Osteoporosis

Question 1

Osteoporosis : Definition

Answer 1

• Osteoporosis involves a significant reduction in bone density.
• Osteopenia refers to a less severe decrease in bone density. Reduced bone density makes the bones weaker and prone to fractures.

Question 2

Osteoporosis : Risk factors

Answer 2

1. Older age : Post menopausal women
2. Life style : Poor nutrient intake, smoking, alcohol,
3. Chronic disease
   * CKD, Hyperthyroidism, RA
   * Longterm steroid use : 7.5 mg of prednisolone for > 3 months

Question 3

Osteoporosis :Medication risk factors

Answer 3

• Medications :
  1. Steroids
  2. PPI
  3. Anti-epilepstics
  4. Anti-oestrogen therapy

Question 4

Osteoporosis : Assessment of risk

Answer 4

1. Identify Demographic for assessment
   * Anyone on long-term oral corticosteroids or with a previous fragility fracture
   * Anyone 50 and over with risk factors
   * All women 65 and over
   * All men 75 and over
2. Calculate 10 year risk for major fracture
   * Q-Fracture tool
   * > 10 % : Qualify for DEXA scan

Question 5

Osteoporosis : Investigations

Answer 5

1. Assess 10 year risk of major fracture
2. DEXA scan; Bone mineral density is measured using DEXA scan which measures the radiation absorbed by the bone.

• T- score - represents the number of standard deviations the patient’s bone density falls below the mean for their age.
• Most important outcome is the T score at the patient hip.
• > 1: normal bone density
• -1 to -2.5 : Osteopenia
• < - 2.5 : Osteoporosis
• < 2.5 + fracture : Severe Osteoporosis

Women > 75 years do not need a DEXA scan for treatment if deemed clinically inappropriate

Question 6

Osteoporosis : Indications for treatment

Answer 6

• Indications for treatment

1. Dexa scan : T score <-2.5
2. Fragility fracture in ;
   * Women > 75 years
   * > 65 years on Long term Steroid therapy
3. Long term steroid therapy
   * < 65 years and DEXA <-1.5
   * > 65 years with fragility fracture

Question 7

Osteoporosis : Management

Answer 7

Correct hypocalcaemia/Vitamin D deficiency before bisphosphonates - as can worsen hypocalcaemia by inhibiting osteoclasts

1. First line : Bisphosphonates (Alendronic acid)
   * Reduce activity of osteoclast activity and preventing bone resorption.

If SE of alendronic acid are nor tolerated;

2. Second line : Risedronate more effective is preventing hip fractures or Etidronate

If Bisphosphonates are not tolerated;

3. Third line: if T score is < -3.5
   * Strontium ranelate
   MOA : Dual action bone agent as it stimulates osteoblasts and inhibits osteoclasts.
   SE : Increases risk of thromboembolic events or CVS events.

• Raloxifine - selective oestrogen receptor modulator
  MOA : Prevent bone loss and reduce risk of vertebral fractures - unknown re: other fractures

SE of Strontium ranelate/Raloxifine : Increases risk of thromboembolic events

Question 8

Osteoporosis : SE of Aldenronic acid

Answer 8

*Osteoporosis : SE of Alendronic acid *
SE:
1. Reflux and oesophageal erosions, should be taken on an empty stomach sitting upright for 30 minutes,
* Oesopgitis, Oesophageal ulcers
2. Osteonecrosis of the jaw and external auditory canal
3. Hypocalacaemia - reduce osteoclast activity
3. CI if eGFR<35

Question 9

Alendronic acid : Medication counselling

Answer 9

1. Medication taken 30minutes before breakfast (empty stomach)
2. Sitting upright during and 30 minutes after taking the tablet