Osteoporosis

Question 1

What is osteoporosis?

Answer 1

A bone defect characterised by reduced bone mineral density and increased porosity

Question 2

What are the types of osteoporosis?

Answer 2

Type I (Post-menopausal)
= Exacerbated bone loss after menopause

Type II (Senile)
= Bone loss due to ageing

Secondary Osteoporosis
= Caused by conditions like steroids, alcohol, and chronic diseases.

Question 3

What are the risk factors for osteoporosis?

Answer 3

(1) Steroid use
(2) Alcohol
(3) Smoking
(4) Low estrogen
(5) Early menopause
(6) Low calcium, inactivity
(7) Chronic diseases
(8) Vitamin D deficiency

Question 4

What is the SHATTERED acronym for osteoporosis?

Answer 4

S: Steroid use

H: Hyperthyroidism
hyperparathyroidism

A: Alcohol, smoking

T: Thin (BMI<22) Testosterone deficiency

E: Early menopause

R: Renal/liver failure/ RA

E: Erosive bone disease

D: Diabetes

Question 5

What is the pathophysiology of osteoporosis?

Answer 5

Bone resorption (osteoclast activity) exceeds bone formation (osteoblast activity)

= leading to decreased bone density and increased fragility

Question 6

What is the gold standard for diagnosing osteoporosis?

Answer 6

DEXA scan (T ≤ -2.5)

Question 7

What is the first-line pharmacological treatment for osteoporosis?

Answer 7

Oral bisphosphonates
(eg, alendronic acid, risedronate)

for T-score ≤ -2.5

Question 8

What supplements should be given if calcium or vitamin D is deficient?

Answer 8

Calcium and/or vitamin D supplements

Question 9

How do bisphosphonates work?

Answer 9

Reduce osteoclastic resorption of bone

Question 10

What are the common side effects of bisphosphonates?

Answer 10

Oesophagitis, dysphagia

Question 11

What are second-line treatments if bisphosphonates are not tolerated?

Answer 11

1. Zoledronic acid
   (IV, annual)
2. Denosumab
   (monoclonal antibody reducing osteoclast activity)

Question 12

What is Teriparatide used for?

Answer 12

Stimulate bone growth in severe osteoporosis, reducing fracture risk

Question 13

What is the FRAX tool used for?

Answer 13

Assesses the 10-year osteoporotic fracture risk, helping determine the need for treatment

Question 14

What is the T-score range for osteopenia?

Answer 14

T-score between -1.0 and -2.5 indicates osteopenia

Question 15

Osteopenia meaning?

Answer 15

low bone density

Question 16

What T-score defines severe osteoporosis?

Answer 16

T-score of -2.5 or lower with a fragility fracture defines severe osteoporosis

Question 17

What is the primary prevention strategy for osteoporosis?

Answer 17

Building peak bone mass through \

(1) exercise
(2) healthy diet (high in calcium and vitamin D)
(3) sunlight exposure

Question 18

What are the side effects of bisphosphonates?

Answer 18

(1) Oesophageal ulcers
(2) Atrial fibrillation
(3) osteonecrosis of the jaw
(4) Atypical stress fractures.

Question 19

What is a commonly used supplement in osteoporotic patients?

Answer 19

Calcium + Vitamin D

Question 20

How is osteoporosis diagnosed on a bone density scan?

Answer 20

(1) Osteoporosis is diagnosed when patients have a T-score of less than 2.5 standard deviations below the mean.

(2) A score of between -1 and -2.5 indicates osteopenia

Question 21

What is the main bone protection therapy following a vertebral fracture?

Answer 21

Bisphosphonates

Question 22

What is the mechanism of action of bisphosphonates?

Answer 22

They are incorporated into osteoclast cells and interfere with cell function, causing cells to be non-functional and apoptose

Question 23

Bone [Blank] occurs at a greater rate than bone [Blank] in osteoporosis?

Answer 23

Bone Resorption occurs at a greater rate than bone formation in osteoporosis.

Question 24

A T score of less than [Blank] on dual-energy x-ray absorptiometry (DEXA) scan indicates osteoporosis?

Answer 24

-2.5

Question 25

Why should patients sit up before taking bisphosphonates?

Answer 25

Reduce the risk of developing an oesophageal ulcer

Question 26

What is the first line of medical treatment to treat osteoporosis?

Answer 26

Bisphosphonates are first line and tend to be given weekly

Question 27

Which subgroup of osteoporosis patients can get raloxifene?

Answer 27

Postmenopausal women

Question 28

Which organ is mainly responsible for excretion of bisphosphonates?

Answer 28

Kidneys

Question 29

[Blank] activity exceeds [Blank] activity in osteoporosis?

Answer 29

1. Osteoclast 2. Osteoblast

Question 30

What is the FRAX tool used for osteoporosis?

Answer 30

Provides a 10-year risk of osteoporotic fracture, which helps decide when to offer bisphosphonates: (1) Low risk - Bisphosphonates not yet needed (2) Medium risk - Perform DEXA to decide if bisphosphonates are needed (10-20%) (3) High risk - Bisphosphonates needed

Question 31

Bone mineral density is [Blank] in osteoporosis?

Answer 31

Low

Question 32

How do bisphonates work?

Answer 32

They inhibits osteoclast activity

Question 33

Which site is most commonly affected by osteoporotic fractures?

Answer 33

Vertebral fractures

Question 34

What is the mechanism of action of Raloxifene?

Answer 34

Raloxifene binds to oestrogen receptors and exerts the same protective action that oestrogen performs on bones by inhibiting osteoclastic action

Question 35

Which patients at risk of osteoporosis should be assessed using a FRAX score?

Answer 35

(1) All women aged over 65 should be assessed and men aged over 75 (2) Younger patients if they have risk factors eg, a previous fragility fracture or frequent use of oral corticosteroids

Question 36

At which sites do osteoporotic fractures usually occur?

Answer 36

Hip Vertebrae Wrist

Question 37

Which organ is mainly responsible for excretion of bisphosphonates?

Answer 37

Kidneys

Question 38

After suffering two fractures, one of the distal radius and one of the neck of the femur, a 90-year-old woman is started on alendronate acid. Which is the most likely side effect she would experience?

Answer 38

Oesophageal irritation

Question 39

Osteonecrosis of the jaw is a severe side effect of which drug?

Answer 39

bisphosphonates

Question 40

An 86-year-old female has confirmed osteoporosis on her FRAX score. Her GP wants to start her on alendronic acid for bone protection. Which of her past medical conditions would be a contraindication to this therapy?

Answer 40

Known anatomical abnormalities = eg, oesophageal stricture

Question 41

A 73-year-old woman underwent a DEXA scan and her T score is -3.5. After a discussion with the GP, it is decided to start her on a weekly tablet to protect her bones. What is the mechanism of action of this medication?

Answer 41

Inhibition of osteoclasts

Question 42

Bisphosphonates are known to cause oesophagitis if not taken correctly. Therefore, how should you take these sorts of drugs? and what advice do you give her?

Answer 42

(1) Take the medicine on an empty stomach first thing in the morning before breakfast and remain upright for at least 30 minutes after taking it (2) She needs to have regular dental checkups

Question 43

Osteoporosis is defined as being greater than 2.5 standard deviations below the average bone density. Which method of screening is the best suited to giving an initial assessment of osteoporosis risk in a General Practice setting?

Answer 43

FRAX

Question 44

What is the initial test for osteoporosis and what confirms the diagnosis?

Answer 44

Initial test = FRAX score Confirmatory test = DEXA scan

Question 45

What blood results are raised in those with osteoporosis?

Answer 45

Alkaline phosphate = ALP

Question 46

What is the first-line treatment for those with osteoporosis where bisphosphonates are contradicted (eg, in chronic kidney disease)

Answer 46

Denosumab

Question 47

A 26-year-old man slips down a flight of stairs and lands on his back. Upon history, examination and imaging it is determined that he has a stable spinal fracture secondary to osteoporosis. What test is most appropriate to investigate the source of his osteoporosis?

Answer 47

Testosterone levels - always check in a man as low testosterone levels are associated with higher bone turnover therefore osteoporosis

Question 48

A 56-year-old postmenopausal woman presents to the emergency department with acute lower back pain following a fall at home, where she tripped over a rug and landed on her buttocks. Examination reveals tenderness over the lower thoracic and lumbar spine. An X-ray confirms a compression fracture of the L2 vertebral body. Subsequently, a dual-energy X-ray absorptiometry (DEXA) scan was performed to assess her bone health, revealing a T score of -2.6. What does this score indicate?

Answer 48

The number of standard deviations your score is above or below the average bone density for a young, healthy adult

Question 49

A 46-year-old man is seen in the clinic following treatment for a hip fracture after a fall from standing. He has rheumatoid arthritis and chronic gastrointestinal problems, including diarrhoea, bloating, and weight loss. He appears pale and thin, with a BMI of 18.0 kg/m². A dual-energy x-ray absorptiometry (DEXA) scan of the hip reveals a T-score of -3.0. Which option is the best next step?

Answer 49

Perform blood tests to exclude secondary causes

Question 50

'A postmenopausal woman who's had an osteoporotic vertebral fracture presents to the gp' What is the best next step

Answer 50

start on a bisphosphonate straight away - don't wait for a DEXA scan

Question 51

A 78-year-old patient presents to the emergency department with a fractured neck of femur. The patient has a past medical history of polymyalgia rheumatica, ischaemic heart disease, and dyspepsia. Her medications include bisoprolol, ramipril, simvastatin, aspirin, omeprazole and prednisolone. As part of the investigations, a bone profile is done. What are the most likely results for this patient?

Answer 51

PTH - normal, calcium - normal, phosphate - normal

Question 52

A 65-year-old woman presents for her routine follow-up clinic appointment. She has been on oral alendronate for five years after being diagnosed with osteoporosis following a fragility fracture of her left wrist. She has had no further fractures since starting alendronate. Her clinician is considering her ongoing management based on the latest guidelines. She has a past medical history of deep venous thrombosis (DVT) 15 years ago. Alongside her alendronate, she also takes vitamin D and calcium supplements. Which management option is the most appropriate next step?

Answer 52

Reassess her using the FRAX tool as In osteoporosis, 10 year fracture risk should be reassessed after 5 years of treatment with alendronate

Question 52

You review a 76-year-old woman who has just been discharged from a fracture clinic following a Colles' fracture of the wrist. This was sustained following a fall from standing height in the garden. She has a past medical history of uterine fibroids for which she had a hysterectomy without oophorectomy at age 45. She takes no regular medication. What should be done to reduce the risk of further fractures?

Answer 52

Start oral bisphosphonate

Question 53

A 57-year-old woman on prednisolone 10 mg for 5 months has a DEXA scan showing T-scores of -1.6 (L2) and -1.7 (femoral neck). What is the best management?

Answer 53

Vitamin D + calcium + oral bisphosphonate due to steroid-induced osteoporosis risk = She has been on >7.5 mg prednisolone for >3 months, meeting the criteria for bone-sparing treatment

Question 54

A 72-year-old woman presents with severe back pain after a minor fall. Imaging confirms a vertebral fracture. What is the best next step and why?

Answer 54

Start bisphosphonates immediately = a recent fragility fracture confirms osteoporosis; no DEXA scan needed

Question 55

A 69-year-old woman visits her GP for a health check. Her medical history includes hyperthyroidism, coeliac disease, and hypertension. Recently, she has experienced a few minor falls without serious injuries and went through menopause at age 50. The GP discusses preventative measures to reduce the risk of potential fractures. Which option is the best next step for the GP to take?

Answer 55

Calculate her FRAX score

Question 56

A 66-year-old woman visits the outpatient department for a review of her osteoporosis, where she is booked in for a DEXA scan. Her T-score from her scan is recorded as -1.6, suggesting reduced bone mineral density. Her consultant wishes to calculate her Z-score. Which patient factors are required to calculate this?

Answer 56

Age, gender, ethnicity

Question 57

Which one of the following is not a risk factor for developing osteoporosis? A. Smoking B. Obesity C. Sedentary lifestyle D. Premature menopause E. Female sex

Answer 57

B - obesity Has a more protective effect than anything else really

Question 58

A 76-year-old man presents to the emergency department following bumping his hand on a gate. An X-ray reveals a Colles fracture. The patient has a past medical history of hyperthyroidism. He does not drink alcohol to excess but he has smoked 20 cigarettes a day for the last 35 years. Why would we Immediately start alendronate?

Answer 58

Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan

Question 59

A 65-year-old woman attends the orthopaedic clinic for a dual-energy X-ray absorptiometry (DXA) scan following a suspected pathological fracture whilst gardening. She has a very active lifestyle including frequent holidays to Spain and Portugal; and has a well-balanced diet. Her DXA scan T-score suggests treatment is required, however she does not want side effects that interfere with her lifestyle What is the most appropriate management option?

Answer 59

oral bisophonates

Question 60

Osteoporosis is a deterioration of bone strength which poses a massive problem to the Western world due to its ageing population. It increases the risk of fracture with minimal trauma. What best describes the pathogenesis of osteoporosis in elderly patients?

Answer 60

If the trabecular framework of the bone is destroyed, there will be large gaps left which cannot be restored

Question 61

A 65-year-old woman presents to her GP with back pain and a history of frequent falls. She reports a family history of osteoporosis and is an ex-smoker. Following a dual-energy X-ray absorptiometry (DEXA) scan, her results indicate a T-score of -2.5 at the lumbar spine and hip, leading to a recommendation for bisphosphonate therapy. Which population is her test score compared against?

Answer 61

Bone mass of young adults of the same sex

Question 62

A 68-year-old woman undergoes a dual-energy X-ray absorptiometry (DEXA) scan. The scan reveals a T-score of -2.4. She asks for clarification on what the T-score means and how it relates to her bone health. She mentions a history of premature menopause at the age of 37. Which option best explains her DEXA scan result?

Answer 62

Compared to a young, healthy individual, her bone mineral density is low