Osteoporosis

Question 1

What is osteoporosis?

Answer 1

• Reduced bone mass which increases risk of fracture
• Primary - age related
• Secondary - due to another condition or drugs
  
  • Post menopausal women

Question 2

What are the risk factors for osteoporosis?

Answer 2

FRACTURES:

• Family history
• Rheumatoid arthritis
• Alcohol
• Cigarettes
• Thin
• Ulcerative colitis
• Reduced mobility
• Endocrinopathies
• Steroid use

Question 3

What kind of hints can help you diagnose osteoporosis?

Answer 3

• People should not fracture a bone if they fall from a standing height at walking speed – if they do this suggests OP and if they have a fragility # (vertebral, distal radius or NOF) this also indicates they may be osteoporotic

Question 4

What investigations should be carried out to diagnose osteoporosis?

Answer 4

• Investigations – normal serum Ca2+, PO4-, ALP but may see reduced density on radiographs however the diagnostic test is a DEXA scan
• T score (SDs from the mean young adult of same sex) – if T score is -1 to -2.5 the patient is osteopenic, it is only if T score is <-2.5 that they are osteoporotic. If Z score is normal however then the changes are probably age related
• Z score (SDs from the mean same age and sex adult) – if this is abnormal also then need to consider secondary causes of OP such as those in the FRACTURES mnemonic above as it is not just age related

Question 5

How is osteoporosis managed conservatively?

Answer 5

Management:

• Conservative
  
  • Stop smoking
  • Regain weight back to normal (esp old people)
  • OT

Question 6

How is osteoporosis managed medically?

Answer 6

• Bisphosphonates prevent resorption of bone therefore reducing bone turnover preventing further breakdown, they are first line.
• Alendronic acid is taken PO once a week with a glass of water and patients must not lie down for 30 minutes after therefore advised to take once dressed in the morning, it should also be 20 minutes before breakfast and other drugs.
• If this is not effective/not tolerated they can try IV zoledronate where they come into hospital once a year for the infusion, but eGFR must be >35.
• The monoclonal antibody denosumab is an alternative.
• P1NP levels can be measured in the blood (measure of bone turnover) to see if it is reducing and therefore working.
  
  • SEs include abdo pain, nausea and rarely osteonecrosis of the jaw and atypical hip fractures.
• Calcium and vitamin D (cholecalciferol) is recommended to maintain bone mineralisation
• Strontium ranelate – works by inhibiting breakdown (like BPs) but also stimulates formation of bone as well