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pre reg afsha endocrine > osteoporosis > Flashcards

osteoporosis Flashcards

1
Q

when is osteoporosis considered severe

A

if there have been one or more fragility fractures

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2
Q

what is osteoporosis

A

progressive bone disease characterised by low bone mass and structural deterioration of bone tissue with subsequent increase in bone fragility and fracture susceptibility

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3
Q

what is a fragility fracture

A

fracture following a fall from standing height or less (i.e. low level trauma)

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4
Q

what are vertebral fractures

A

fractures of the spine
can occur spontaneously, or as a result of routine activities

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5
Q

risk factors for osteoporosis

A
  • postmenopause
  • men >50
  • long term oral CCs
  • increasing age
  • vitamin D deficiency and low calcium intake
  • lack of physical activity
  • BMI less than 18.5
  • smoker
  • excess alcohol
  • parenteral history of hip fractures
  • early menopause
  • previous fracture at site characteristic of osteoporotic fractures
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6
Q

What BMI is a risk factor for osteoporosis

A

less than 18.5

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7
Q

what sites are characteristic of osteoporotic fractures

A

wrist
spine
hip

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8
Q

name a non-osteoporotic cause for fragility fracture

A

metastatic bone cancer

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9
Q

what is a possible undiagnosed secondary cause of osteoporotic fragility fracture

A

hyperthyroidism

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10
Q

A 10 year fragility fracture risk score should be calculated before arranging a DXA scan to measure BMD, or starting a bisphosphonate except in people

A
  • over 50 with history of fragility fractures (offer DXA scan)
  • under 40 who have major risk factor for fragility factors: offer DXA scan, then refer to specialist who is experienced in treatment of osteoporosis depending on BMD T Score
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11
Q

what does a DXA scan measure

A

bone mineral density

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12
Q

what is the T score

A

the number of standard deviations below the mean BMD of young adults at their peak bone mass
more negative = worse

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13
Q

what two tools do you use to measure fragility fracture risk and which one is preferred

A

Q Fracture - preferred
FRAX online assessment calculators

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14
Q

People at high risk of a fragility fracture risk (calculated using Q fracture or FRAX) should offered…

A

DXA scan to confirm osteoporosis

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15
Q

People at intermediate risk of fragility fracture (calculated using Q fracture or FRAX) whose fracture risk if close to recommended threshold and how have risk factors that may be underestimated by FRAX should be..

A

should be offered DXA scan

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16
Q

what to do with pt who have a low risk of fragility fracture (calculated using Q fracture or FRAX)

A

lifestyle advice - do not give treatment or DXA scan

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17
Q

offer bisphosphonate treatment (if appropriate and no contraindications) in pt with BMD score of….

A

-2.5 or lower

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18
Q

if t score is greater than -2.5 what do you do

A

no treatment
modify risk factors, treat underlying conditions and repeat DXA at interval appropriate for pt based on their risk profile, using clinical judgement (usually wihtin 2 years)

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19
Q

HRT in younger post menopausal women

A

can be considered to reduce risk of osteoporotic fracture and relief of menopausal symptoms

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20
Q

how does menopause increase risk of osteoporosis

A

lower oestrogen levels = increased bone turnover and enhanced bone resorption

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21
Q

Follow up should be arranged to assess and manage the adverse effects of bone sparing treatment, adherence to treatment, the need for continuing treatment with bisphosphonates after …..

A

5 yrs
3 yrs for zolendronate

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22
Q

name two diseases associated with osteoporosis

A

RA and diabetes

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23
Q

….. of liver enzymes interferes with vitamin D metabolism so can increase the risk of fracture in some patients (+ drug examples)

A

INDUCTION
(inducers: BS CRAP GPS)

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24
Q

4 lifestyle changes to improve bone health and reduce risk of fragility fractures

A
  • Increase level of physical activity
  • Stop smoking
  • Maintain normal BMI (between 18.5-24.9 kg/m2)
  • Reduce alcohol intake
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25
Q

lifestyle changes for pt at risk of fractures/osteoporosis

A
  • Adequate intake of calcium and vit D
  • Calcium: preferably obtain through increasing dietary intake; supplements if necessary
  • Daily dietary supplement of vit D may be considered for at risk pt
26
Q

elderly pt at risk because… and what they might benefit from

A
  • Esp housebound or living in residential or nursing homes
  • High risk of vit D deficiency
  • May benefit from calcium + vit D treatment
  • Elderly people also have increased risk of falls
27
Q

1st line options in postmenopausal osteoporosis and why

A

alendronic acid, risedronate sodium
due to broad spectrum of anti-fracture efficacy
both have been shown to reduce occurrence of vertebral, non-vertebral and hip fractures

28
Q

alternative bisphosphonate for postmenopausal osteoporosis

A

Ibandronic acid may be considered as an alternative to AA and RS

29
Q

alternatives for postmenopausal osteoporosis for women in whom oral bisphosphonates not suitable or not tolerated

A

○ Parenteral bisphosphonates or denosumab
○ Alternatives: raloxifene HCl or strontium ranelate
- HRT is another alternative (generally for younger postmenopausal women with menopausal symptoms and high risk of fractures)
- tibolone is another option in younger postmenopausal women, esp those with menopausal symptoms

30
Q

why is HRT as an alternative to oral bisphosphonates for postmenopausal menopause generally restricted to younger postmenopausal women with menopausal symptoms who are at high risk of fractures

A

○ This is due to adverse effects e.g. CVD and cancer in older postmenopausal women & women on long-term HRT

31
Q

name 2 drugs that are reserved for postmenopausal women with severe osteoporosis who are at very high risk of fractures

A

Teriparatide - if at v high risk of fractures esp vertebral

Romosozumab - if previous fragility fracture and at imminent risk of another within 24 months

  • these are also recommended over oral BS in postmenopausal women with at least one severe or two moderate low trauma vertebral fractures*
32
Q

Glucocorticoid-induced osteoporosis - when does bone loss occur and when should bone protection treatment be started

A
  • Glucocorticoid treatment strongly associated with bone loss & increased risk of fractures
  • Greatest rate of bone loss occurs early after initiation, and increases with dose and duration of therapy
  • Bone-protection treatment should be started at onset of glucocorticoid treatment in pt at high risk of fracture
33
Q

when to consider bone protection treatment for women

A

Women ≥70 OR with previous fragility fracture OR taking large dose of GC (prednisolone ≥7.5 mg daily or equivalent)

34
Q

when to consider bone protection treatment for men

A

≥70 with previous fragility fracture OR taking large dose of GC (7.5mg mg daily or equivalent)

35
Q

what is large dose GC defined as

A

prednisolone ≥7.5 mg daily or equivalent

36
Q

1st line & alternative treatment for Glucocorticoid-induced osteoporosis

A
  • 1st line: Oral bisphosphonates alendronic acid or risedronate sodium
  • Alternatives in pt intolerant of oral bisphosphate, or in whom they are unsuitable: zoledronic acid, denosumab, teriparatide
37
Q

Glucocorticoid-induced osteoporosis - when to stop and when to continue treatment

A
  • If GC treatment stopped, review the need to continue bone-protection treatment
  • Continue bone-protection treatment with long-term GC treatment
38
Q

1st lien for osteoporosis in men and alternatives

A
  • alendronic acid or risedronate sodium
  • oral bisphosphates unsuitable or not tolerated, alternatives are zoledronic acid, denosumab, teriparatide or strontium ranelate
39
Q

there is increased fracture risk in men having which therapy for which cancer? what should you do

A
  • androgen deprivation therapy for prostate cancer
  • consider fracture risk assessment when starting this therapy
40
Q

bisphosphonate free period

A

some pt may benefit from this as therpeutic effects last for some time after treatment cessation, although limited evidence to support this

41
Q

review bisphosphonate treatment after 5 years for:

A

alendronic acid, risedronate, ibandronic acid

42
Q

review bisphosphonate treatment after 3 year with

A

zolendronic acid

43
Q

based on fracture risk assessment, continuing bisphosphonates beyond 5 years (3 years for zolendronate) can generally be recommended for…

A
  • over 75
  • history of previous hip or vertebral fracture
  • one or more fragility fractures during treatment
  • long term GC treatment
44
Q

there is no evidence for treatment beyond …. years with bisphosphonates so management of these pt needs to be on case by case basis with specialist input as appropriate

A

10 years

45
Q

a calcium intake of at least ….. daily is recommended for people at increased risk of fragility

A

1000mg

46
Q

who is at risk of vitamin D deficiency

A

over 65
not exposed to much sunlight (e.g. because of clothing or staying indoors)

47
Q

FRAX underestimates some risk factors e.g.

A
  • regular use of CCs equal to or less than 5mg prednisolone daily
  • use of CCs more than or equal to 7.5mg prednisone daily for more than 3 months
  • history of multiple fragility fractures
  • high alcohol intake
  • heavy smoking
48
Q

in people over 80, interpret the estimated 10 year fracture risk with caution because

A

short term fracture risk may be underestimated

49
Q

what is high risk, intermediate risk and low risk of fracture according to Q Fracture

A

high risk: risk score is 10% or more
intermediate: close to but below 10%
low: below 10%

50
Q

only two bisphosphonates are licensed in men, with particular doses. what are they

A

alendronic acid once daily (10mg tabs)
risedronate once weekly (35mg tabs)

51
Q

If the person’s calcium intake is adequate (700 mg/day, how much vitamin D should you prescribe without calcium for people not exposed to much sunlight

A

10 micrograms (400 international units

52
Q

If calcium intake is inadequate what should you prescribe

A

Prescribe 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily.

53
Q

if calcium intake if inadequate in elderly people who are housebound or living in nursing home what should you prescribe

A

Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily

54
Q

upper GI adverse effects of bisphosphonates are more common in …. (+advice)

A

common in the first month of treatment and often improve with continuing use. They are less likely if the recommended method of taking bisphosphonates is followed

55
Q

what to do if pt on bisphosphonates has symptoms of atypical fracture including new onset hip, groin, or thigh pain

A

stop treatment and arrange an X-ray of the femur.

56
Q

a patient comes in and asks for some pain killers. upon questioning, she tells you she has had some recent pain in the hip, groin, thigh region. you look at her PMR and see that she is on alendronic acid 70mg once weekly. what do you do

A

tell her to stop treatment and refer to A&E to arrange an X-ray of the femur.

57
Q

For people who remain at high risk of an osteoporotic fragility fracture (e.g. over 75, previous hip or vertebral fracture), how long to continue treatment with alendronic acid and risendronate?

A

up to 10 years for alendronic acid
up to 7 years for risedronate

58
Q

For people whose fracture risk was intermediate the last time they were assessed, reassess after a minimum

A

of 2 years

59
Q

for people taking oral corticosteroids, how long to continue treatment with bisphosphonates and/or calcium and vit D

A

until treatment with oral corticosteroids has stopped, then reassess the osteoporotic fragility fracture risk to determine the need for continuing treatment with a bisphosphonate and calcium and vitamin D

60
Q

safety info for all bisphoshphonates - 3 main points

A
  • atypical femoral (thigh) fractures
  • osteonecrosis of jaw
  • osteonecrosis of external auditory canal

pre reg afsha endocrine (29 decks)

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