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end of y3 > osteoporosis > Flashcards

osteoporosis Flashcards

1
Q

characteristics of osteoporosis

A

1) low bone density
2) microarchitecture disruption (impaired mineralisation)
3) decreased bone strength
4) increased risk of fractures

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2
Q

processes contributing to decrease bone mass

A

1) Decreased bone formation
2) Excessive bone resorption

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3
Q

causes of decreased bone mass

A

1) age
2) menopause
3) low serum Ca

  • increased oxidative stress -> increased osteoblast apoptosis

4) alcohol consumption, smoking

  • increased RANKL activation -> increased osteoclast growth -> increased bone resorption

5) secondary causes

  • glucocorticoid use induced osteoporosis
    ** inhibit decrease in osteoblast differentiation and increase death of osteoblast and osteocytes
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4
Q

clinical presentation of osteoporosis

A
  • asymptomatic, no pain until fracture actually happen
  • often undiagnosed until pt present w low-trauma fragility fracture
    -spine: height loss due to compression, kyphosis (forward rounding of upper back)
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5
Q

what to look out for osteoporosis

A

1) family history of osteoporosis or fragility fractures
2) previous fragility fracture
3) low body weight
4) advanced age
5) height loss (Decrease by > 2cm over the past few years)
6) early menopause (<45yo)
7) presence of diseases that can lower bone density
8) diet (low Ca intake < 500mg/day)
9) excessive alcohol intake (>2 units/day)
10) smoker
11) prolonged immobility
12) history of falls

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6
Q

diagnosis components for osteoporosis

A

1) history of fragility fracture
2) bone mineral density (BMD) measurement

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7
Q

history of fragility fracture for osteoporosis

A
  • vertebral, hip, wrist, humerus, rib, pelvis
  • occur spontaneously or from minor trauma that would not normally result in fracture
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8
Q

BMD measurement for osteoporosis

A

1) indication

  • post menopausal women
    ** classifications using OSTA tool
    –> high risk (>20): do DXA scan
    –> medium risk (0-20): do DXA scan if presence of other risk factors
  • men > 65 yo

2) how to do BMD measurement?

  • DXA hip and/or spine

3) T-score

  • ≤ -2.5 SD: osteoporosis
  • -1 to -2.5 SD: osteopenia (do FRAX)
  • ≥ -1 SD: normal bone density

4) Z-score

  • ≤ -2 SD indicates coexisting problems that contribute to osteoporosis
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9
Q

indication for treatment initiation for osteoporosis

A

1) fragility fracture
2) no fragility fracture but DXA T-score ≤ -2.5 SD
3) no fragility fracture and osteopaenic but high risk fracture cuz FRAX scoring indicates 10-yr probability for major osteoporotic fracture ≥ 20% or hip fracture ≥ 3%

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10
Q

what to do when initiating treatment for osteoporosis

A

check serum Ca and 25(OH) Vit D levels

  • serum 25(OH) Vit D should be 20-50 mg/dL
  • correct serum Ca levels before initiating therapy with Ca and Vit D supplement
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11
Q

treatment algorithm for osteoporosis

A

1st line: PO bisphosphonates
2nd line: IV bisphosphonates, denosumab
alternative therapies: antiresorptive agents (oestrogen, calcitonin), anabolic agents (romosozumab, parathyroid hormone therapies)

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12
Q

types of bisphosphonates

A

1) PO (cheapest)

  • risedronate 35mg q weekly
  • alendronate 50mg q weekly

2) IV

  • zoledronic acid 5mg q year as 30 mins IV infusion
  • ensure adequate hydration prior to administration
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13
Q

bisphosphonates PO dosing administration

A
  • take oral on empty stomach w at least 240mL plain water and wait 30 mins before taking food cuz F severely affected by food and drinks
  • avoid lying down for 30 mins after taking drug to prevent acid reflux
  • X take with Ca, Al, Mg, Fe containing products within 2 hrs of meds
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14
Q

MOA of bisphosphonates

A

slow bone loss by increasing osteoclast cell death

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15
Q

bisphosphonates AE - significant

A

1) atypical femoral fractures after prolonged use

  • discontinue therapy

2) severe bone/joint/muscle pain, upper GI mucosa irritation, ocular effects (iritis, uveitis), hypocalcemia
3) osteonecrosis of jaw (ONJ)

  • risk factors
    ** invasive dental procedures while on bisphosphonates
    ** history of cancer/radiotherapy
    ** poor oral hygiene
  • counselling points
    ** smoking cessation
    ** avoid invasive dental procedures
    ** good oral hygiene
  • discontinue therapy based on risk/benefit and consult dentist

4) osteonecrosis of external auditory canal

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16
Q

bisphosphonates AE - PO related

A

N, abdominal pain, heart-burn like symptoms

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17
Q

bisphosphonates AE - IV related

A

flu-like symptoms

18
Q

bisphosphonates CI

A

1) hypocalcemia
2) abnormalities of esophagus which may delay emptying
3) severe renal impairment (CrCl < 30)
4) pregnancy, lactation
5) for PO: inability to stand/sit up for ≥ 30 mins (bedbound, dementia)

19
Q

bisphosphonates precautions

A

1) Active upper GI disease
2) risk factors for developing ONJ or osteonecrosis of external auditory canal

20
Q

bisphosphonates treatment duration

A

1) low fracture risk

  • PO 5 yrs
  • IV 3 yrs
  • restart treatment after 2 yrs if BMD decrease by > 4-5% or treatment criteria met

2) high risk fracturs

  • requirements: 10 yr total risk of fractures > 20%, previous vertebra fracture
  • PO 10 years
  • IV 6 years
21
Q

denosumab MOA

A
  • human mab against RANKL
  • prevent development of osteoclast
22
Q

denosumab efficacy vs bisphosphonates

A

similar or better bone density results

23
Q

dosing instructions for denosumab

A
  • subcu injection every 6 monthly
  • co-administer 1000mg Ca + ≥ 400 IU Vit D daily
24
Q

denosumab AE

A
  • muscle, back, bone, joint pain
  • N/V/C/D, slight tiredness, increased cholesterol level
  • ONJ or atypical femur fracture
  • X discontinue cuz increased risk of spinal column fracture (counsel so pt won’t default appointment)
25
Q

denosumab CI

A

hypocalcaemia, pregnancy, Vit D deficiency, eczema

26
Q

indication for oestrogen

A
  • bone health in younger women
  • women who also need to treat menopause
27
Q

types of oestrogen therapy

A

raloxifene

28
Q

calcitonin MOA

A
  • reduce blood Ca -> oppose effect of parathyroid hormone
  • inhibit osteoclastic bone resorption
29
Q

calcitonin formulations

A

injection, nasal spray

30
Q

calcitonin AE

A
  • red streaks on skin
  • injection site reaction
  • feeling of warmth
  • redness of upperbody
31
Q

calcitonin CI

A

hypersensitivity, hypocalcemia

32
Q

MOA of romosozumab

A
  • remove sclerostin inhibition of canonical Wnt signalling pathway that regulates bone growth
  • increase bone formation and decrease bone resorption
33
Q

romosozumab AE

A

-MI, increased risk of CV death, stroke, transient hypocalcemia

34
Q

romosozumab CI

A
  • hypersensitivity
  • uncorrected hypocalcemia
  • history of MI/stroke (within preceding year)
35
Q

types of parathyroid hormone therapy

A

teriparatide

36
Q

teriparatide indication

A

last line if X tolerate/CI other therapy

37
Q

MOA of teriparatide

A

stimulate new bone formation and increase bone strength

  • increase activation of Vit D
  • increase calcium mobilisation from bone
  • regulate excretion of Ca through kidney
38
Q

teriparatide administration

A
  • OD subcu injection
  • max treatment duration 24 months in 1 lifetime
39
Q

teriparatide AE

A

calciphylaxis, transient orthostatic hypotension

40
Q

teriparatide CI

A

1) hypercalcemia
2) hypersensitivity
3) skeletal malignancy or bone metastases
4) metabolic bone disease
5) severe renal impairment (CrCl < 30)
6) pregnant

41
Q

monitoring parameters for osteoporosis treatment

A
  • serum creatinine to ensure renal function dont worsen
  • serum calcium
  • serum 25(OH) Vit D
42
Q

osteoporosis non pharmaco

A

1) daily recommended Ca intake 1200g/day of elemental Ca

  • supplement
  • high Ca food
    ** yoghurt, orange juice, 240mL of milk, cheese, tofu w Ca
  • optimise Vit D intake (prevent falls)
    ** go outdoors, increase physical activities

2) Exercise

  • weight bearing, muscle strengthening, balance exercises
  • brisk walk, gym, taichi

3) smoking cessation, reduce alc intake
4) do fall risk assessment (+ the drugs that cause sedation)
5) advocate home safety

end of y3 (8 decks)

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