Osteoporosis

Question 1

What is osteoporosis?
WHO definition?

What is Osteopenia?

Answer 1

Osteoporosis is a condition where there is reduction i bone density - Bone density less than 2.5 sd below the young adult mean density

Osteopenia refers to less severe reduction in bone density than osteoporosis (-1 to -2.5)

Question 2

What is the consequence of reduced bone density?

Answer 2

bone is less strong and more prone to fractures

Question 3

Which tool can be used to assess risk of fragility fractures over the next 10 years?

What risk factors does it take into account?

Answer 3

FRAX tool

1. Age (post menopausal women main risk)
2. Sex
3. Weight (low BMI is risk)
4. Height
5. Previous fracture
6. Parental fracture
7. Current smoker
8. glucocorticoids
9. Alcohol intake
10. RA
11. Secondary osteoporosis

Question 4

Why are postmenopausal women at particular risk of osteoporosis?

Answer 4

oestrogen is protective against osteoporosis

unless they are on HRT, they have less oestrogen

Question 5

Who should be assessed using the FRAX tool?

Answer 5

Women over 65
Men over 75
younger patients with risk factors - fragility fractures, hx of falls, low BMI, long term steroids, RA

fit for use anyone between 40-90

Question 6

What are the categories of the FRAX result without BMD and what management should be implemented?

Answer 6

low risk: reassure and give lifestyle advice

intermediate risk: offer BMD test (DEXA)

high risk: offer bone protection treatment

Question 7

How is BMD measured?

Answer 7

DEXA scan

-1 to -2.5 osteopoenia

less than -2.5 osteoporosis

Less than -2.5 + fracture = severe osteoporosis

Question 8

What are the possible outcomes for FRAX + BMD?

Answer 8

Treat

Lifestyle advice and reassure

Question 9

What is the management of osteoporosis?

How do each of them work

What is the order of priority?

What are the side effects?

Answer 9

1. lifestyle advice
2. vitamin D and Calcium e.g Calchichew-D3 for inadequate calcium, those lacking sun exposure should get additional vitamin D, ADcalD3
3. Bisphosphonates (interfere with osteoclasts, prevent bone resorption)
   (Alendronate 70mg) 1st line , given as prophylaxis for long term steroid use
   S.E: reflux, oesophageal ulcers
   alternative: risedronate

If patients cannot tolerate bisphosphonates:

4. Raloxifine - secondary prevention (selective oestrogen receptor modulator) - stimulates oestrogen receptors in bone but blocks in breast and uterus. less breast cancer risk than HRT
5. Strontium ranelate: (dual:promotes osteblasts, inhibits osteoclasts) if no other tx option (stimulate osteoblasts, block osteoclasts) S.E - > risk of cvs disease, > risk of thromboembolism, steven johnson syndrome

6. Denosumab: monoclonal antibody to RANKL - reduces bone resorption
7. Teriparatide - recombinant form of parathyroid hormone - effective at increasing bone density but role in managing osteopororis not yet well defined
8. Hormone replacement therapy
   for prevention, due to > risk of CVS disease and breast cancer not recommended unless suffering from vasomotor symptoms

Question 10

What are the side effects of Alendronate?

Answer 10

S.E: reflux, oesophageal ulcers

Question 11

What are side effects of strontium ranelate

Answer 11

> CVS risk
DVT/PE risk
risk of steven johnson syndrome

Question 12

What lifestyle advice should you give to patients with osteopororsis?

Answer 12

Activity and exercise
Maintain a health weight
Adequate calcium intake
Adequate vitamin D
Avoiding falls
Stop smoking
Reduce alcohol consumption