Osteoporosis Flashcards
Risk factors for osteoporosis
‘SHATTERED’
Steroid use
Hyperthyroidism, hyperparathyroidism, hypercalciuria
Alcohol and smoking
Thin (BMI <18.5)
Testosterone low
Early menopause, late menarche, amenorrhoea
Renal or liver failure
Erosive/inflammatory bone disease (e.g. Myeloma, RA)
Dietary – reduced calcium or malabsorption, diabetes type 1
Also:
- older age
- FHx
- prolonged immobility
Diagnosis of osteoporosis
DEXA scan
T-score: BMD SD away from the young, healthy mean (gender and ethnicity matched)
> 0 = BMD better than reference
0 to -1: no evidence of osteoporosis
-1 to -2.5: osteopenia
-2.5 or worse: osteoporosis
What is the T score?
SD away from the young, healthy mean (gender and ethnicity matched)
What is the Z score?
population and age specific
What bloods are seen in osteoporosis
NORMAL Ca2+, PO43-, ALP
Indications for DXA scan
- low trauma fracture
- women 65+ with 1+ RF for osteoporosis
- prior to giving long-term prednisolone
- bone and bone remodelling disorders
What is FRAX?
risk assessment tool for estimating 10y risk of osteoporotic fracture in untreated patients
Lifestyle measures to prevent fragility fractures
- stop smoking, reduce alcohol
- treat underlying EDs/aim for normal weight
- weight-bearing exercises (my increase BMD)
- balance exercises (reduce risk of falls)
- calcium and vit D (diet ± supplements)
- home-based falls prevention programme
Indications for FRAX assessment (not DXA necessarily)
All women 65+, all men 75+
All women and men 50+ with 1 RF for osteoporosis
Wome and men <50 with:
- untreated premature menopause
- current/frequent oral corticosteroid use
- previous fragility fracture
Then BMD measured using DXA scan if intermediate risk or higher, and risk re-calculated with T-score
1st line pharmacological management of osteoporosis (usually)
Oral bisphosphonates:
Alendronate (70mg weekly or 10mg daily, also available as dissolvable tablet)
or Risedronate (35mg weekly or 5mg daily)
plus vit D ± calcium
What to advise patients about how to take oral bisphosphonates
- take first thing in the morning, at least 30 mins before first food or drink (other than water)
- swallow whole with a glass of plain water, while sitting or standing
- remain upright (sitting or standing) for 30 mins after taking the tablet
- at least 30mins between taking bisphosphonate and taking calcium/antacids, or don’t take on day bisphosphonate is taken
- maintain good dental hygiene, inform dentist
- report any Sx of jaw swelling/pain/redness, or new onset hip/groin/thigh pain, or SEVERE upper GI Sx (common to have some)
SEs of oral bisphosphonates
Common:
- upper GI Sx (e.g. indigestion, abdo pain, nausea)
- bowel disturbance
- headaches
- MSK pain
Uncommon:
- oesophageal reactions including ulcers
Rare/very rare:
- osteonecrosis of the jaw/external auditory canal
- atypical stress fractures (femur)
CIs and cautions for bisphosphonates
CIs:
- hypocalcaemia
- severe CKD (threshold depends on drug)
- those unable to stay upright for 30 mins
- oesophageal/other abnormalities which would delay oesophageal emptying
- pregnant/breastfeeding
Cautions:
- upper GI problems e.g. dysphagia, peptic ulcer, oesophageal disease, etc.
WHY do bisphosphonates need to be taken the way they are?
- food and calcium decrease absorption
- can cause oesophageal disease so need to ensure tablet doesn’t sit in oesophagus
2nd+ line management of osteoporosis
bisphosphonates:
- zolendronic acid: annual IVI
- ibandronate PO/IV (monthly/every 3m)
mAb: denosumab
- SC every 6 months
raloxifene (oestrogen receptor modulator)
HRT if premature menopause
Teriparatide (recombinant PTH)
- daily SC
Strontium ranelate (but safety concerns)
