Osteoporosis

Question 1

What is osteoporosis?

Answer 1

Osteoporosis is a clinical disorder characterized by an abnormally low bone mass and defects in bone structure. This combination renders the bone fragile and at a greater than normal risk of fracture.

Question 2

How is osteoporosis defined clinically?

Answer 2

It is defined as a hip bone mineral density of

Question 3

What is severe osteoporosis? What is osteopenia?

Answer 3

Severe osteoporosis is

Question 4

What are two types of primary osteoporosis?

Answer 4

• Postmenopausal – occurs in 50-65 year old females

- Senile – occurs in the elderly

Question 5

Give some secondary causes of osteoporosis?

Answer 5

Hypercortisonism, gonadal hormone insufficiency, hyperthyroidism, alcohol abuse.

Question 6

What is the pathophysiology of osteoporosis

Answer 6

Bone depletion may be brought about by predominant bone resorption, decreased bone formation or a combination of the two. Hormonal factors and peak bone density have a large impact.

Question 7

Give 9 risk factors for osteoporosis?

Answer 7

• Cauc/Asian
• Family history of osteoporosis
• Low peak bone mass
• Early menopause
• Chronic lack of exercise
• Smoking/alcohol
• Age
• RA
• Corticosteroid use

Question 8

What is the usual presentation of osteoporosis?

Answer 8

Low trauma fragility fractures are the most common methods of presentation – these are defined as fractures caused by a force equivalent to the force of a fall from the height of an ordinary chair or less.
Fragility fractures occur most commonly in the spine, hip and wrist

Question 9

When should you do Dexa scanning?

Answer 9

• If a fragility fracture occurs this should trigger bone density measurement (although it can be assumed in women >75).
• Patients with any risk factor above should be considered for DEXA scanning, especially if fractures are a feature

Question 10

Outline some possible assessments of bone mineral density

Answer 10

• Single-energy X-ray absorptiometry (SXA) and Digital x-ray radiogrammetry (DXR)/Dual energy x-ray absorptiometry (DXA) assessment of mineral content of the entire skeleton

Question 11

What is the best measure of BMD?

Answer 11

• DEXA at the hip is the gold standard for the diagnosis of osteoporosis with an accuracy at the hip >90%

Question 12

Give four categories of other investigations for osteoporosis

Answer 12

• FBC and ESR
• U&Es, LFTs, serum calcium and alkaline phosphate
• Testosterone/GnR In men
• Serum immunoglobulins and paraproteins

Question 13

What is the term osteopaenia used for?

Answer 13

The term osteopaenia is sometimes used to describe bone which appears less dense than normal on x-ray, without defining whether the loss of density is due to osteoporosis or osteomalacia.

Question 14

What are three signs of osteoporosis on x-ray?

Answer 14

Loss of trabecular definition, thinning of the cortices and insufficiency fractures

Question 15

What three things can be seen in an osteoporotic spine?

Answer 15

Compression fractures of the vertebral bodies, wedging at multiple levels or distortions of the intervertebral discs are the most common.

Question 16

What shoudl radiographic assessment of OP be backed uo by?

Answer 16

Radiographic assessment should be backed up by a DEXA bone scan of the spine and hips, using the lower value of the two,

Question 17

What is the overall management for OP

Answer 17

Treatment for osteoporosis should be a combination of drug treatment and lifestyle, nutrition, exercise and measures to reduce falls.

Question 18

Give three specific treatments for patients with diagnosed OP

Answer 18

• Consider hip protectors and assessment of ongoing risk of falls
• Reduce polypharmacy, especially sedatives
• Ensure adequate calcium (0.5 -1g) and vitamin D (800 IU). Supplementation may be necessary.

Question 19

What can post-menopausal OP be treated with?

Answer 19

Postmenopausal osteoporosis can be treated with a bisphosphonate. If bisphosphonates are unsuitable then calcitriol may be considered.

Question 20

Name two bisphosphonates

Answer 20

Alendronate, disodium etidronate

Question 21

How do bisphosphonates work?

Answer 21

Act by reducing osteoclastic bone resorption and the general rate of bone turnover. Can be given once per week. Must be taken separately from food as they are poorly absorbed. Must also be prescribed with calcium/vitamin D.

Question 22

When is HRT used?

Answer 22

HRT should not be considered first-line therapy for long term prevention of postmenopausal osteoporosis. Is an option in condition where bisphosphonates not tolerated.

Question 23

When are bisphosphonates used?

Answer 23

First-line bisphosphonate is only recommended in post-menopausal women ages under 65 with confirmed osteoporosis but without fragility fractures, if they have an independent clinical risk factor for fracture and at least one additional indicator of low BMD

Question 24

What is second line treatment for OP?

Answer 24

Denosumab is a monoclonal antibody that reduces osteoclast activity which is given by 6 monthly subcutaneous injection.

Question 25

What is OP prognosis?

Answer 25

Osteoporotic fragility fractures can cause substantial pain and severe disability often leading to a reduced quality of life, and hip and vertebral fractures are associated with decreased life expectancy.

Question 26

Outline the prognosis (mortality and independence) following hip fracture in elderly patient

Answer 26

Hip fracture has a mortality of 20% at three months and only 50% regain full independence after fracture.