Osteoporosis

Question 1

What is osteoporosis?

Answer 1

• progressive systemic skeletal disease
• characterised by
  
  • reduced bone mass and micro-architectural deterioration of bone tissue

Question 2

How will the bones be affected as a result of O?

Answer 2

• More fragile
• More susceptible to fractures

Question 3

Which bones are commonly affected by osteoporotic fractures?

Answer 3

• spine
• forearm
• hip
• shoulder

Question 4

What is osteoporotic fractures?

Answer 4

• fractures that result from mechanical forces that would not ordinarily result in fracture

Question 5

How would you clinically define Osteoporosis?

Answer 5

• bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass

Question 6

What are the RF of osteoporosis?

* think BMD dependent and independent

Answer 6

BMD dependent

• Post-menopausal women
• Caucasian/asian
• Chronic kidney disease
• Vitamin D deficiency
• Endocrine disorders (Cushing syndrome, hyperparathyroidism)
• Osteogenesis imperfecta

BMD independent

• Age
• Previous fragility fracture
• Family history of hip fracture
• Corticosteroids
• Alcohol (3 units or greater / day)
• Smoking
• Rheumatoid arthritis
• Low body mass index

Question 7

What is the Px of O?

Answer 7

Age

1. Age > activity of osteoclasts increases and is not matched by osteoblasts

Oestrogen

1. osteoclast survive longer in absence of Oestrogen
2. Oestrogen def > arrest of osteoblastic activity

Prolong steroid use

1. Increase turnover of bone

Question 9

Which pt group should be considered for fracture risk assessment?

Answer 9

• All women aged 65 years and over
• All men aged 75 years and over

Women aged under 65 years and men aged under 75 years in the presence of risk factors

• Previous fragility fracture
• History of falls
• Family history of hip fracture
• Current use or frequent recent use of oral or systemic glucocorticoids
• Low BMI (
• Other causes of secondary osteoporosis
• Smoking
• Alcohol intake of more than 14 units per week for men and women.

Question 10

Which pt group under 50 should be screened for fracture risk assessment?

Answer 10

• Current or frequent use of oral corticosteroids.
• Untreated premature menopause.
• A previous fragility fracture

Question 11

Which pt group under 40 should be screened for fracture risk assessment?

Answer 11

• Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for 3 months or more.
• Previous fragility fracture of the spine, hip, forearm, or proximal humerus.
• History of multiple fragility fractures.

Question 12

What medications apart from steroid would increase risk of O?

Answer 12

• SSRIs
• GNRH agonists
• aromatise inhibitors
• antiepileptics
• PPIs
• thiazolidinediones

Question 13

What risk assessment tools are used to assess fracture risk?

Answer 13

• FRAX
• QFracture

Question 14

What scan is used to assess fracture risk?

Answer 14

• DXA
  
  • Osteopenia: A T-score of -1 to -2.5
  • Osteoporosis: A T-score of ≤ -2.5

Question 15

When would you consider to perform a vertebral fracture assessment?

Answer 15

• History of ≥4cm height loss
• Kyphosis
• Recent or current long-term oral corticosteroids
• BMD T-score ≤-2.5

Question 16

What are pathologicla fractures?

Answer 16

• fractures that occur secondary to malignancy (primary bone or metastasis)

Question 17

How would you mx high risk of fragility fracture?

Answer 17

• DXA scan

T-score is ≤ -2.5:

• Medication
• Optimise RF
• Treat underlying cause

T-score is > -2.5:

• Optimise RF
• Treat underlying cause

Question 18

How would you mx low risk of fragility fracture?

Answer 18

• Optimise risk factors
• treat any underlying conditions
• follow up within 5 years

Question 19

What pharmacological tx are used for O?

Answer 19

• bisphosphonates (first lines)
  
  • Alendronate
    
    • PO daily in the morning before 30mins of eating or drinking
  • Zoledronic acid
    
    • IV injection once/year
• Denosumab
  • monoclonal antibody against Receptor Activator of Nuclear factor Kappa B ligand (RANK ligand)
  • SC injection every 6 months.
• Raloxifene
  
  • ​selective oestrogen receptor modulator
• HRT
• Vit D and Calcium supplementation

Question 20

What are the SE of Biphosphonates?

What are the contraindications of Biphosphonates?

Answer 20

• GI disturbance
• oesophagitis
• headaches
• renal impairment
• hypocalcaemia
• pregnancy
• lactation
• hypersensitivity.

Question 21

What is FRAX?

Answer 21

• estimates the 10-year risk of fragility fracture
• aged 40-90 years

Question 22

What is QFracture?

Answer 22

• estimates the 10-year risk of fragility fracture
• aged 30-99 years

Question 23

When should the DEXA scan be offered?

Answer 23

• A FRAX score of 10% or greater

Question 24

How yould you interpret the results of FRAX tool?

Answer 24

• low risk: reassure and give lifestyle advice
• intermediate risk: offer BMD test
• high risk: offer bone protection treatment

Question 25

When would it be better to use DEXA scan straight away instead of the fracture screening tools?

Answer 25

• before starting treatments that effect bone density
  
  • sex hormone deprivation for treatment for breast or prostate cancer
• in people aged under 40 years who have a major risk factor
  
  • multiple fragility fracture
  • major osteoporotic fracture
  • current or recent use of high-dose oral or high-dose systemic glucocorticoids (> 7.5 mg prednisolone/day for >3months).