Osteoporosis

Question 1

Typical demographic

Answer 1

Older females

Question 2

Major risk factors for osteoporosis

Answer 2

steroid use
rheumatoid arthritis
alcohol excess
Family Hx
low body mass index
current smoking

Question 3

Other (non major) risk factors

Answer 3

• sedentary lifestyle
• premature menopause
• Caucasians and Asians
• endocrine disorders
• multiple myeloma, lymphoma
• GI disorders: IBD, coeliac, gastrectomy, liver disease
• CKD
• osteogenesis imperfecta
• homocystinuria

Question 4

Give examples of medications which may worsen osteoporosis

Answer 4

SSRIs
antiepileptics
proton pump inhibitors
glitazones
long term heparin therapy
aromatase inhibitors e.g. anastrozole

Question 5

What investigations must be completed after a patient develops a fragility fracture?

Answer 5

Bloods: FBC, CRP, calcium, albumin, creatinine, phosphate, ALP and liver transaminases, TFTs

Bone densitometry ( DXA)

Question 6

What is the T score used in DEXA scanning?

Answer 6

T score: based on bone mass of young reference population
T score of -1.0 means bone mass of one standard deviation below that of young reference population

Question 7

What is Z score in DEXA scanning?

Answer 7

Z score is adjusted for age, gender and ethnic factors

Question 8

Explain the cut offs for the T score and how someone maybe diagnosed with osteoporosis

Answer 8

> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

Question 9

When is the risk of osteoporosis thought to rise significantly in patients taking steroids?

Answer 9

taking the equivalent of prednisolone 7.5mg a day for 3 or more months

Question 10

If a patient is on steroids and is >65years with a history of previous fragility fracture, should they receive bone protection

Answer 10

Yes

Question 11

If a patient on steroids is <65 with no history of fragility fracture, how do we decide if they require bone protection?

Answer 11

DEXA scan

T score:
>0 = Reassure
Between 0 and -1.5 = Repeat bone density scan in 1-3 years
< -1.5 = Offer bone protection

Question 12

First line agent

Answer 12

Alendronate

Question 13

If patients cannot take alendronate, what should be used instead?

Answer 13

Risedronate or etidronate

Question 14

Other osteoporosis treatments

Answer 14

strontium ranelate
raloxifene
denosumab

Question 15

Raloxifene mechanism of action

Answer 15

selective oestrogen receptor modulator (SERM)

Question 16

Raloxifene side effects

Answer 16

may worsen menopausal symptoms
increased risk of thromboembolic events
may decrease risk of breast cancer

Question 17

Adverse effects of strontium ranelate

Answer 17

increased risk of cardiovascular events and
thromboembolic events
may cause serious skin reactions such as Stevens Johnson syndrome

Question 18

Mechanism of action of strontium

Answer 18

increases deposition of new bone by osteoblasts
(promotes pre-osteoblasts to become osteoblasts)
reduces the resorption of bone by inhibiting osteoclasts

Question 19

Mechanism of denosumab

Answer 19

human monoclonal antibody that inhibits RANK ligand

in turn inhibits the maturation of osteoclasts

Question 20

how is denosumab given

Answer 20

subcutaneous injection every 6 months

Question 21

What is teriparatide and what is its mechanism of action

Answer 21

recombinant form of parathyroid hormone

Question 22

HRT has been shown to reduce the incidence of vertebral fracture and non-vertebral fractures. TRUE/FALSE?

Answer 22

TRUE
- Due to increased rates of cardiovascular disease and breast cancer it is no longer recommended for primary or secondary prevention of osteoporosis