Osteoporosis Flashcards
What are bisphosphonates?
Bisphosphonates are analogues of pyrophosphate, a molecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis.
What are the clinical uses of bisphosphonates?
Bisphosphonates are used for the prevention and treatment of osteoporosis, hypercalcaemia, Paget’s disease, and pain from bone metastases.
What are the adverse effects of bisphosphonates?
Adverse effects include oesophageal reactions (oesophagitis, oesophageal ulcers), osteonecrosis of the jaw, increased risk of atypical stress fractures, acute phase response, and hypocalcaemia.
What specific risk factors are associated with bisphosphonates?
Patients receiving IV bisphosphonates for cancer have a substantially greater risk than those taking oral bisphosphonates. Poor dental hygiene and prior dental procedures are also risk factors.
What does the BNF advise regarding dental check-ups for bisphosphonate patients?
The BNF advises that ‘all patients with cancer and patients with poor dental status should have a dental check-up … before bisphosphonate treatment.’
What counselling is suggested for patients taking oral bisphosphonates?
‘Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast; patient should stand or sit upright for at least 30 minutes after taking tablet.’
What should be corrected before giving bisphosphonates?
Hypocalcemia and vitamin D deficiency should be corrected before giving bisphosphonates. Calcium should only be prescribed if dietary intake is inadequate; vitamin D supplements are normally given.
What is the recommended duration of bisphosphonate treatment?
The duration of bisphosphonate treatment varies according to risk. Some authorities recommend stopping at 5 years if the patient is < 75-years-old, has a femoral neck T-score of > -2.5, and is low risk according to FRAX/NOGG.
What is the management approach for patients >= 75 years of age following a fragility fracture?
Patients >= 75 years of age who have had a fragility fracture are presumed to have underlying osteoporosis and should be started on first-line therapy (an oral bisphosphonate), without the need for a DEXA scan.
What do the 2014 NOGG guidelines suggest for women over 50 years who have had a fragility fracture?
The 2014 NOGG guidelines suggest treatment is started in all women over the age of 50 years who’ve had a fragility fracture, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.
What is the management approach for patients < 75 years of age following a fragility fracture?
If a patient is under the age of 75 years, a DEXA scan should be arranged. The results can then be entered into a FRAX assessment to determine the patient’s ongoing fracture risk.
Provide an example of a patient management scenario for a 79-year-old woman with a fragility fracture.
A 79-year-old woman falls onto an outstretched hand and sustains a Colles’ fracture. Given her age, she is presumed to have osteoporosis and is started on oral alendronate 70mg once weekly. No DEXA scan is arranged.
What is the main concern regarding osteoporosis?
The increased risk of fragility fractures.
Who should be assessed for osteoporosis risk according to NICE guidelines?
All women aged >= 65 years and all men aged >= 75 years.
What are some risk factors for younger patients to be assessed for osteoporosis?
Previous fragility fracture, current or recent glucocorticoid use, history of falls, family history of hip fracture, secondary osteoporosis causes, low BMI, smoking, and high alcohol intake.
What are examples of secondary causes of osteoporosis?
Hypogonadism, endocrine conditions, malabsorption conditions, inflammatory arthropathies, low BMI, smoking, and excessive alcohol intake.
What is the first step in assessing osteoporosis risk?
Exclude secondary causes of osteoporosis.
When should a DEXA scan be offered without calculating the fragility risk score?
> 50 years with a history of fragility fracture or < 40 years with a major risk factor.
What clinical prediction tools does NICE recommend for assessing fracture risk?
FRAX or QFracture.
What does a 10-year fracture risk of ≥ 10% indicate?
A DEXA scan should be arranged.
What does the FRAX calculator provide?
A colour ‘risk’ indication: green, orange, or red.
What should be done for patients in the orange zone of the FRAX risk assessment?
They should have a DEXA scan if not already done.
When should a patient’s osteoporosis risk be reassessed?
NICE recommends recalculating risk using FRAX/QFracture.
What is the main concern regarding osteoporosis?
The increased risk of fragility fractures.
Who should be assessed for osteoporosis risk according to NICE guidelines?
All women aged >= 65 years and all men aged >= 75 years.
What are some risk factors for younger patients to be assessed for osteoporosis?
Previous fragility fracture, current or recent glucocorticoid use, history of falls, family history of hip fracture, secondary osteoporosis causes, low BMI, smoking, and high alcohol intake.
What are examples of secondary causes of osteoporosis?
Hypogonadism, endocrine conditions, malabsorption conditions, inflammatory arthropathies, low BMI, smoking, and excessive alcohol intake.
What is the first step in assessing osteoporosis risk?
Exclude secondary causes of osteoporosis.
When should a DEXA scan be offered without calculating the fragility risk score?
> 50 years with a history of fragility fracture or < 40 years with a major risk factor.
What clinical prediction tools does NICE recommend for assessing fracture risk?
FRAX or QFracture.
What does a 10-year fracture risk of ≥ 10% indicate?
A DEXA scan should be arranged.
What does the FRAX calculator provide?
A colour ‘risk’ indication: green, orange, or red.
What should be done for patients in the orange zone of the FRAX risk assessment?
They should have a DEXA scan if not already done.
When should a patient’s osteoporosis risk be reassessed?
NICE recommends recalculating risk using FRAX/QFracture.
What are significant risk factors for osteoporosis?
Advancing age and female sex are significant risk factors for osteoporosis. The prevalence of osteoporosis increases from 2% at 50 years to more than 25% at 80 years in women.
What are the most important risk factors for osteoporosis used by major risk assessment tools like FRAX?
History of glucocorticoid use, rheumatoid arthritis, alcohol excess, history of parental hip fracture, low body mass index, current smoking.
What are other risk factors for osteoporosis?
Sedentary lifestyle, premature menopause, Caucasians and Asians, endocrine disorders, multiple myeloma, lymphoma, gastrointestinal disorders, chronic kidney disease, osteogenesis imperfecta, homocystinuria.
What medications may worsen osteoporosis?
SSRIs, antiepileptics, proton pump inhibitors, glitazones, long term heparin therapy, aromatase inhibitors (e.g., anastrozole).
What investigations are recommended for secondary causes of osteoporosis?
History and physical examination, blood tests (including full blood count, sedimentation rate, serum calcium, etc.), thyroid function tests, bone densitometry (DXA).
What additional procedures may be indicated for osteoporosis investigations?
Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging, protein immunoelectrophoresis, urinary Bence-Jones proteins, 25OHD, PTH, serum testosterone, SHBG, FSH, LH, serum prolactin, 24 hour urinary cortisol/dexamethasone suppression test, endomysial and/or tissue transglutaminase antibodies, isotope bone scan, markers of bone turnover, urinary calcium excretion.
What blood tests should be ordered as a minimum for all patients with osteoporosis?
Full blood count, urea and electrolytes, liver function tests, bone profile, CRP, thyroid function tests.
What is a T score in relation to osteoporosis?
A T score is based on the bone mass of a young reference population.
What does a T score of -1.0 indicate?
A T score of -1.0 means bone mass is one standard deviation below that of the young reference population.
What is a Z score?
A Z score is adjusted for age, gender, and ethnic factors.
What are the classifications based on T scores?
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
What is a significant risk factor for osteoporosis?
The use of corticosteroids.
What guidelines are followed for glucocorticoid-induced osteoporosis?
The 2002 Royal College of Physicians (RCP) guidelines.
When does the risk of osteoporosis significantly rise?
Once a patient is taking the equivalent of prednisolone 7.5mg a day for 3 or more months.
How should we manage patients likely to take steroids for at least 3 months?
Start bone protection straight away.
Who should be offered bone protection according to RCP guidelines?
Patients over the age of 65 years or those who’ve previously had a fragility fracture.
What should patients under the age of 65 years receive?
A bone density scan, with further management based on T score.
What is the management based on T score for patients under 65?
Greater than 0: Reassure; Between 0 and -1.5: Repeat bone density scan in 1-3 years; Less than -1.5: Offer bone protection.
What is the first-line treatment for corticosteroid-induced osteoporosis?
Alendronate.
What should patients also be replete in?
Calcium and vitamin D.
What organization updated their osteoporosis management guidelines in 2021?
The National Osteoporosis Guideline Group (NOGG) updated their guidelines in 2021.
What is the usual symptom of osteoporosis?
Osteoporosis is usually asymptomatic until a fracture occurs.
What should be considered when managing osteoporosis?
Consider clinical scenarios such as high-risk patients, those starting glucocorticoids, and patients with recent fragility fractures.
What lifestyle changes should be advised for patients at risk of osteoporosis?
Patients should be advised on a healthy diet, moderation of alcohol, avoidance of smoking, and sufficient calcium and vitamin D intake.
What is the first-line drug treatment for patients at risk of fragility fractures?
Bisphosphonates are the first-line drug treatment for patients at risk of fragility fractures.
What are the typical first-line oral bisphosphonates?
Oral bisphosphonates such as alendronate and risedronate are typically first-line.
What is the recommended treatment for patients following a hip fracture?
The NOGG recommends IV zoledronate as the first-line treatment following a hip fracture.
What is the BMD threshold for defining osteoporosis?
The BMD threshold for defining osteoporosis is a T-score of -2.5 SD or below.
What should be done for postmenopausal women or men age ≥50 starting glucocorticoids?
Start bone protective treatment if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months.
What is the follow-up plan for prescribing bisphosphonates?
Plan to prescribe oral bisphosphonates for at least 5 years, or intravenous bisphosphonates for at least 3 years and then re-assess fracture risk.
What are common side effects of bisphosphonates?
Common side effects include gastrointestinal discomfort, oesophagitis, and hypocalcaemia.
What is denosumab?
Denosumab is a human monoclonal antibody that inhibits RANK ligand, reducing osteoclast maturation.
What is the role of raloxifene in osteoporosis treatment?
Raloxifene is a selective estrogen receptor modulator that prevents bone loss and reduces vertebral fracture risk.
What is strontium ranelate known for?
Strontium ranelate is a dual action bone agent that increases new bone deposition and reduces bone resorption.
What is teriparatide?
Teriparatide is a recombinant form of parathyroid hormone effective at increasing bone mineral density.
What does romosozumab do?
Romosozumab is a monoclonal antibody that inhibits sclerostin, increasing bone formation and decreasing bone resorption.
What organization updated their osteoporosis management guidelines in 2021?
The National Osteoporosis Guideline Group (NOGG) updated their guidelines in 2021.
What is the usual symptom of osteoporosis?
Osteoporosis is usually asymptomatic until a fracture occurs.
What should be considered when managing osteoporosis?
Consider clinical scenarios such as high-risk patients, those starting glucocorticoids, and patients with recent fragility fractures.
What lifestyle changes should be advised for patients at risk of osteoporosis?
Patients should be advised on a healthy diet, moderation of alcohol, avoidance of smoking, and sufficient calcium and vitamin D intake.
What is the first-line drug treatment for patients at risk of fragility fractures?
Bisphosphonates are the first-line drug treatment for patients at risk of fragility fractures.
What are the typical first-line oral bisphosphonates?
Oral bisphosphonates such as alendronate and risedronate are typically first-line.
What is the recommended treatment for patients following a hip fracture?
The NOGG recommends IV zoledronate as the first-line treatment following a hip fracture.
What is the BMD threshold for defining osteoporosis?
The BMD threshold for defining osteoporosis is a T-score of -2.5 SD or below.
What should be done for postmenopausal women or men age ≥50 starting glucocorticoids?
Start bone protective treatment if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months.
What is the follow-up plan for prescribing bisphosphonates?
Plan to prescribe oral bisphosphonates for at least 5 years, or intravenous bisphosphonates for at least 3 years and then re-assess fracture risk.
What are common side effects of bisphosphonates?
Common side effects include gastrointestinal discomfort, oesophagitis, and hypocalcaemia.
What is denosumab?
Denosumab is a human monoclonal antibody that inhibits RANK ligand, reducing osteoclast maturation.
What is the role of raloxifene in osteoporosis treatment?
Raloxifene is a selective estrogen receptor modulator that prevents bone loss and reduces vertebral fracture risk.
What is strontium ranelate known for?
Strontium ranelate is a dual action bone agent that increases new bone deposition and reduces bone resorption.
What is teriparatide?
Teriparatide is a recombinant form of parathyroid hormone effective at increasing bone mineral density.
What does romosozumab do?
Romosozumab is a monoclonal antibody that inhibits sclerostin, increasing bone formation and decreasing bone resorption.
What is osteoporosis?
Osteoporosis is a disorder affecting the skeletal system characterised by loss of bone mass.
How does age affect bone mineral density?
Bone mineral density decreases with age.
What does the World Health Organisation define as osteoporosis?
Osteoporosis is defined as a bone mineral density (BMD) of less than 2.5 standard deviations (SD) below the young adult mean density.
Why is osteoporosis important?
It increases the risk of fragility (i.e. non-traumatic) fractures.
What are the consequences of certain fragility fractures?
Certain fragility fractures, such as fractured neck of femur, are associated with significant morbidity and mortality.
What percentage of post-menopausal women will suffer an osteoporotic fracture?
Around 50% of post-menopausal women will suffer an osteoporotic fracture at some point.
What are the major risk factors for osteoporosis?
The major risk factors are age and female gender.
What are other risk factors for osteoporosis?
Other risk factors include corticosteroid use, smoking, alcohol, low body mass index, and family history.
What screening tools are recommended for assessing osteoporosis risk?
Guidelines recommend using a screening tool such as FRAX or QFracture to assess the 10-year risk of developing a fragility fracture.
What should be done for a patient who has sustained a fragility fracture?
A patient who has sustained a fragility fracture should also be assessed for osteoporosis.
What is used to assess actual bone mineral density?
A dual-energy X-ray absorptiometry (DEXA) scan is used.
What areas does a DEXA scan focus on?
The DEXA scan looks at the hip and lumbar spine.
What T score indicates the need for treatment?
If either the hip or lumbar spine has a T score of < -2.5, then treatment is recommended.
What is the first-line treatment for osteoporosis?
The first-line treatment for osteoporosis is an oral bisphosphonate such as alendronate.
Are there other treatments available for osteoporosis?
Other treatments are available, but the vast majority of patients are managed with oral bisphosphonates.
