Osteoporosis Flashcards

1
Q

What is the pathophysiology behind osteoporosis?

A

Bone loss is faster than bone generation, resulting in weak and brittle bones

Cell types implicated
- Osteoblasts: Responsible for bone matrix synthesis (generate new bone matrix and osteocytes)
and subsequent mineralization
- Osteocytes: initiate formation or resorption responses
- Osteoclasts: Responsible for maintaining mineralised bones, remodelling and mechanosensing

Over time, rate of bone mass decline gets faster - Even worse once women reach menopause

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2
Q

What are some possible causes for decreased bone mass?

A
  • Age
  • Menopause – ↓ estrogen results in ↑osteoclast resorption and ↓ osteoblastic bone deposition
  • Low serum Ca – causes equilibrium of serum Ca and bone Ca to shift, with Ca moving out of bone
  • Alcohol consumption
  • Smoking
  • Physical inactivity
  • Medication use – glucocorticoids, immunosuppressants, antiseizures (esp phenobarbital and phenytoin), aromatase inhibitors, GnRH agonists and antagonists, heparin, chemotherapy
  • Secondary to other diseases
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3
Q

What are the clinical manifestations of osteoporosis?

A

Asymptomatic, often undiagnosed until presented with fragility fracture
- Spine – vertebral compression: height loss, kyphosis (hunchback)
- Hip – neck of femur fracture, IT fracture
- Wrist – Colles fracture
- Humerus
- Pelvis

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4
Q

How should it be decided if patients should go for BMD screening?

A

Should assess post-menopausal women, men ≥65yo – especially if any risk factors present

OSTA Risk Assessment
- High risk (>20) – consider DXA scan as the chance of finding osteoporosis is high in this group
- Medium risk (0-20) – consider DXA scan if any other risk factors for osteoporosis is present
- Low risk (0) – consider deferring DXA
- OSTA Score=0.2 ×[Body weight (kg)-Age (years)]
Female: Low: > -1, Intermediate: -1 to -4, High: < -4 Male: Low: > -1, Intermediate: -1 to -6, High: < -6

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5
Q

How is osteoporosis diagnosed?

A

Hx of fragility fracture
- Occurs spontaneously or from minor trauma that would not ordinarily result in a fracture
- Asymptomatic vertebral fracture can be identified as a >20% decrease in vertebral height

Bone mineral density (BMD) measurement using DXA hip and/or spine
- Dual-energy X-ray absorptiometry
- T-score
- Z-score

Clinical Hx, physical exam and labs also done to exclude secondary causes of bone loss (esp if Z-score ≤ -2 SD)
- SCr – check for CKD-MBD
- CBC – check malignancy & malabsorption
- 25-OH Vit D – check baseline (>20ng/mL optimal)
- Corrected Ca (elevated may suggest hyperparathyroidism, decreased may suggest malabsorption, vitamin D deficiency)

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6
Q

How is T-score for osteoporosis interpreted?

A

Compares BMD against a young adult reference population
→ ≤ -2.5 SD → osteoporosis
→ -1 to -2.5 SD → osteopenia
→ ≥ -1 SD → normal bone density

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7
Q

How is Z-score for osteoporosis interpreted?

A

Compares BMD against expected BMD for the patient’s age and sex
→ ≤ -2 SD suggests coexisting problems (e.g. glucocorticoid therapy or alcoholism) that can contribute to osteoporosis

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8
Q

When should osteoporosis treatment start?

A
  • Patients presenting with fragility fracture or
  • Patients without fragility fracture but DXA BMD T-score ≤ -2.5 or
  • Patients without fragility fractures but osteopenic DXA BMD T-score (-1 to -2.5) and high fracture risk (FRAX)
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9
Q

What is the MOA of the bisphosphonates?

A

Slow bone loss by increasing osteoclast cell death

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10
Q

How are bisphosphonates used in osteoporosis therapy?

A

Tx duration for low fracture risk
- PO: 5 years
- IV: 3 years

Tx duration for low fracture risk
- PO: 10 years
- IV: 6 years

Check BMD Q2-3 years – if satisfactory, can consider drug holiday (ie stop bisphosphonate)

If drug holiday, check BMD again in another 2-3 years and see if to restart Tx

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11
Q

How should PO bisphosphonates be taken?

A

PO Admin Instructions (prevent GI irritation): Take on an empty stomach first thing in the morning. Take tablet with ≥240ml of plain water (approx. 1 mug). Wait ≥30 min before consuming anything.
→ Normal tab – Do not chew or crush
→ Effervescent tab – Dissolve in the water and wait for fizzing to stop (can stir to speed up dissolution). Drink the solution, then drink extra plain water after than (≥30ml). Do not swallow the undissolved tablet whole, chew the tablet or leave the tablet to dissolve in mouth

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12
Q

What are the side effects of the bisphosphonates?

A

→ Significant: atypical femoral fractures (w prolonged use), severe bon/joint/muscle pain, upper GI irritation, ocular effects, hypocalcaemia, osteonecrosis of jaw and external auditory canal
→ PO: nausea, abdominal pain, heartburn-like symptoms (check admin technique)
→ IV: flu-like symptoms

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13
Q

What are the contraindications for bisphosphonates?

A

Hypocalcaemia, abnormalities of the oesophagus which may delay emptying, severe renal impairment (CrCl < 30ml/min), pregnancy and lactation

Precautions: active upper GI disease, risk factors for osteonecrosis of jaw or external auditory canal

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14
Q

What is the MOA of denosumab?

A

Human monoclonal antibody against RANKL – prevents development of osteoclasts

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15
Q

How is denosumab dosed?

A

SC injection Q6/12 – Co-administer 1000mg Ca + ≥400 IU vitamin D daily

DO NOT discontinue – may increase risk of spinal column fractures

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16
Q

What are the side effects of denosumab?

A

muscle/back/bone/joint pain, N/V, C/D, slight tiredness, increased cholesterol levels

ONJ, atypical femoral fracture

17
Q

What are the contraindications for denosumab?

A

Hypocalcaemia, pregnancy

18
Q

What is the MOA of raloxifene for osteoporosis?

A

→ Selective oestrogen receptor modulator
→ Mixed oestrogen receptor agonism and antagonism
→ Mimics effects of oestrogen on bone density in postmenopausal women
→ However, still increases risk of blood clots and can cause hot flashes

19
Q

What is the MOA of calcitonin for osteoporosis?

A
  • Peptide hormone secreted by parafollicular cells of thyroid gland
  • Reduces blood calcium, opposing effects of PTH
  • Inhibits osteoclastic bone resorption
20
Q

What are the side effects of calcitonin?

A

red skin streaks, inj site rxns, redness of face/neck/arms/upper chest, feeling of warmth

21
Q

What are the contraindications for calcitonin?

A

hypersensitivity, hypocalcemia

22
Q

What is the MOA of romosozumab?

A

Removes sclerostin inhibition of canonical
Wnt signalling pathway that regulates
bone growth – inc bone formation and
dec bone resorption

23
Q

How is romosozumab dosed for osteoporosis?

A

SC Q1/12 x 12/12

24
Q

What are the side effects of romosozumab?

A

MI, inc risk of CV death,
stroke, transient hypocalcaemia,
hypersensitivity reactions

ONJ, atypical femoral fracture

25
Q

What are the contraindications for romosozumab?

A

hypersensitivity, uncorrected hypocalcaemia, Hx of MI/stroke in preceding 1 year

26
Q

What is the MOA of teriparatide?

A

Synthetic PTH analog

Stimulates new bone formation and increase bone strength

Continuous physiological PTH levels favour bone resorption to increase plasma calcium, but intermittent high-dose clinical PTH levels have opposite effect of suppressing bone resorption to favor bone growth

27
Q

What are the side effects of teriparatide?

A

serious calciphylaxis and worsening of previous stable cutaneous calcification, transient orthostatic hypotension, transient and minimal hypercalcemia

28
Q

What are the contraindications for teriparatide?

A

hypersensitivity, pre-existing hypercalcemia, skeletal malignancies or bone metastases, other metabolic bon1 diseases (e.g. Paget’s, hyperparathyroidism), unexplained ALP elevations, previous implant or external beam radiation therapy to skeleton, hereditary disorders predisposing to osteosarcoma, severe renal impairment, pregnancy

29
Q

How should osteoporosis therapy be chosen?

A

1st Line – PO Bisphosphonates
2nd Line – IV Bisphosphonates (cannot sit up for 30mins)
3rd line – RANKL inhibitor (cannot sit up for 30mins + CrCl<30)