osteoporosis in practice Flashcards
medical term for fracture
#
most common osteoporotic fractures
hip
wrist
spine
What is the most serious consequence of falls in older people?
hip fracture
interventions after a hip fracture
- secondary prevention
- check adherance and administratin if already taking meds
- falls assessment - inc med review
- prevention of VTE with LMWH
- pain management
What type of fractures are vertebral/spine fractures?
compression fractures
interventions for spine #
- secondary # prevention
- liefstyle advice
- pain control and analgesia
- physiotherapy
- surgical management
risk factors for osteoporosis
fragility # excess alcohol smoking immobility drugs parent hip fracture secondary causes falls
drugs that increase risk of #
corticosteroids PPIs anti-epileptics SSRIs aromatase inhibitors
secondary causes of OP
amenorrhoea eating disorders IBD RA COPD early menopause/hypogonadism low BMI
What is primary prevention?
identifying people who have never had a # but at are at increased risk of #
initiating treatment to prevent #
What is secondary prevention?
people who have already had a # and reducing the risk of a further #
Who should have a fracture risk assessment?
- all older patients (female >65, male >75)
- patients with specified risk factor
2 risk assessment tools for # risk
FRAX
QFracture
3 options after # risk assessment
lifestyle advice only
refer for DXA
start treatment
What does FRAX assessment give results as?
10yr risk of osteoporotic fracture and 10yr risk of hip fracture (%)
What do the colours of a FRAX scan mean? (NOGG guidance)
red - start treatment
amber - DXA scan
green - lifestyle advice
lifestyle advice
smoking alcohol vitamin D calcium exercise
treatment options for osteoporosis
bisphosphonates denosumab HRT raloxifene (SERM) teriparatide strontium romosozumab (not used yet)
oral bisphosphonates
alendronic acid
risedronate
ibandronic acid
parenteral bisphosphonates
zoledronic acid
ibandronic acid
How is denosumab given?
subcutaneous injection
1st line for osteoporosis
oral bisphosphonates
When are oral BPs cost effective?
if patient eligible for risk assessment and had a 10yr probability of fracture of at least 1%
How to take oral BPs?
- 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
cautions and contraindications with oral BP
- eGFR <35 (alendronic acid)
- eGFR <30 (risedronate)
- hypocalcaemia
- dysphagia/swallowing difficulties
- GI bleed (or recent)
When are oral BPs reviewed?
after 5 years
Which oral BP has less GI side effects?
risedronate
When is alendronic acid not appropriate?
renal impairment
hypocalcaemia
GI risk factors
1st line option for oral BPs
alendronic acid
2nd line treatment for oral BPs
risedronate
What happens if risedronate is not appropriate?
refer to secondary care or specialist (usually injections)
difference between alendronic acid and ibandronate
ibandronate is taken once monthly
wait for 1hr before eating
What is given if can’t tolerate oral bisphosphonate?
Zoledronic acid
-> IV infusion
When is zoledronic acid cost effective?
elegible for risk assessment and 10yr fracture probability over 10% (or 1% if can’t tolerate oral BPs)
Where is zoledronic acid given?
secondary care
dose of zoledronic acid
5mg annual IV over 15mins
side effects of zoledronic acid
flu-like symptoms (for a few days, paracetamol) hypocalcaemia rare - atypical # - osteonecrosis of the jaw
checks before giving IV infusion of zoledronic acid
renal function Ca Vit D ( for Ca absorption, before each infusion, >50 nanomoles/L)
regular checks with zoledronic acid
regular dental check ups
What reminder card is given with zoledronic acid?
osteonecrosis of the jaw reminder card
How is denosumab given?
subcutaneous injection
What is denosumab?
mAb
RANKL inhibitor
Where is denosumab initiated?
in hospital
dose of denosumab
60mg SC injection 6 monthly
What needs to be checked before every denosumab injection?
bloods - renal risk - Ca - vit D hypocalcaemia
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
What can denosumab increase the risk of?
UTI
chest infection
rash/cellulitis
interactions with denosumab
none
rare side effects of denosumab
atypical #
osteonecrosis of jaw
What to look out for/resport with denosumab?
hip/thigh/groin pain
What type of drug in raloxifene?
SERM
Who can take raloxifene
post-meopoause women
risks with raloxifene
VTE
hot flushes
leg cramps
flu-like symptoms
When is HRT usueful for osteoporosis?
early menopause (<45yrs)
When is strontium ranelate Aristo used?
severe osteporosis
when other meds not tolerated/not suitable
Monitoring for strontium
skin reactions
- Steven Johnston syndrome
- DRESS
When should CV risk be reviewed with strontium?
every 6-12 months (QRISK)
contraindications for strontium
existing CV disease (inc risk of blood clots) IHD PAD CVD VTE uncontrolled hpt temp/permanent immobilisation
When should strontium be withheld?
before surgery
immobilisation, blood clots
Can stromtium be used in CV risk factors? (diabetes, smoking)
yes, with caution
What is teriparatide?
recombinant fragment of PTH
anabolic agent
How is teriparatide given?
daily SC injection
teriparatide course
2 year course
daily SC injection
What fractures does teriparatide reduce?
vertabral #
side effects of teriparatide
limb pain nausea headache dizziness depression HYPERcalcaemia
difference between antiresorptives and teriparatide in s/e
teriparatide can cause hypERcalcaemia
-> antiresorptives - hypocalcaemia
Where is teriparatide stored?
in the fridge
What is romosozumab?
humanised mAb that inhibits sclerostin
stimulates osteoblasts AND reduces osceoclast activity
romosozumab course
12 months (injections twice a month) NOT USED YET
potential s/e of romosozumab
cardiac adverse effects
not used yet
What osteoporosis drug do you not need to take Ca/Vit D with?
teriparatide
When is Ca/Vit D recommended?
dietary Ca intake is poor
housebound/institutionalised
dose of Ca for patients with osteoporosis
700mg Ca
levels of Vit D that are in deficit
< 25 nmol/L
normal vitamin D plasma levels
> 50 nmoles/L
25-50 nmol/L may be enough for some people
2 forms of vitamin D that are given (which is preferred)
ergocalciferol (D2, plant derived)
colecalciferol (D3, lanolin derived, sheep’s woll)
- D3 preferred
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
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
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
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)
When is bone loss the highest with oral steroids?
rapid in first 3 months of steroid treatment
When is there a high risk for glucocorticoid induced osteoporosis?
70+ yrs
female
high dose prednisolone and other risk factors
<1.5 BMD
Why would bisphosphonates be avoided in women of childbearing potential?
they have long retention time in bone
-> should avoid them, abnormality risk
renal impairment and risedronate
risedronate can be used up to GFR 30ml/min
denosumab and renal impairment
denosumab not renally cleared so can use in renal impairment
BUT CAUTION because it increases the risk of hypocalcaemia
How often to bisphosphonates need to be reviewed?
after 5+ years of use
-> 3yrs for zoledronic acid (because its longer acting than oral BPs
What is discussed/decided at a review for bisphosphonates?
- decide to continue or drug holiday
- weigh up risks and benefits
What is a drug holiday for bisphosphonates?
stop BPs for usually 1-2yrs
What should happen after 10yrs of BP treatment?
drug holiday if there hasn’t been one already
rare side effects with bone medications (why drug holidays are used)
atypical fractures
osteonecrosis - BRONJ, MRONJ
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 #
BRONJ and MRONJ
BRONJ - bisphosphonate related osteonecrosis of the jaw
MRONJ - medication related ostronecrosis of the jaw
What is osteonecrosis?
death of bone
What other meds can cause ostronecrosis?
denosumab
What is osteonecrosis usually associated with?
invasive dental procedures
treatment for ostronecrosis of the jaw
radical surgical management to remove large segments of necrotic bone
preventative measures for ONJ
dentally fit before starting BPs
maintain good oral hygiene
How long are BPs used for usually?
up to 5 years
can be up to 10yrs and no drug holiday if Hx of hip #
long term risks of BPs
ONJ
atypical #
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
What does denosumab reduce?
at hip and spine
Why is denosumab not suitable for drug holidays?
it’s not retained in the bone
What happend after stopping denosumab?
increased bone resorption
rapid decline in BMD
-> risk of vertebral #
What can missing one dose/delaying treatment for a few months with denosumab cause?
increased # risk
What should be started after stopping denosumab?
alternative treaement eg. bisphosphonates
What can bone turnover markers be used for?
- monitor bone protection therapies (adherance)
- help with drug holidays
