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Year 3 - Musculoskeletal > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What is osteoporosis?

A

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

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2
Q

How can osteoporosis be defined using DEXA bone scanning?

A

A result on DEXA bone scanning

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3
Q

How does bone mass change throughout life?

A

> Teens = Increase in bone size

> Around 30 = Peak bone mass

> Menopause (50yrs) = Accelerated loss begins

> Later life = Gradual loss

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4
Q

What are the associations with increased risk of fracture?

A 
> 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)
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5
Q

What online tool is used to assess fracture risk?

A

FRAX = Who fracture risk assessment tool

Q fracture

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6
Q

Who is likely to suffer from osteoporosis?

A

> 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

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7
Q

What is the lifetime risk of a 50 year old woman of having a hip fracture?

A

17%

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8
Q

If you have suffered a vertebral fracture what are you more likely to suffer from in the future?

A

> 5 times more likely to have another vertebral fracture

> 2 times more likely to have a hip fracture

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9
Q

What endocrine causes are there for osteoporosis?

A 
> Thyrotoxicosis
> Hyper and hypoparathyroidim
> Cushings
> Hyperprolactinaemia
> Hypopituitarism
> Early menopause
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10
Q

What Rheumatic causes are there for osteoporosis?

A

> Rheumatoid arthritis
Ankylosing spondylitis
Polymyalgia rheumatica

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11
Q

What gastroenterological causes are there for osteoporosis?

A

> 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

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12
Q

What medications are associated with increased risk of osteoporosis?

A

> Steroids

> PPI

> Enzyme inducting antiepileptic medications

> Aromatase inhibitors

> GnRH inhibitors

> Warfarin

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13
Q

What are the cornerstones in managing osteoporosis?

A

Minimise risk factors

Ensure good calcium and Vitamin D status

Falls prevention strategies

Medications

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14
Q

How is it determined whether someone requires treatment for osteoporosis or not?

A

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
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15
Q

SIGNs guidelines for osteoporosis and referral for DEXA scanning?

A

Referral for DEXA scanning based on FRAX or QFracture score of >10% fracture risk at any site over next 10 years

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16
Q

SIGNs guidelines for treatment of osteoporosis?

A

Treatment decisions after DXA scanning and individual report-fracture risk around 20% 10 year risk would be treatment threshold

17
Q

If an individual is over the age of 65 and exposed to oral glucocorticoids for >3 months what should be done?

A

> Investigations

> General measures, advise treatment

18
Q

If an individual has been on glucocorticoids for >3months and has a fragility fracture what should be done?

A

> Investigations

> General measures, advise treatment

19
Q

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?

A

> General measures, advise treatment

20
Q

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?

A

Repeat bone mineral density measurement (DXA scan) In 1-3 years if glucocorticoids continued

21
Q

what is a fragility fracture?

A

A fracture occurring on minimal trauma after the age of 40 (Includes forearm, spine, hip, ribs and pelvis)

22
Q

What are general measures taken in steroid induced osteoporosis?

A

> 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

23
Q

In a patient with previous fragility fracture which test are indicated?

A

> 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

24
Q

Medications used in osteoporosis?

A

> Biphosphonates (First line)
HRT
Selective Oestrogen Receptor modulators (SERMS)
Denosumab (Monoclonal Abx against RANKL)
Teriparatide

25
Q

What are the side effect of HRT (used in osteoporosis)?

A

> Increased risks of blood clots

> Increased risk of breast cancer with extended use into late 50s/early 60s

> Increased risk of Heart disease and stroke if used after large gap from menopause

26
Q

What are the negative side effect of Selective Oestrogen Receptor modulators (SERMS) - (used in osteoporosis)?

A

Hot flushes if taken close to menopause

Increased clotting risks

Lack of protection at hip site

27
Q

What is required before taking Biphosphonates (Used in osteoporosis)?

A

> Adequate renal function
Adequate calcium and Vitamin D status
Good dental health (Notify dentist that on Biphosphonates)

28
Q

What is the action of nitrogen containing Biphosphonates?

A

Inhibit Osteoclasts

29
Q

Examples of Biphosphonates?

A

> Aledronate *
Risedronate
Raloxifene

30
Q

What are the negative side effects of Biphosphonates?

A

> Oesophagitis
Iritis/uveitis
ONJ ?
Atypical femoral shaft fractures ?

31
Q

What usually need to occur after 10 years of Biphosphonate treatment?

A

A “drug holiday” coming off for 1-2 years

32
Q

What is Denosumab?

A

A monoclonal antibody against RANKL

33
Q

What is Denosumab used for and how does it work?

A

Is a monoclonal antibody against RANKL. Reduces osteoclastic bone respiration

Used in osteoporosis

34
Q

If someone has significant renal impairment which drug should not be used in osteoporosis therapy? Which drug should be consider as an alternative?

A

Biphosphonates should not be used in individuals with significant renal impairment.

Consider denosumab as a alternative (A monoclonal antibody against RANKL)

35
Q

How is Denosumab administered?

A

As a subcutaneous injection every 6 months

36
Q

What are the negative side effect of denosumab?

A

Allergy/rash

Symptomatic hypocalcaemia if given when vitamin D deplete

?ONJ

? Atypical femoral shaft fractures

37
Q

How does Teriparatide work?

A

> Teriparatide is a recombinant form of PTH that is used in patients with osteoporosis

> The usual drugs used in osteoporosis are anti resorptive agents

> Usual PTH demineralises bone however intermittent pulses of exogenous PTH stimulates osteoblastic activity (Given once daily)

38
Q

What are the side effects of teriparatide ?

A

Injection site irritation

Rarely hypercalcaemia

Allergy

COST

39
Q

In osteoporosis therapy most drugs are anti-resopative, which drug is not and what does it do instead?

A

Teriparate a recombinant form of PTH which when given intermittently acts to add bone instead

Year 3 - Musculoskeletal (30 decks)

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