Osteoporosis Flashcards
Osteoporosis is a
progressive bone disease characterised by low bone mass measured by bone mineral density (BMD), & microarchitectural deterioration of bone tissue
==> HIGHER risk of fragility fractures
Osteoporosis more common in
post-menopausal women, men over 50 years old, pt taking long term corticosteroid (glucocorticoid)
— age
- Vit D deficiency
- Low calcium
- lack of physical activity
- Low BMI
- Smoking
- EtOH excess
- Hx of hip fractures
- early menopause
Osteoporosis lifestyle changes
~ excercise, normal BMI, alcohol intake reduced
~ adequate intake of calcium + vitamin D
~ Elderly patients, (housebound or live in residential or nursing homes) = high risk of vitamin D deficiency & may benefit from calcium + vitamin D tx. Elderly patients also have increased risk of falls
Postmenopausal osteoporosis tx
oral bisphosphonates alendronic acid and risedronate sodium = 1st-line options Alendronic acid and risedronate sodium have been shown to reduce occurrence of vertebral, non-vertebral and hip fractures. SIGN (2021) also recommend that ibandronic acid may be considered as an alternative oral bisphosphonate. Parenteral bisphosphonates or denosumab are alternative options for women who are intolerant of oral bisphosphonates or in whom they are unsuitable, with raloxifene hydrochloride or strontium ranelate as additional alternative options.
~ HRT additional alternative option, but use generally restricted to younger postmenopausal women with menopausal symptoms at high risk of fractures (as risk of SE CVD / cancer in older postmenopausal women and women on long-term HRT therapy. ~ SIGN (2021) also recommend tibolone as an option in younger postmenopausal women, particularly those with menopausal symptoms.
Teriparatide is reserved for postmenopausal women with severe osteoporosis at very high risk of fractures, particularly vertebral fractures. SIGN (2021) also recommend romosozumab as an option for postmenopausal women with severe osteoporosis who have previously experienced a fragility fracture and are at imminent risk of another (within 24 months). In postmenopausal women with at least one severe or two moderate low-trauma vertebral fractures, teriparatide or romosozumab are recommended over oral bisphosphonates.
Glucocorticoid-induced osteoporosis
Glucocorticoid treatment strongly associated with bone loss + increased risk of fractures
~ greatest rate of bone loss & early after initiation of glucocorticoids and increases with dose and duration of therapy. Bone-protection tx started at onset of glucocorticoid tx in patients at high risk of fracture.
Women aged ≥70 years, OR with previous fragility fracture, OR who are taking large doses of glucocorticoids (prednisolone ≥7.5 mg daily or equivalent) should be considered for bone-protection treatment. Men aged ≥70 years with a previous fragility fracture, OR who are taking large doses of glucocorticoids, should also be considered for treatment. For some premenopausal women & younger men (particularly those with previous history of fracture or who are receiving large doses of glucocorticoids), bone-protection treatment may be appropriate. SIGN (2021) = bone-protection tx considered in all men + women taking large doses of glucocorticoids (prednisolone ≥7.5 mg daily or equivalent) for 3 months or longer.
~ oral bisphosphonates alendronic acid or risedronate sodium = 1st line
~ Zoledronic acid, denosumab or teriparatide alternative options in patients intolerant of oral bisphosphonates or unsuitable.
If glucocorticoid treatment stopped, need to continue bone-protection tx reviewed. However, bone-protection tx continued with long-term glucocorticoid tx.
Osteoporosis in men
~ oral bisphosphonates alendronic acid or risedronate sodium = 1st line
~ Zoledronic acid or denosumab = alternatives if intolerant of oral bisphosphonates or in whom they are unsuitable; teriparatide or strontium ranelate additional alternative options.
Men having androgen deprivation therapy for prostate cancer increased fracture risk. Fracture risk assessment should be considered when starting this therapy. A bisphosphonate can be offered to men with confirmed osteoporosis; denosumab may be considered as an alternative if bisphosphonates are unsuitable or not tolerated.
Bisphosphonate tx duration
Bisphosphonate tx reviewed after 5 years of tx with alendronic acid, risedronate sodium or ibandronic acid, & after 3 years of tx with zoledronic acid
~ Based on fracture-risk assessment, continuation beyond this period can generally be recommended for patients over 75 years of aga, Hx of previous hip / vertebral fracture, have had one or more fragility fractures during treatment, or are taking long-term glucocorticoid treatment. Due to limited evidence, recommendations on duration are based on limited extension studies in postmenopausal women. NO evidence for treatment beyond 10 years; management of these patients should be on case-by-case basis with specialist input as appropriate
