Osteoporosis, fibromyalgia

Question 1

What are the risk factors for Osteoporosis?

Answer 1

• Increase in the prevalence of OP due to increase in life expectancy, sedentary lifestyle, and the diet low in Ca and Vitamin-D
• failure to achieve an optimal peak bone mass by the second decade of life.
  *Accelerated loss due to certain chronic diseases or medication toxicities
  *nutritional deficiencies
  *genetic variables

Question 2

What is the effect of post menopausal estrogen reduction on bone remodelling ?

Answer 2

After menopause, due to lack of oestrogen, osteoblast under fill areas of resorption resulting in thinning of the bone.

Question 3

How to clinically screen for asymptomatic OP?

Answer 3

All patients > 50 should be screened for asymptomatic OP. Their height should be checked every year on bare foot. Spinal inspection should look for kyphotic posture and palpation should aim to identify boney fragility at the thoracic and other spinous processes.

Question 4

What are the risk factors for osteoporotic fractures?

Answer 4

• Age and gender * height and weight* Previous fracture * Parental Hx of hip fracture.* Current tobacco smoking.* RA and glucocorticoid use.* Secondary OP* 3 or more units of alcohol intake/ day.* Low BMD and low sex hormone.* Low intake of vitamin D and ca

Question 5

What is the aim of DEXA in OP screening.

Answer 5

The current guidelines recommend to measure the BMD of L-1 to L-4 and proximal femur in all men and woman > 50.

Question 6

What is the BMD , T score indicates ?

Answer 6

It indicates the difference in the BMD of the patient as compared to the average BMD of an average healthy 30 year old.

Question 7

What is the BMD , Z- score indicates?

Answer 7

It indicates the difference of BMD of the patient as compared to the average bone density of people of similar age and gender. In post menopausal woman the Z and T scores should be ordered.

Question 8

What is the normal BMD T score ?

Answer 8

> or equal to -1.0.

Question 9

What is the BMD in Low bone mass or osteopenia?

Answer 9

T-score -1.5 to -2.49

Question 10

What is the BMD in OP ?

Answer 10

A T score < or equal to -2.5

Question 11

What are the 3 ways to clinically diagnose osteoporosis ?

Answer 11

1) The presence of a fragility fracture2) Measurement of bone mineral density (BMD) - DEXA3)Histomorphometric analysis of tetracycline-labelled Bone biopsy

Question 12

What category of woman should get their BMD assessed?

Answer 12

*Age 65 and older
*Postmenopausal women with secondary osteoporosis regardless of age
*Postmenopausal women >50 with additional risk factors
*Postmenopausal women with fragility fracturesF
ollow-up: Every 2-5 years
Rate of bone loss is 0.5 T score units every 5 years

Question 13

What category of men should get their BMD assessed?

Answer 13

Age 70 and older>50 years with history of fracture or loss of at least 2.5 cm heightHistory of 5mg/day glucocorticoid use for more than 3 monthsFamily history of osteoporosis or fractures in absence of trauma

Question 14

What is the action of anti-resorption agent Bisphosphonates?

Answer 14

It Induces osteoclast apoptosis – can cause osteonecrosis.

Question 15

What is the action of anti-resorption agent Denosumab?

Answer 15

It is a Monoclonal antibody that binds to RANK ligand andprevents it activating osteoclasts. It has to be administered subcut, every 6 months. The main side effects are hypocalcemia, skin infection and rash.

Question 16

What are the indications for estrogen replacement therapy ?

Answer 16

It is indicated in woman who reach menopause prematurely and are at increased risk of OP. It acts by promoting osteoclast apoptosis. However, it has an increased risk of breast cancer.

Question 17

What is the benefit of Selective Oestrogen Receptor Modulators Raloxefene ?

Answer 17

It acts on oestrogen receptors in bone much like oestrogen but works as an anti-oestrogen in breast tissue without increased breast cancer risk.

Question 18

What is the action of Bisphosphonate ?

Answer 18

It Work by inhibiting the activity and shortening the half life of osteoclasts, reducing bone turnover. It is the First line therapy and reduces fractures by up to 50% in high risk women. > 5 year use may cause atypical fractures. Therefore, clinicians must establish the patient’s baseline before prescribing the drug.

Question 19

What is the action of Teriparatide?

Answer 19

It is a Parathyroid hormone analogue which increases osteoblast activity. It is indicated in patients where bisphosphonates were deemed ineffective. It is alsoUseful for prevention in patients with risk of glucocorticoid-induced osteoporosis.

Question 20

What is the action of the anabolic agent Strontium?

Answer 20

It is a drug Chemicallysimilar to calcium and replaces calcium in bones – activates osteoblasts and inhibits osteoclasts.

Question 21

What is the action of Romosozumab?

Answer 21

It is a monoclonal antibody that inhibitssclerostin which is released by osteocytes. This promotes bone formation.

Question 22

What is fibromyalgia ?

Answer 22

The most common cause of generalized, musculoskeletal pain inwomen between the ages of 20 and 55. It is a disorder of pain regulation a central pain sensitisation disorder. There is an 8.5 times increased risk with a kin having an Hx of FM.

Question 23

What is the presentation of fibromyalgia ?

Answer 23

The patients presents with Widespread musculoskeletal pain and fatigue. They may also have headaches, cognitive and mood disturbance.

Question 24

What are the physical signs of Fibromyalgia ?

Answer 24

• reproducible pain and tenderness upon palpation of certain soft-tissue locations.* No pain in “control” locations* No evidence of joint or muscle inflammation.

Question 25

What is the 1990 American College of Rheumatology Classification Criteria for Fibromyalgia?

Answer 25

It has > 85% Sensitivity & Specificity and consist of:* Symptoms of “widespread pain”▪ Above AND below the waist▪ Right AND left side of body▪ Positive in 11 out of 18 tender points

Question 26

What is the 2010 American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia?

Answer 26

1) Wide Spread Pain ≥ 7 and Symptom severity ≥ 5 or WPI 3 – 6 and SS ≥ 9. 2) The symptoms persist for at least 3 months.3) There is no other explanation for the symptoms.

Question 27

What are the Laboratory work ups in Fibromyalgia ?

Answer 27

• Full Blood Count (FBC)* Erythrocyte Sedimentation Rate (ESR)* C-Reactive Protein (CRP)* Others ( should be normal)* Antinuclear antibody* Rheumatoid factor* Thyroid function tests (TSH, Free T4)* Creatine Kinase (CK)

Question 28

What are the goals of Fibromyalgia Tx?

Answer 28

• Reduce widespread pain* Reduce fatigue* Reduce cognitive dysfunction

Question 29

What is the approach to the tx of FM?

Answer 29

Initially, Confirm the diagnosisPatient educationTreat comorbidities (mood disorders, sleep disorders) In most cases exercise and pharmacological approach will work. * In some patients Specialty referral, Drug combo therapy, PT, and Psychological interventions (e.g., CBT) may be needed.

Question 30

What are the pharmacological choices in FM ?

Answer 30

• Antidepressants* Amitriptyline - TCA* Duloxetine - SNRI* Milnacipran - SNRI* Anticonvulsants* Gabapentin* Pregabalin

Question 31

What should be the elements of patient education in FM ?

Answer 31

• Fibromyalgia is a real illness* Fibromyalgia is not a persistent infection* Stress reduction will help* Improved sleep hygiene will help* Exercise will help* Treatment for depression or anxiety will help

Question 32

what is the pathogenesis of Polymyalgia Rheumatica?

Answer 32

Genetic factors (HLA DR4), environmental factors, infections such as Parvovirus-B19 or adenovirus generates autoantibodies and induce molecular mimicry triggering T cell mediated immune attack to the large joints and periarticular structures with sparing of muscles. It may co-occur with Giant cell arteritis.

Question 33

What is the clinical presentation of Polymyalgia Rheumatica?

Answer 33

The patients are woman > 50. They may present with Pain and stiffness to shoulders and/or hips which often starts unilateral but progresses to bilateral over time. It is worse in the morning and they may experience difficulty dressing and brushing hair. The Physical examination may show decreased ROM, but overall musclestrength is normal.

Question 34

What are the labs in Polymyalgia Rheumatica?

Answer 34

Elevated ESR and CRP with normal CK, which helps to distinguish PR from polymyositis and dermatomyositis

Question 35

What is the Tx of Polymyalgia Rheumatica?

Answer 35

• Low-dose corticosteroids* Methotrexate