Osteoporosis Flashcards
What is osteoporosis?
A metabolic bone disease characterised by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk
How can osteoporosis be defined using DEXA bone scanning?
A result on DEXA bone scanning
How does bone mass change throughout life?
> Teens = Increase in bone size
> Around 30 = Peak bone mass
> Menopause (50yrs) = Accelerated loss begins
> Later life = Gradual loss
What are the associations with increased risk of fracture?
> Age > Bone metabolic disease > Falls > Bone turnover > Low BMI > Female > Rheumatoid arthritis > Long term steroid use > Diabetes mellitus > Endocrine issues > Other medications (SSRIs, PPIs, ant epileptics etc)
What online tool is used to assess fracture risk?
FRAX = Who fracture risk assessment tool
Q fracture
Who is likely to suffer from osteoporosis?
> I in 2 women over 50 will have an osteoporotic fracture before they die (Post menopausal)
> I in 5 men over 50 will suffer and osteoporotic fracture
> Endocrine causes
> Rheumatic causes
> Gastroenterological causes
> Medications
What is the lifetime risk of a 50 year old woman of having a hip fracture?
17%
If you have suffered a vertebral fracture what are you more likely to suffer from in the future?
> 5 times more likely to have another vertebral fracture
> 2 times more likely to have a hip fracture
What endocrine causes are there for osteoporosis?
> Thyrotoxicosis > Hyper and hypoparathyroidim > Cushings > Hyperprolactinaemia > Hypopituitarism > Early menopause
What Rheumatic causes are there for osteoporosis?
> Rheumatoid arthritis
Ankylosing spondylitis
Polymyalgia rheumatica
What gastroenterological causes are there for osteoporosis?
> Inflammatory diseases: UC and crohns
> Liver diseases: PBC, CAH, Alcoholic cirrhosis, Viral cirrhosis( hep C)
> Malabsorption: chronic pancreatitis, coeliac disease, whipples disease, short gut syndromes and ischaemic bowel
What medications are associated with increased risk of osteoporosis?
> Steroids
> PPI
> Enzyme inducting antiepileptic medications
> Aromatase inhibitors
> GnRH inhibitors
> Warfarin
What are the cornerstones in managing osteoporosis?
Minimise risk factors
Ensure good calcium and Vitamin D status
Falls prevention strategies
Medications
How is it determined whether someone requires treatment for osteoporosis or not?
Measure BMD using DEXA of hip and spine:
> Normal:
- T score above -1
- Reassure lifestyle advice
> Osteopenia:
- T score -1 to -2.5
- Lifestyle advice, treat if previous fracture
> Osteoporosis:
- T score below -2.5
- Lifestyle advice and offer treatment
- Less than -2.5 + a fracture = severe osteoporosis
SIGNs guidelines for osteoporosis and referral for DEXA scanning?
Referral for DEXA scanning based on FRAX or QFracture score of >10% fracture risk at any site over next 10 years
SIGNs guidelines for treatment of osteoporosis?
Treatment decisions after DXA scanning and individual report-fracture risk around 20% 10 year risk would be treatment threshold
If an individual is over the age of 65 and exposed to oral glucocorticoids for >3 months what should be done?
> Investigations
> General measures, advise treatment
If an individual has been on glucocorticoids for >3months and has a fragility fracture what should be done?
> Investigations
> General measures, advise treatment
If an individual <65 yrs old has been on glucocorticoids for >3 months and has a DXA scan hi and spine with a T-score -1.5 or lower what should be done?
> General measures, advise treatment
If an individual <65 yrs old has been on glucocorticoids for >3 months and has a DXA scan hi and spine with a T-score between 0 and -1.5 what should be done?
Repeat bone mineral density measurement (DXA scan) In 1-3 years if glucocorticoids continued
what is a fragility fracture?
A fracture occurring on minimal trauma after the age of 40 (Includes forearm, spine, hip, ribs and pelvis)
What are general measures taken in steroid induced osteoporosis?
> Reduce dose
Consider glucocorticoid sparing therapy e.g. azathioprine
Consider alternative route of admission
Recommend good nutrition, especially adequate calcium and Vitamin D
Recommend regular wight bearing exercise
Maintain body weight
Avoid tobacco use and alcohol abuse
Access falls risk
In a patient with previous fragility fracture which test are indicated?
> FBC, ESR
Bone and liver function test (Ca , P all, Phos, Albumin, ALT/GT)
Serum creatinine
Serum TSH
If indicated:
> Lateral thoracic and lumbar spine radiograph
> Serum paraproteins and Bence Jones protein
> Isotope bone scan
> Serum FSH if hormonal status unclear (Woman)
> Serum testosterone, LH, and SHBG (Man)
> Serum 25OHD and PTH
> BMD monitoring if required
Medications used in osteoporosis?
> Biphosphonates (First line)
HRT
Selective Oestrogen Receptor modulators (SERMS)
Denosumab (Monoclonal Abx against RANKL)
Teriparatide
