osteoporosis in practice Flashcards
what is the literal definition of osteoporosis?
porous bones
what are the symptoms of osteoporosis?
Osteoporosis has no symptoms per se but it is important to patients because it
increases risk of fracture!
what does # mean?
fracture
how do we increase public health when it comes to osteoporosis and bone health?
- education of younger people
- effective fracture reduction to reduce morbidity, mortality and cost
when does fracture risk increase?
it increases with age
what are the most common areas of osteoporotic fracture?
hip, wrist and spine
who are hip fractures more serious in and why?
Hip fracture is the most serious consequence of falls among
older people
– Reduced function, loss of independence, loss of confidence, high
mortality rate (
what interventions are there to prevent further hip fractures?
• Prevent further fracture “secondary prevention” (see later) • If already on treatment check adherence and administration • Lifestyle advice • Falls assessment • Including medication review • Prevention of venous thromboembolism with LMWH • Appropriate pain management
what are vertebral fractures in practice?
• Spine: Compression fractures
– Acute and chronic back pain
– Height loss, kyphosis
what are interventions for vertebral fractures?
• Secondary fracture(#) prevention • Lifestyle advice • Pain control and analgesia review • Physiotherapy • Surgical management
what are the risk factors for osteoporosis?
• Fragility # • Excess alcohol • Smoking • Immobility • Drugs e.g. • Parental hip fracture • Secondary causes e.g. menopause/hypogonadism – low BMI • (Falls)
what are some drugs that increase the patients risk of osteoporosis?
– Corticosteroids – PPIs – Anti-epileptics – SSRIs – Aromatase inhibitors
what are some secondary causes of osteoporosis?
– amenorrhoea – eating disorders – inflammatory bowel disease – Rheumatoid Arthritis – COPD – early menopause/ hypogonadism – low BMI
how do we identify someone who may need treatment- primary prevention?
People who have never had a fracture but are at increased risk of fracture NICE G146 on fracture risk assessment outlines who should be assessed (updated 2017)
how do we identify people who need secondary treatment?
People who have already had a fracture and need to reduce the risk of further fracture Fracture liaison services have an important role here- pick up over 50s with fragility fracture and offer DXA scan
who do you target for fracture risk assessment?
– All older patients (>65 female >75 male)
– Other patients with specified risk factors
what are the fracture risk assessment tools availible?
FRAX® and QFracture®
what are the options availible following risk assessment?
– lifestyle advice only
– refer for DXA or
– start treatment
what is FRAX and who can it be used for?
• FRAX is an online tool that can be used to assess fracture risk (40-90 yrs) • Gives a result as: • 10 year risk of osteoporotic fracture and 10 yr risk of hip fracture (%)
what does FRAX link to?
Links to NOGG (National Osteoporosis Guideline Group) guidance which classifies patients as red (start treatment) amber (DXA scan) or green (lifestyle advice)
what are the pharmacological treatment options for osteoporosis?
bisphosphonates
denosumab
less common: HRT, raloxifene, teriparatide, strontium
why is patient information essential in osteoporosis?
Prophylactic treatment requires motivation
• Patients must be involved in treatment decision
what should you explain to a person who has osteoporosis?
– Why they have been prescribed their medication
– How it works
– Benefits
– How to take correctly
– Side effects & what to do if they occur
– Length of treatment
what is first line treatment for osteoporosis?
oral bps
- cost effective if patient is eligible for risk assessment and has a 10 year probabiliyy of fracture at least 1%
how to you avoid drug interactions due to absorption with oral bps?
– Avoid any other medicines for at least 30 mins
– Avoid calcium supplements for at least 2 hours (preferably 4hrs)
what are the main cautions and contraindications with oral bisphosphonates?
– eGFR <35ml/min/1.73m2 Alendronic acid
– eGFR <30ml/min/1.73m2 Risedronate (however note that some clinicians will use below this)
– Known hypocalcaemia
– Dysphagia/swallowing difficulties
– (Recent) GI bleed
– Note that Risedronate may cause fewer GI side-effect
when should you review oral BPS?
Review after 5 years (continue vs. stop vs. pause in treatment ‘drug
holiday’)
what advice would you give for oral bisphosphonates?
• This medication will help to reduce chance of breaking a bone (by up to 50%);
you only need to take it once a week.
• Take at least 30 minutes before breakfast, with a full glass of water, then
remain upright for 30 mins after (because…)
• If you take calcium supplements take at a completely different time or miss
the morning dose on that day.
• The most common side effect with this medication is heartburn/indigestion,
though not everybody gets this. If it happens to you and it is severe, stop
taking the medicine and go to see your GP. They may be able to switch you to
an alternative [i.e. some people may tolerate risedronate better from GI point
of view]
• Maintain good dental hygiene, report any thigh/hip/groin pain…
• Usually we would review your treatment after 5 years, to check that you still
need it and to reduce the risk of any longer term side effects.
what is the difference in counselling with oral bisphosphonates and ibandronate?
similar but once monthly, 1 hr rather than 30min
what is the dose of zolendronic acid?
– 5mg annual IV infusion over 15 minutes
what is the s/e of zolendronic acid?
– Flu-like symptoms common
– Hypocalcaemia
– Rarely atypical #, osteonecrosis of jaw (all antiresorptives)
when should you review zolendronic acid?
after 3 years- consider drug holiday
what do you check in zolendronic acid?
– RENAL function
– CALCIUM and
– VITAMIN D before each infusion (correct first)
• Regular dental check-ups + ONJ reminder card
when is the first dose of denosumab given? what is the dose?
First dose in hospital; after that via GP
• Dose: 60 mg SC injection 6 monthly
what do you check before each injection of denosumab?
• Check bloods before each injection (renal, calcium, vitamin D); hypocalcaemia
risk
• Correct calcium deficiency, vitamin D loading if D low.
how can denosumab cause hypocalcemia?
• Not renally excreted but caution in renal impairment due to increased risk of
hypocalcaemia (deaths and hospital admissions reported)
what does denosumab increase the risk of?
?Increased risk of UTI/chest infection, rash/cellulitis
what are the drug interactions with deosumab?
No drug interactions known
what do we have to be aware of with denosumab- what may fracture may occur?
Rare atypical fracture/osteonecrosis of jaw (good dental hygiene, report
hip/thigh/groin pain)
when is raloxifene used?
Rarely used oral Selective Oestrogen Receptor Modulator (post-meno
women), initiated by specialist
– Increased risk of VTE, commonly causes hot flushes, leg cramps, flu-
like symptoms
what benefit does HRT have ?
not recommended for sole purpose of bone protection but will be
beneficial for bones e.g. if used for menopausal symptoms
– Particularly useful in early menopause (<45yrs)
when are strontium ranelate aristo used?
For ‘severe’ osteoporosis where other medications
not suitable or not tolerated, initiated by a specialist
what do you have to monitor/ review with strontium ranelate aristo?
• Patient Alert Card
• Monitor for skin reactions (SJS, DRESS)- highest early
in treatment
• Review cardiovascular risk every 6-12m
• C/I in IHD, PAD, CVD, VTE, uncontrolled HTN,
temporary/permanent immobilisation
– Withhold post-surgery, for example
– Caution if cardiovascular risk factors e.g. diabetes, smoking
what is teripartide?
Recombinant fragment of PTH
initiated by a specalist if certain criteria met
what kind of agent is teriparatide?
Only anabolic agent currently on the UK market
what are the s/e of teriparatide?
Limb pain, nausea, headache dizziness (esp. at start of therapy), depression
what risks are associated with teriparatide?
Risk HYPER calcaemia (unlike antiresorptives)
what is romosozumab?
Humanised monoclonal antibody that inhibits
sclerostin, first-in-class
• Launched in UK Mar 20
• Stimulates osteoblasts AND reduces osteoclast
function
what are the potential s/e with romosozumab?
Significant potential cardiac adverse events
how long would romosuozumab be prescribed for?
• Would be prescribed for 12 months (injections
twice a month) then followed by other tx
when do you consider calcium and vitamin D for patients?
Consider for all patients on osteoporosis medication
(other than teriparatide)
Recommended particularly if dietary calcium intake
poor/ housebound or institutionalised
what are the leveks of vitamin D you should be aware of? what do they mean?
- <25nmol/L deficient
- 25-50nmol/L may be inadequate for some people
- > 50nmol/L sufficient for most of population
what types of vitamin D is there availible?
Ergocalciferol (D2, plant derived)
• Colecalciferol (D3, lanolin derived)* preferred
when is rapid correction of vit d needed?
– Symptomatic disease (osteomalacia)
– Due to commence parenteral antiresorptive tx
• Loading dose to provide 300,000 units vitamin D either as separate
weekly or daily doses over 6-10 weeks
• Followed by regular maintenance therapy (800 – 2000 units daily)
how often should you check adjusted serum calcium ? and why
1
month following loading/maintenance in case
primary hyperparathyroidism has been masked
how do glucocrticoid induce osteoporosis?
Steroids increase bone resorption (early, transient) decrease bone
formation (long-term)
when is bone loss greatest with glucorticoids?
Bone loss v. rapid in 1st 3months of steroid treatment
– some features of dose responsive effect, particularly at the spine
does increased fracture risk corelate to BMD?
no it is independent
how do steroids increase fracture risk?
risk higher on >7.5mg/day, all doses increase # risk
significantly at the spine
– Increased risk of vertebral and non-vertebral (including hip) #,
Spine # more common than hip #
– Could also be due in part to disease itself
– # risk declines after d/c and on continued therapy
– Interventions need to be started early!
what do you consider in younger patients?
• Treatment may be appropriate in some circumstances, referral to specialist clinic • Consider risk vs benefit • Optimal duration for bone protection unknown • Child-bearing potential – Long-retention time in bone, avoid
what do you have to consider with a person who has renal impairment?
• Risedronate can be used up to GFR 30ml/min
• Denosumab not renally cleared so can use in
renal impairment BUT caution as significantly
increased risk of hypocalcaemia
• Other factors can complicate the picture, such
as renal bone disease, consider referral to
specialist
when you review medication, what are the two options?
– can decide to continue or drug holiday at this point
– weigh up the risks and benefits
how long is the drug holiday for bisphosphonates?
Drug holiday = Stop bisphosphonate, usually for 1-2 years
what is an atypical fracture?
rare side effect- increases with duration
Usually thigh bone often atraumatic
• Can be bilateral
• Report thigh, hip and groin pain (X-ray
to rule out)
• Benefits of treatment generally
outweigh risks
what is BRONJ-MRONJ?
• Osteonecrosis – death of bone • Case reports (2003) – BRONJ • Associated with other medications – MRONJ e.g. Denosumab • Usually associated with invasive dental procedures
what is recommended with MRONJ?
• Radical surgical management to remove large segments
of necrotic bone.
what is a good preventative measure of MRONJ?
• Multidisciplinary approach – dentists, pharmacists, medical
practitioners and patients
Best Practice:
• Patients should be dentally fit prior to initiation with a
bisphosphonate and maintain good oral hygiene
how do you gradually stop bisphosphonate treatment?
• Gradual in BMD, in BTM
what does denosuma reduce?
fractures at hip and
spine- evidence from extension studies up to
10 yrs (3yr FREEDOM study + extension)
why can you not take a drug holiday from denosumab?
as not
retained in the bone
what happens on cessation of denosumab?
increased bone
resorption, rapid decline in BMD
within 3m of scheduled
dose omitted
what are some examples of bone resportion markers?
TX, NTX
what are markers of bone fomration?
P1NP, Osteocalcin,
Bone specific ALP
what needs to be considered with pareneteral treatment?
– KIDNEY function very important
– CALCIUM and VITAMIN D level need to be checked before
Zoledronic IV/Ibandronic IV/Denosumab SC
– MHRA: Risk of hypocalcaemia
– Higher risk of atypical fracture and ONJ .
