osteoporosis in practice Flashcards
1
Q
medical term for fracture
A
#
2
Q
most common osteoporotic fractures
A
hip
wrist
spine
3
Q
What is the most serious consequence of falls in older people?
A
hip fracture
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
5
Q
What type of fractures are vertebral/spine fractures?
A
compression fractures
6
Q
interventions for spine #
A
- secondary # prevention
- liefstyle advice
- pain control and analgesia
- physiotherapy
- surgical management
7
Q
risk factors for osteoporosis
A
fragility # excess alcohol smoking immobility drugs parent hip fracture secondary causes falls
8
Q
drugs that increase risk of #
A
corticosteroids PPIs anti-epileptics SSRIs aromatase inhibitors
9
Q
secondary causes of OP
A
amenorrhoea eating disorders IBD RA COPD early menopause/hypogonadism low BMI
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 #
11
Q
What is secondary prevention?
A
people who have already had a # and reducing the risk of a further #
12
Q
Who should have a fracture risk assessment?
A
- all older patients (female >65, male >75)
- patients with specified risk factor
13
Q
2 risk assessment tools for # risk
A
FRAX
QFracture
14
Q
3 options after # risk assessment
A
lifestyle advice only
refer for DXA
start treatment
15
Q
What does FRAX assessment give results as?
A
10yr risk of osteoporotic fracture and 10yr risk of hip fracture (%)
16
Q
What do the colours of a FRAX scan mean? (NOGG guidance)
A
red - start treatment
amber - DXA scan
green - lifestyle advice
17
Q
lifestyle advice
A
smoking alcohol vitamin D calcium exercise
18
Q
treatment options for osteoporosis
A
bisphosphonates denosumab HRT raloxifene (SERM) teriparatide strontium romosozumab (not used yet)
19
Q
oral bisphosphonates
A
alendronic acid
risedronate
ibandronic acid
20
Q
parenteral bisphosphonates
A
zoledronic acid
ibandronic acid
21
Q
How is denosumab given?
A
subcutaneous injection
22
Q
1st line for osteoporosis
A
oral bisphosphonates
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%
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
25
cautions and contraindications with oral BP
- eGFR <35 (alendronic acid)
- eGFR <30 (risedronate)
- hypocalcaemia
- dysphagia/swallowing difficulties
- GI bleed (or recent)
26
When are oral BPs reviewed?
after 5 years
27
Which oral BP has less GI side effects?
risedronate
28
When is alendronic acid not appropriate?
renal impairment
hypocalcaemia
GI risk factors
29
1st line option for oral BPs
alendronic acid
30
2nd line treatment for oral BPs
risedronate
31
What happens if risedronate is not appropriate?
refer to secondary care or specialist (usually injections)
32
difference between alendronic acid and ibandronate
ibandronate is taken once monthly
| wait for 1hr before eating
33
What is given if can't tolerate oral bisphosphonate?
Zoledronic acid
| -> IV infusion
34
When is zoledronic acid cost effective?
elegible for risk assessment and 10yr fracture probability over 10% (or 1% if can't tolerate oral BPs)
35
Where is zoledronic acid given?
secondary care
36
dose of zoledronic acid
5mg annual IV over 15mins
37
side effects of zoledronic acid
```
flu-like symptoms (for a few days, paracetamol)
hypocalcaemia
rare
- atypical #
- osteonecrosis of the jaw
```
38
checks before giving IV infusion of zoledronic acid
```
renal function
Ca
Vit D ( for Ca absorption, before each infusion, >50 nanomoles/L)
```
39
regular checks with zoledronic acid
regular dental check ups
40
What reminder card is given with zoledronic acid?
osteonecrosis of the jaw reminder card
41
How is denosumab given?
subcutaneous injection
42
What is denosumab?
mAb
| RANKL inhibitor
43
Where is denosumab initiated?
in hospital
44
dose of denosumab
60mg SC injection 6 monthly
45
What needs to be checked before every denosumab injection?
```
bloods
- renal risk
- Ca
- vit D
hypocalcaemia
```
46
How is denosumab excreted?
not renally excreted
| - so can use in renal impairment but higher risk of hypocalcaemia if kidneys not working, can lead to death
47
What can denosumab increase the risk of?
UTI
chest infection
rash/cellulitis
48
interactions with denosumab
none
49
rare side effects of denosumab
atypical #
| osteonecrosis of jaw
50
What to look out for/resport with denosumab?
hip/thigh/groin pain
51
What type of drug in raloxifene?
SERM
52
Who can take raloxifene
post-meopoause women
53
risks with raloxifene
VTE
hot flushes
leg cramps
flu-like symptoms
54
When is HRT usueful for osteoporosis?
early menopause (<45yrs)
55
When is strontium ranelate Aristo used?
severe osteporosis
| when other meds not tolerated/not suitable
56
Monitoring for strontium
skin reactions
- Steven Johnston syndrome
- DRESS
57
When should CV risk be reviewed with strontium?
every 6-12 months (QRISK)
58
contraindications for strontium
```
existing CV disease (inc risk of blood clots)
IHD
PAD
CVD
VTE
uncontrolled hpt
temp/permanent immobilisation
```
59
When should strontium be withheld?
before surgery
| immobilisation, blood clots
60
Can stromtium be used in CV risk factors? (diabetes, smoking)
yes, with caution
61
What is teriparatide?
recombinant fragment of PTH
| anabolic agent
62
How is teriparatide given?
daily SC injection
63
teriparatide course
2 year course
| daily SC injection
64
What fractures does teriparatide reduce?
vertabral #
65
side effects of teriparatide
```
limb pain
nausea
headache
dizziness
depression
HYPERcalcaemia
```
66
difference between antiresorptives and teriparatide in s/e
teriparatide can cause hypERcalcaemia
| -> antiresorptives - hypocalcaemia
67
Where is teriparatide stored?
in the fridge
68
What is romosozumab?
humanised mAb that inhibits sclerostin
| stimulates osteoblasts AND reduces osceoclast activity
69
romosozumab course
```
12 months (injections twice a month)
NOT USED YET
```
70
potential s/e of romosozumab
cardiac adverse effects
| not used yet
71
What osteoporosis drug do you not need to take Ca/Vit D with?
teriparatide
72
When is Ca/Vit D recommended?
dietary Ca intake is poor
| housebound/institutionalised
73
dose of Ca for patients with osteoporosis
700mg Ca
74
levels of Vit D that are in deficit
< 25 nmol/L
75
normal vitamin D plasma levels
> 50 nmoles/L
| 25-50 nmol/L may be enough for some people
76
2 forms of vitamin D that are given (which is preferred)
ergocalciferol (D2, plant derived)
colecalciferol (D3, lanolin derived, sheep's woll)
- D3 preferred
77
When is rapid correction of Vit D deficiency given?
- 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
dose of rapid correction of Vit D
- 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
What needs to be checked after starting vit D treatment and why?
check adjusted serum Ca 1 month after loading/maintenance dose in case primary hyperparathyroidism has been masked
80
oral steroids and osteoporosis
- # 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
When is bone loss the highest with oral steroids?
rapid in first 3 months of steroid treatment
82
When is there a high risk for glucocorticoid induced osteoporosis?
70+ yrs
female
high dose prednisolone and other risk factors
<1.5 BMD
83
Why would bisphosphonates be avoided in women of childbearing potential?
they have long retention time in bone
| -> should avoid them, abnormality risk
84
renal impairment and risedronate
risedronate can be used up to GFR 30ml/min
85
denosumab and renal impairment
denosumab not renally cleared so can use in renal impairment
| BUT CAUTION because it increases the risk of hypocalcaemia
86
How often to bisphosphonates need to be reviewed?
after 5+ years of use
| -> 3yrs for zoledronic acid (because its longer acting than oral BPs
87
What is discussed/decided at a review for bisphosphonates?
- decide to continue or drug holiday
| - weigh up risks and benefits
88
What is a drug holiday for bisphosphonates?
stop BPs for usually 1-2yrs
89
What should happen after 10yrs of BP treatment?
drug holiday if there hasn't been one already
90
rare side effects with bone medications (why drug holidays are used)
atypical fractures
| osteonecrosis - BRONJ, MRONJ
91
atypical fracture
```
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
BRONJ and MRONJ
BRONJ - bisphosphonate related osteonecrosis of the jaw
MRONJ - medication related ostronecrosis of the jaw
93
What is osteonecrosis?
death of bone
94
What other meds can cause ostronecrosis?
denosumab
95
What is osteonecrosis usually associated with?
invasive dental procedures
96
treatment for ostronecrosis of the jaw
radical surgical management to remove large segments of necrotic bone
97
preventative measures for ONJ
dentally fit before starting BPs
| maintain good oral hygiene
98
How long are BPs used for usually?
up to 5 years
| can be up to 10yrs and no drug holiday if Hx of hip #
99
long term risks of BPs
ONJ
| atypical #
100
What happens when after stopping BPs?
gradual reduction in BMD
increase in BTM (bone turnover markers)
risk remains reduced for a period of time after
101
What does denosumab reduce?
at hip and spine
102
Why is denosumab not suitable for drug holidays?
it's not retained in the bone
103
What happend after stopping denosumab?
increased bone resorption
rapid decline in BMD
-> risk of vertebral #
104
What can missing one dose/delaying treatment for a few months with denosumab cause?
increased # risk
105
What should be started after stopping denosumab?
alternative treaement eg. bisphosphonates
106
What can bone turnover markers be used for?
- monitor bone protection therapies (adherance)
| - help with drug holidays
