Osteoporosis

Question 1

Risk factors for Osteoporosis?

Answer 1

ABCDEF₃G

Alcohol & Smoking

Bone Marrow disorders (Myeloma, Leukaemia, Lymphoma Metastatic Ca)

Chronic liver disease, Chronic kidney disease

Drugs: steroids, thyroxine (over-tx), PPI/H2 blockers, anti-oestrogen/androgens, anti-convulsants, lithium

Endocrine: hyper-PTH, hyper-thyoid, Cushing’s, Hypogonadism

Family Hx & Fracture (previous), Female (late menarchy, early menopause***)

GI - malabsorption: coeliac, IBD, CF

Question 2

What drugs cause osteoporosis other than steroids? (6)

Answer 2

Osteoporosis = ALPaCHINO

Anti-androgen (e.g. Letrozole)

Lithium

Phenytoin

Cyclosporin

Heparin

Oroxine (Thyroxine) over replacement

Question 3

Osteoporosis - PRICMCP?

Answer 3

P: age of diagnosis, how dx (# or DEXA). If # - was it minimal sress/standing height #, compression # (back pain)

R: ABCDEF₃G. Any risk facator for falls?

I: DEXA - how low, what is it now? T/Z score

C: of Disease: Fracture (axial-skeleon) - impaired mobility, ADL. Spine # (neurological complications?), infection, thrombosis. Complications of medications: Bisphosphonate - atypical femoral #, ONJ, interstitial nephritis, oesophagitis

M: exercise program/falls prevention program, Calcium + Vit D (if deplete), Bisphosphonates, Denosumab, HRT. Surgical hx for # Mx.

C: Adherence to therapy and 1-2 yearly DEXA

P: understanding of significant complications

Question 4

Osteoporosis examination? (5)

Answer 4

Malnutrition/Malnourished

Denition

Bowing of the legs? (osteomalacia/Rickets)

Signs of Hyperthyroid & Cushing’s

Signs of Vertebral #: Occiput to wall distance - i.e. ?thoracic kyphosis

Question 5

What investigations would you like to see in this patient with osteoporosis?

Answer 5

Bloods: Calcium, Vit D, ALP (if elevated - suspect osteomalacia, Paget’s malignancy), PO4 (low in osteomalacia), PTH (hyperparathyroidism), TSH, EUC/LFT (CKD/CLD), FBC/film/ESR/EPG (BM disorders/MM - esecially if osteoporosis is unexpectedly severe), testosterone level in men.

DEXA: looking for T-score <-2.5. Look for Z-score: if <2 SD below age-related mean - possible secondary cause for reduced BMD.

Skeleal XR to look for trabecular bone loss in the verebal body & rule out crush #.

Question 6

What are the indications for BMD scan? (4)

Answer 6

1. # after minimal trauma
2. F >65, M>70
3. Prolonged steroid use
4. Medical conditions with risk of OP: Hyper-PTH, Hyper-Thyroid, CKD, CLD, Malabsorption, RA, Crohn’s…etc.

Question 7

What are XR features of OP on the Spine? (3)

Answer 7

Anterior wedging

Codfish deformity (From expansin of intervertebral disc)

Loss of bone density

Question 8

What are the complications of Bisphosphonate therapy? (3) and typical timing of events following initiation of Bisphosphonates?

Answer 8

1. ONJ: impaired healing after tooth extracion with exposed bone. Occur usually at leat 2y after staring. Mx with surgical debridement. Make sure oral healh is adequate before initiation.

Risk is highe with IV formulations + previous dental infections

2. Atypical femoral #: usually afer about 7y. Risk ceases in 1y once drug is stopped
3. Oesophagitis (if PO) if so use IV regime

Question 9

Would you consider “drug holiday” for this patient with Osteoporosis on Bisphosphonates?

Answer 9

FIT study sugested tha BMD peak occurs 5y and plateus - if you take bisphosphonates off, BMD remains the same for abou a year.

Question 10

Zolendronate - how often is it given and main side effect?

Answer 10

Given once yearly as IV infusion.

Can cause Atrial fibrillation***

Question 11

Indications for Teriparatide? (3)

Answer 11

BMD <-3 and

2 or more minimal trauma # and

1 # despite 12m of anti-resorptive therapy.

Must be given as an only agent and only for 18 months.

Question 12

What is your approach to management of this patient’s osteoporosis?

Answer 12

Goals: prevent #, stabilise or increase BMD

Confirm dx - DEXA, look for T-score <-2.5

A: investigate for secondary causes/risk factors - EUC/LFT (CKD/CLD), FBC/film/EPG (if backpain, BM disorders), TFT, morning testosterone, PTH, Vit D and Calcium. ALP (ricketts).

Screen for complications: of disease - vertebral crush #, guided by symptoms, falls risk; of treatment - ONJ, atypical femoral # → imaging if pain

T: Non-pharm

• Correct modifiable risk-factors: smoking & ETOH cessation. Exercise. Sun-exposures.
• Diet: 3-4 serves of calcium in elderly (1200-1500mg daily), Calcium + Viamin D supplement (Calcitriol in CKD, Ostelin in others)
• Avoid causative drugs - steroids e.g. lowest effective dose in shortest duration. Consider seroid sparing.
• Falls prevention: PT - balance/strengthening exercise, OT - home modificaitons, Hip protectors, walking aids, night lights, rails…etc.

T: Pharm

• If steroid induced OP: co-administer agents, in combination with Calcium and 25-OH Vit D (shown to be effecive)
• Bisphosphonate, dose reduction if eGFR <30
• Denosumab
• SERM (Raloxifene) - in women intolerant of bisphosphonate. Sfx: VTE, hot flushes.
• Teriparatide (S/C daily injection), risk of Sarcoma.
• Verebroplasty - may relieve acute severe pain.
• Orthopaedic surgery

Involve: dietitian (optimise nuritional status, supplements), PT/OT for falls prevention, GP and family for education & support. Osteoprosis society

Ensure F/U and monitor

• DEXA: 1-2 yearly.
• Review for ?drug holiday if on Bisphosphonate for 5y to minimise risk of adynamic bone disease
• Review side effects

Question 13

Despite tx BMD still falling. What would you do? (4)

Answer 13

Investigate for poor compliance: if so consider IV Zolendronate, S/C Denosumab.

Ensure Calcium and Vit D replete

Investigate for poor absorption of the drugs (if oral tx)

Rule out secondary causes

Question 14

How much Calcium and Vitamin D supplements would you give this patient?

Answer 14

Calcium: 1200-1500mg daily if elderly

Vit D: if deficient (25-OH D <25nmol/L) → 3000-5000IU/d for 6-12 weeks then 1000 IU thereafter.

If not but you suspect inadequate intake, 800IU/d