OSTEOPOROSIS Flashcards
What is osteoporosis?
- Progressive bone disease
- Reduction of bone mass and density causing increased risk of fractures
Signs and symptoms
- fracture
- reduced bone density on DEXA scan
- pain
- reduced mobility
- reduced height
RF
Postmenopausal women/ females
Men over 50
Patients taking long-term oral corticosteroids (glucocorticoids)
Vit D and Calcium Deficiency
Long term CS treatment
Lack of exercise, smoking, drinking
Low BMI
History of fractures
Early menopause
Lifestyle changes
Increase Exercise
Smoking Cessation
Maintain an Ideal BMI
Reduce Alcohol Intake
Increase intake of Vitamin D and Calcium (supplements if needed)
Which drugs can lower Vit D?
Carbamazepine
Phenytoin
What are the two main types of osteoporosis?
- Postmenopausal (PM)
osteoporosis
And - Glucocorticoid-induced
osteopororis
- “Corticosteroid” induced
Treatment of osteoporosis (post-menopausal)
- Bisphosphonates
- 1st = alendronic acid
- 2nd = risendronate
Oral CI
- IV bisphosphonates (ibandronic, zoledronic)
- Denosumab
- Raloxifene
- HRT/ tibolone (not used in older women = increase CVD, cancer)
MoA of bisphosphonates
Slows rate of bone growth and dissolution by absorbing onto the hydroxyapatite crystals in bone.
Teripatide
- reserved for postmenopausal women
- severe osteoporosis
- very high risk of fractures
Osteoporosis in men
- PO
- IV
- Denosumab
Glucocorticoid-Induced osteoporosis - treatment
- PO bisphosphonates
- alendronic acid
- risedronate - IV bisphophonates
- Zoledronic acid
- Teriparatide
- Densosumab
Choice for bone metastases in breast cancer/severe hypercalcaemia of malignancy
Pamidronate (IV)
Zolendronic acid
- IV
- most potent
- highest risk of osteonecrosis of jaw
Start prophylaxis at onset of glucocorticoid treatment in the following
Women
- 70 years or over
- Previous fragility fracture
- Large doses of glucocorticoids (prednisolone ≥7.5 mg daily or equivalent)
Men aged ≥70 or over AND either:
- Previous fragility fracture
- Large doses of glucocorticoids
Large dose corticosteroids for >3 months
What should you ensure before starting bisphosphonates?
- Correcting Hypocalcaemia and Vitamin D deficiency
- Monitor these levels as well as serum electrolytes
Which electrolytes can bisphosphonates
effect?
- Calcium
- cause HYPOcalcaemia
- most important - Magnesium
- cause HYPOmagnesia
What is the main
electrolyte to monitor for bisphosphonates?
Ca
Which Bisphosphonate can be given orally?
And how often?
- Alendronic acid
- Tablet 10mg (daily) or 70mg (weekly)
- Oral solution - Ibadronic acid
- Risedronate
- Tablet 5mg (daily) or 35mg
(weekly)
Which bisphosphonate is given via injection and how often?
- Ibandronic acid
- Every 3 months - Zoledronic acid
- every 12 months
Note: Pamidronate is IV but not licensed for osteoporosis
Bisphosphonate SE
Atypical Femoral Fractures
Osteonecrosis of the Jaw
Osteonecrosis of the External Auditory Canal
Bone, joint, muscle pain
Oesophageal irritation
Atypical Femoral Fractures
Report any thigh, hip or groin pain
Greater risk with long term therapy
Review after 5+ years use
Osteonecrosis of the Jaw
Report any dental pain, swelling, non-healing sores or discharge
- Before starting = dental checkup + necessary remedial dental work.
- Good oral hygiene and routine dental checkups
Osteonecrosis of the Jaw high risk
zolendronic acid
Osteonecrosis of the External Auditory Canal
Report ear pain, discharge or ear infection
Long-term therapy - 2+ years
Osteonecrosis of auditory canal - risk factors
Ear operation
Chemo
Steroid use
Cotton bud use
Counselling - alendronic acid
70 mg weekly OR 10 mg daily
- Swallow whole with plenty of water
- Whilst standing or sitting upright
- On an empty stomach, 30 minutes before breakfast or other meds
- Remain upright 30 mins after
Risendronate
35 mg weekly OR 5 mg daily
Can be taken like alendronic acid or at any time or day
- 2 hour gap between risendronate and food, drink, antacids, calcium containing products e.g. milk, iron or mineral supplements.
- Stand or sit upright for 30 mins
- Avoid at bedtime/before rising.
Oesophageal reactions
- REPORT dysphagia, new or worsening heartburn or retrosternal pain
- Medication should be take with a full glass of water whilst standing and should remain upright for 30 mins after
What happens if dysphagia or heartburn occurs with bisphosphonates?
- stop taking bisphosphonates
- seek medical attention
How often should bisphosphonates be reviewed?
Every 3 years:
- Zoledronic acid
Every 5 years:
- Alendronic acid
- Risedronate
- Ibandronic acid
Can bisphosphonates be taken in pregnancy?
AVOID
So if child bearing age, they must use contraception
How often is denosumab administered?
s/c
every 6m
