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PHA223 > osteoporosis in practice > Flashcards

osteoporosis in practice Flashcards

1
Q

medical term for fracture

A

#

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2
Q

most common osteoporotic fractures

A

hip
wrist
spine

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3
Q

What is the most serious consequence of falls in older people?

A

hip fracture

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4
Q

interventions after a hip fracture

A
  • secondary prevention
  • check adherance and administratin if already taking meds
  • falls assessment - inc med review
  • prevention of VTE with LMWH
  • pain management
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5
Q

What type of fractures are vertebral/spine fractures?

A

compression fractures

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6
Q

interventions for spine #

A
  • secondary # prevention
  • liefstyle advice
  • pain control and analgesia
  • physiotherapy
  • surgical management
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7
Q

risk factors for osteoporosis

A 
fragility #
excess alcohol
smoking
immobility
drugs
parent hip fracture
secondary causes
falls
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8
Q

drugs that increase risk of #

A 
corticosteroids
PPIs
anti-epileptics
SSRIs
aromatase inhibitors
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9
Q

secondary causes of OP

A 
amenorrhoea
eating disorders
IBD
RA
COPD
early menopause/hypogonadism
low BMI
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10
Q

What is primary prevention?

A

identifying people who have never had a # but at are at increased risk of #
initiating treatment to prevent #

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11
Q

What is secondary prevention?

A

people who have already had a # and reducing the risk of a further #

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12
Q

Who should have a fracture risk assessment?

A
  • all older patients (female >65, male >75)

- patients with specified risk factor

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13
Q

2 risk assessment tools for # risk

A

FRAX

QFracture

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14
Q

3 options after # risk assessment

A

lifestyle advice only
refer for DXA
start treatment

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15
Q

What does FRAX assessment give results as?

A

10yr risk of osteoporotic fracture and 10yr risk of hip fracture (%)

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16
Q

What do the colours of a FRAX scan mean? (NOGG guidance)

A

red - start treatment
amber - DXA scan
green - lifestyle advice

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17
Q

lifestyle advice

A 
smoking
alcohol
vitamin D
calcium
exercise
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18
Q

treatment options for osteoporosis

A 
bisphosphonates
denosumab
HRT
raloxifene (SERM)
teriparatide
strontium
romosozumab (not used yet)
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19
Q

oral bisphosphonates

A

alendronic acid
risedronate
ibandronic acid

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20
Q

parenteral bisphosphonates

A

zoledronic acid

ibandronic acid

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21
Q

How is denosumab given?

A

subcutaneous injection

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22
Q

1st line for osteoporosis

A

oral bisphosphonates

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23
Q

When are oral BPs cost effective?

A

if patient eligible for risk assessment and had a 10yr probability of fracture of at least 1%

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24
Q

How to take oral BPs?

A
  • take on an empty stomach
  • with a full glass of water (helps absorption)
  • avoid any other meds for at least 30mins
  • avoid Ca supplements for 4hrs, take Ca at lunchtime
  • upright for 30mins
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25
Q

cautions and contraindications with oral BP

A
  • eGFR <35 (alendronic acid)
  • eGFR <30 (risedronate)
  • hypocalcaemia
  • dysphagia/swallowing difficulties
  • GI bleed (or recent)
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26
Q

When are oral BPs reviewed?

A

after 5 years

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27
Q

Which oral BP has less GI side effects?

A

risedronate

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28
Q

When is alendronic acid not appropriate?

A

renal impairment
hypocalcaemia
GI risk factors

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29
Q

1st line option for oral BPs

A

alendronic acid

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30
Q

2nd line treatment for oral BPs

A

risedronate

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31
Q

What happens if risedronate is not appropriate?

A

refer to secondary care or specialist (usually injections)

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32
Q

difference between alendronic acid and ibandronate

A

ibandronate is taken once monthly

wait for 1hr before eating

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33
Q

What is given if can’t tolerate oral bisphosphonate?

A

Zoledronic acid

-> IV infusion

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34
Q

When is zoledronic acid cost effective?

A

elegible for risk assessment and 10yr fracture probability over 10% (or 1% if can’t tolerate oral BPs)

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35
Q

Where is zoledronic acid given?

A

secondary care

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36
Q

dose of zoledronic acid

A

5mg annual IV over 15mins

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37
Q

side effects of zoledronic acid

A 
flu-like symptoms (for a few days, paracetamol)
hypocalcaemia
rare
- atypical #
- osteonecrosis of the jaw
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38
Q

checks before giving IV infusion of zoledronic acid

A 
renal function
Ca
Vit D ( for Ca absorption, before each infusion, >50 nanomoles/L)
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39
Q

regular checks with zoledronic acid

A

regular dental check ups

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40
Q

What reminder card is given with zoledronic acid?

A

osteonecrosis of the jaw reminder card

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41
Q

How is denosumab given?

A

subcutaneous injection

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42
Q

What is denosumab?

A

mAb

RANKL inhibitor

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43
Q

Where is denosumab initiated?

A

in hospital

44
Q

dose of denosumab

A

60mg SC injection 6 monthly

45
Q

What needs to be checked before every denosumab injection?

A 
bloods
- renal risk
- Ca
- vit D
hypocalcaemia
46
Q

How is denosumab excreted?

A

not renally excreted

- so can use in renal impairment but higher risk of hypocalcaemia if kidneys not working, can lead to death

47
Q

What can denosumab increase the risk of?

A

UTI
chest infection
rash/cellulitis

48
Q

interactions with denosumab

A

none

49
Q

rare side effects of denosumab

A

atypical #

osteonecrosis of jaw

50
Q

What to look out for/resport with denosumab?

A

hip/thigh/groin pain

51
Q

What type of drug in raloxifene?

A

SERM

52
Q

Who can take raloxifene

A

post-meopoause women

53
Q

risks with raloxifene

A

VTE
hot flushes
leg cramps
flu-like symptoms

54
Q

When is HRT usueful for osteoporosis?

A

early menopause (<45yrs)

55
Q

When is strontium ranelate Aristo used?

A

severe osteporosis

when other meds not tolerated/not suitable

56
Q

Monitoring for strontium

A

skin reactions

  • Steven Johnston syndrome
  • DRESS
57
Q

When should CV risk be reviewed with strontium?

A

every 6-12 months (QRISK)

58
Q

contraindications for strontium

A 
existing CV disease (inc risk of blood clots)
IHD
PAD
CVD
VTE
uncontrolled hpt
temp/permanent immobilisation
59
Q

When should strontium be withheld?

A

before surgery

immobilisation, blood clots

60
Q

Can stromtium be used in CV risk factors? (diabetes, smoking)

A

yes, with caution

61
Q

What is teriparatide?

A

recombinant fragment of PTH

anabolic agent

62
Q

How is teriparatide given?

A

daily SC injection

63
Q

teriparatide course

A

2 year course

daily SC injection

64
Q

What fractures does teriparatide reduce?

A

vertabral #

65
Q

side effects of teriparatide

A 
limb pain
nausea
headache
dizziness
depression
HYPERcalcaemia
66
Q

difference between antiresorptives and teriparatide in s/e

A

teriparatide can cause hypERcalcaemia

-> antiresorptives - hypocalcaemia

67
Q

Where is teriparatide stored?

A

in the fridge

68
Q

What is romosozumab?

A

humanised mAb that inhibits sclerostin

stimulates osteoblasts AND reduces osceoclast activity

69
Q

romosozumab course

A 
12 months (injections twice a month) 
NOT USED YET
70
Q

potential s/e of romosozumab

A

cardiac adverse effects

not used yet

71
Q

What osteoporosis drug do you not need to take Ca/Vit D with?

A

teriparatide

72
Q

When is Ca/Vit D recommended?

A

dietary Ca intake is poor

housebound/institutionalised

73
Q

dose of Ca for patients with osteoporosis

A

700mg Ca

74
Q

levels of Vit D that are in deficit

A

< 25 nmol/L

75
Q

normal vitamin D plasma levels

A

> 50 nmoles/L

25-50 nmol/L may be enough for some people

76
Q

2 forms of vitamin D that are given (which is preferred)

A

ergocalciferol (D2, plant derived)
colecalciferol (D3, lanolin derived, sheep’s woll)
- D3 preferred

77
Q

When is rapid correction of Vit D deficiency given?

A
  • symptomatic disease (osteomalacia)
  • if starting a parenteral antiresorptive
  • > loading dose and then maintenance

-> if no rush for vit D, then just start at maintenance dose

78
Q

dose of rapid correction of Vit D

A
  • loading dose 300,000 units Vit D as separate weekly/daily doses over 6-10 weeks
  • followed by regular maintenance therapy 800-2000 units daily
79
Q

What needs to be checked after starting vit D treatment and why?

A

check adjusted serum Ca 1 month after loading/maintenance dose in case primary hyperparathyroidism has been masked

80
Q

oral steroids and osteoporosis

A
  • # risk higher on > 7.5mg/day
  • all doses increase # risk at the spine
  • increased risk of vertebral and non-vertebral #
    • > spine # more common than hip
  • # risk declines after stopping steroid/continued long term (because greatest loss at beginning)
81
Q

When is bone loss the highest with oral steroids?

A

rapid in first 3 months of steroid treatment

82
Q

When is there a high risk for glucocorticoid induced osteoporosis?

A

70+ yrs
female
high dose prednisolone and other risk factors
<1.5 BMD

83
Q

Why would bisphosphonates be avoided in women of childbearing potential?

A

they have long retention time in bone

-> should avoid them, abnormality risk

84
Q

renal impairment and risedronate

A

risedronate can be used up to GFR 30ml/min

85
Q

denosumab and renal impairment

A

denosumab not renally cleared so can use in renal impairment

BUT CAUTION because it increases the risk of hypocalcaemia

86
Q

How often to bisphosphonates need to be reviewed?

A

after 5+ years of use

-> 3yrs for zoledronic acid (because its longer acting than oral BPs

87
Q

What is discussed/decided at a review for bisphosphonates?

A
  • decide to continue or drug holiday

- weigh up risks and benefits

88
Q

What is a drug holiday for bisphosphonates?

A

stop BPs for usually 1-2yrs

89
Q

What should happen after 10yrs of BP treatment?

A

drug holiday if there hasn’t been one already

90
Q

rare side effects with bone medications (why drug holidays are used)

A

atypical fractures

osteonecrosis - BRONJ, MRONJ

91
Q

atypical fracture

A 
rare
increasing risk with increased duration of treatment
usually thigh bone
can be bilateral (x-ray both sides)
report hip/thigh/groin pain
x-ray to rule out atypical #
92
Q

BRONJ and MRONJ

A

BRONJ - bisphosphonate related osteonecrosis of the jaw

MRONJ - medication related ostronecrosis of the jaw

93
Q

What is osteonecrosis?

A

death of bone

94
Q

What other meds can cause ostronecrosis?

A

denosumab

95
Q

What is osteonecrosis usually associated with?

A

invasive dental procedures

96
Q

treatment for ostronecrosis of the jaw

A

radical surgical management to remove large segments of necrotic bone

97
Q

preventative measures for ONJ

A

dentally fit before starting BPs

maintain good oral hygiene

98
Q

How long are BPs used for usually?

A

up to 5 years

can be up to 10yrs and no drug holiday if Hx of hip #

99
Q

long term risks of BPs

A

ONJ

atypical #

100
Q

What happens when after stopping BPs?

A

gradual reduction in BMD

increase in BTM (bone turnover markers)

risk remains reduced for a period of time after

101
Q

What does denosumab reduce?

A

at hip and spine

102
Q

Why is denosumab not suitable for drug holidays?

A

it’s not retained in the bone

103
Q

What happend after stopping denosumab?

A

increased bone resorption
rapid decline in BMD
-> risk of vertebral #

104
Q

What can missing one dose/delaying treatment for a few months with denosumab cause?

A

increased # risk

105
Q

What should be started after stopping denosumab?

A

alternative treaement eg. bisphosphonates

106
Q

What can bone turnover markers be used for?

A
  • monitor bone protection therapies (adherance)

- help with drug holidays

PHA223 (43 decks)

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