Osteoporosis

Question 1

What is osteoporosis?

Answer 1

A skeletal condition characterized by low bone mass, deterioration of bone tissue, and disruption of bone architecture that leads to compromised bone strength and an increased risk of fracture

Question 2

What are the non-modifiable risk factors for osteoporosis?

Answer 2

• Advanced age (>65 years)
• Female gender
• Caucasian or South Asian
• Family history of osteoporosis
• History of low trauma fracture.

Question 3

What are the modifiable risk factors for osteoporosis?

Answer 3

• Low body weight (58 kg or BMI <21)
• Premature menopause (age <45)
• Calcium/vitamin D deficiency
• Inadequate physical activity
• Cigarette smoking
• Excessive alcohol intake (>3 drinks/day)
• Iatrogenic factors (e.g., corticosteroids, aromatase inhibitors).

Question 4

How is osteoporosis diagnosed?

Answer 4

Dual energy x-ray absorptiometry (DEXA) of the lumbar spine and hip is gold standard

Question 5

What does a T-score of -2.5 or less indicate?

Answer 5

Osteoporosis.

Question 6

What is the T-score range for normal bone mineral density (BMD)?

Answer 6

T-score ≥ -1.

Question 7

What is osteopenia defined by in terms of T-score?

Answer 7

T-score between -1 and -2.5.

Question 8

What does a Z-score less than -2 indicate?

Answer 8

It should prompt evaluation for causes of secondary osteoporosis.

Question 9

What can plain radiographs indicate in relation to osteoporosis?

Answer 9

They lack sensitivity but rib fractures or vertebral compression fractures without trauma history should prompt evaluation for osteoporosis.

Question 10

What is the first-line treatment for osteopenia?

Answer 10

Risk modification: weight-bearing exercise, vitamin D3 supplementation, limiting alcohol, and smoking cessation.

Question 11

What are the first-line treatments for osteoporosis?

Answer 11

• Vitamin D (400-800 IU) and calcium supplementation (at least 1000mg)
• Oral bisphosphonates or IV if oral not tolerated

Question 12

What are the second-line treatments for osteoporosis?

Answer 12

• Denosumab
• Teriparatide.

Question 13

True or False: Regular weight-bearing exercise helps to prevent osteoporosis.

Answer 13

True.

Question 14

What are some secondary causes of osteoporosis?

Answer 14

• Coeliac disease
• Eating disorders
• Hyperparathyroidism
• Hyperthyroidism
• Multiple myeloma; causes low BMD and vertebral fractures

Question 15

What should patients be reassured about regarding oral bisphosphonates?

Answer 15

Serious side effects are very rare
* Reflux and oesophageal erosions
* Atypical fractures (e.g., atypical femoral fractures)
* Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
* Osteonecrosis of the external auditory canal

Question 16

How does osteoporosis in men compare to women?

Answer 16

It is less common, and secondary causes should be excluded.

Question 17

Fill in the blank: Hypogonadism may be treated with _______.

Answer 17

Testosterone.

Question 18

What is a T-score

Answer 18

Number of SDs from the mean bone density of persons of same gender at age of peak density (25)

Question 19

What is the Z score

Answer 19

comparison of the patient’s
BMD with an age- & gender-matched population

Question 20

What advice would you give to a patient who has been started on oral bisphosphonates

Answer 20

• take on an empty stomach and other drugs/food should be avoided for 30 mins afterwards to maximise gut absorption
• swallow whole with water and avoid bending down for 30 mins to reduce chances of indigestion

Question 21

Give 2 contraindications of bisphosphonates

Answer 21

Achalasia
Poor swallow

Question 22

What may be prescribe in the event that bisphosphonates are contraindicated or not tolerated

Answer 22

IV zolendronic acid
Denosumab

Question 23

how do bisphosphonates work and give 3 examples

Answer 23

interfere with the way osteoclasts attach to bone, reducing activity and reabsorption of bone
* Alendronate 70 mg once weekly (oral)
* Risedronate 35 mg once weekly (oral)
* Zoledronic acid 5 mg once yearly (intravenous)

Question 24

how should treatment with bisphosphonates be monitored

Answer 24

reassess treatment after 3-5 years
- repeat DEXA and stop treatment if the T-score is > -2.5
- treatment should be continued in high risk pt

Question 25

what blood test results would you expect to see in osteoporosis

Answer 25

normal ALP,calcium, phosphate and PTH

Question 26

what is Paget’s disease

Answer 26

disease of increased but uncontrolled bone turnover
- primarily a disorder of osteoclasts: ↑↑ osteoclastic resorption, ↑ osteoblastic activity

Question 27

what are the most commonly affected areas of Paget’s disease

Answer 27

• skull
• spine
• pelvis
• long bones of lower extremities e.g. femur

Question 28

what are predisposing factors of Paget’s disease

Answer 28

• increasing age
• male sex
• northern latitude
• family history

Question 29

what are clinical features of Paget’s disease

Answer 29

only 5% of patients are symptomatic
* older male with bone pain and an isolated raised ALP
* bone pain (e.g. pelvis, lumbar spine, femur)
* classical, untreated features: bowing of tibia, bossing of skull

Question 30

what are appropriate investigations for Paget’s disease

Answer 30

• bloods
• x-ray
• bone scintigraphy

Question 31

what are blood test results of Paget’s disease

Answer 31

• raised ALP
• calcium + phosphate typically normal (↑Ca2+ associated with prolonged immobilisation)

Question 32

what are x-ray findings of Paget’s disease

Answer 32

• osteolysis in early disease –> mixed lytic/sclerotic lesions later
• skull: thickened vault, osteoporosis circumscripta

Question 33

what is involved in the management of Paget’s disease

Answer 33

• bisphosphonates either oral risedronate or IV zoledronate
• calcitonin used less commonly

Question 34

what are complications of Paget’s disease

Answer 34

• deafness (cranial nerve entrapment)
• bone sarcoma (1% if affected for > 10 years)
• fractures
• skull thickening
• high-output cardiac failure

Question 35

a patient has been diagnosed with PMR and started on prednislone 15mg OD - what is the most appropriate approach to bone protection

Answer 35

start oral aledronate + ensure calcium and vitamin D replete

Bone protection for patients who are going to take long-term steroids should start immediately

Question 36

what are the NICE guidelines for patients >65 starting long term corticosteroids therapy

Answer 36

co-prescribe bisphosphonates to prevent glucocorticoid induced osteoporosis