Na+ and hence directly impacts the excitability of the excitable cells.

85
Q

What is the relationship between concentrations of calcium and permeability to sodium?

A

Inversely proportional and therefore if there is low calcium concentrations, cells are highly permeable to sodium and if there is high calcium concentrations, cells have a low permeability to sodium.

86
Q

Explain the clinical complications of hypocalcaemia?

A

Low calcium concentration, high sodium permeability, depolarisation within the cell. The cells become more excitable, increase in muscle and nerve excitability resulting in muscle spasms (respiratory muscles), can be fatal.

87
Q

Explain the clinical complication of hypercalcaemia.

A

High calcium concentration, low sodium permeability, hyperpolarisation within the cell. The cells become less excitable, decrease in muscle and nerve excitability resulting in cardiac arrhythmias.

88
Q

What is bound calcium attached to?

A

Plasma proteins (tight regulation of bound calcium is not as important)

89
Q

Where is the vast majority of calcium stored in the body?

A

In bones and teeth (99%)

90
Q

Aside from bones and teeth, where else is extracellular calcium stored?

A

In the cytosol (1000nM)
Can either be bound or in intracellular Ca2+ stores (endoplasmic reticulum etc)

91
Q

How does calcium enter and leave the body?

A

Via dietary intake and excreted via the kidneys

92
Q

Describe the differences between the two types of bone.

A

Trabecular bone is known as the ‘spongy’ bone in the internal structure of the bone. It is porous and therefore has a low density and increase vascularity.
Cortical bone however forms the outermost layer and is dense, smooth, solid white structure and therefore is responsible for providing the structural, mechanical support.

93
Q

Which type of bone stores the calcium?

A

Cortical bone

94
Q

What lies in the hollow portion inside the bone?

A

Bone marrow

Endocrinology (13 decks)

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