Osteoporosis Flashcards
What is osteoporosis?
A skeletal condition characterised by low bone mass, deterioration of bone tissue, and disruption of bone architecture that leads to compromised bone strength and an increased risk of fracture.
Non-modifiable risk factors of OP.
Advanced age >65 yo
Female gender
Caucasian or south Asians
Family history of osteoporosis-genetic
History of low trauma fracture
Modifiable risk factors of Osteoporosis.
Low body weight 58kg or BMI <21
Premature menopause <45
Calcium/Vit D def.
Inadequate physical activity
Cigarette smoking
Excessive alcohol intake
Drugs
Give example of drugs that can cause OP.
Corticosteroids
Aromatase inhibitors
PPis
SSRIs, anti-epileptics
How is a diagnosis of osteoporosis made?
By DEXA scanning of the lumbar spine and hip.
This is the gold standard for diagnosis.
How is a diagnosis of OP established from DEXA scan?
By T score.
T-score of minus 2.5 or less means osteoporosis.
Explain the T-score.
The number of SDs from the mean bone density of persons of same gender at age of peak density aka 25 years.
T score of minus 2.5 or less = OP
Normal BMD is T-score of -1 or more
What is osteopenia?
T-score between -1 and -2.5
What is the Z-score?
A comparison of the patient’s BMD with an age and gender matched population.
What does a Z-score of less than -2 suggest?
That prompt evaluation for causes of secondary osteoporosis should be done.
Also plain radiograph lack sensitivity to diagnose osteoporosis, but rib fractures or vertebral compression fractures without trauma history should prompt evaluation for OP.
Other investigations that are done in OP.
DEXA gold standard
Fracture risk assessment tool (FRAX)
X-ray
ALP
Serum calcium and albumin
Serum crea, phosphate and Vit D
Serum PTH and Thyroid
Serum cortisol, ACTH etc…
Serum testosterone
Symptoms and signs of OP.
There is usually no symptoms of OP.
Fractures is the only symptom of osteoporosis.
Vertebral fracture is suggested by the sudden onset of severe back pain.
Pain from mechanical derangement, increaseing kyphosis, height loss and abdominal protuberance may follow from vertebral fractures.
Colle’s fracture are common as well.
Any other sort of fracture from low-trauma or no trauma.
If there are no usual symptoms of OP except for fractures, how is the condition picked up?
By screening.
Explain assessment of Osteoporosis
1st step is to perform a FRAX assessment on patients at risk of osteoporosis;
Women aged > 65
Men > 75
Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids, endocrine disorders and rheumatoid arthritis.
Next step in management based on the probability of a major osteoporotic fracture from the FRAX score:
FRAX outcome without a BMD result will suggest one of three outcomes:
Low risk – reassure
Intermediate risk – offer DEXA scan and recalculate the risk with the results
High risk – offer treatment
FRAX outcome with a BMD result will suggest one of two outcomes:
Treat
Lifestyle advice and reassure
Indications of DEXA scanning.
Women aged >65
Men aged >70
Fragility fractures
Women < 65 with risk factors
Men < 70 with risk factors
Who should be screened for osteoporosis?
Should be based on risk factors.
All adult patients (50 years and older) should be evaluated for osteoporosis risk factors. DEXA is recommended in women 65 years and older and in men 70 years of age and older.
In younger postmenopausal women or in men aged 50 to 69 years, DEXA should be performed if at least 1 major or 2 minor risk factors for osteoporosis are present.
US Preventive Services Task Force (USPSTF) recommends that women aged 65 years and older and those aged 60 to 64 years with risk factors for the condition be screened.
Treatment of osteopenia.
Focus on risk modification.
Do weight bearing exercise, vit D3 supplementation (800-2000 IU/day), limiting alcohol and smoking cessation.
Dietary advice regarding calcium intake.
Treatment of osteoporosis.
1st line - Oral bisphosphonates or IV if oral is not tolerated + Vitamin D + calcium supplementation.
2nd line - Denosumab or teriparatide + Vitamin D + Calcium supplementation.
Give examples of secondary causes of OP.
Coeliac disease
Eating disorders
Hyperparathyroidism
Hyperthyroidism
Multiple myeloma
Cushing’s
Hormonal treatment of OP.
HRT
Testosterone
Osteoporosis risk factors
SHATTERED
Steroid use of > 5mg/d of prednisolone
Hyperthyroidism, hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI < 18.5)
Testosterone low
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease like myeloma or RA
Dietary - low Ca2+, malabsorption etc…
What is the issue with oral bisphosphonates?
The compliance is poor.
They are poorly absorbed, the patients need reassurance that serious side effects are very rare.
Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
Atypical fractures (e.g. atypical femoral fractures)
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
Osteoporosis is less common in men, what needs to be excluded?
Secondary causes such as hypogonadism.
