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PHA332 > Osteoporosis In Practice > Flashcards

Osteoporosis In Practice Flashcards

1
Q

What are the most common osteoporotic fractures?

A

-hip
-wrist
-spine

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2
Q

If a patient is to experience a fracture how would we intervene ?

A

-we want to prevent further fractures
-if the patient is already on treatment check the patients adherence and administration to this medication.
-give lifestyle advice e.g. wear sensible footwear etc
- fall assessments including a medication review
-prevention of a VTE with a low molecular weight heparin
-give appropriate pain management e.g. analgesics
-physiotherapy

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3
Q

What are the risk factors for osteoporosis?

A

-excess alcohol intake
-smoking
-immobility
-drugs such as steroids, PPIs, anti epileptics, SSRIs
-secondary causes: IBD, eating disorders, COPD, rheumatoid arthritis, early menopause, low BMI
-falls

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4
Q

What is primary prevention in osteoporosis?

A

This refers to patients who have never had a fracture before but are at an increased risk of fracture for example, patients on long term steroids.

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5
Q

What is secondary prevention?

A

This refers to patients who have already had a fracture and need to reduce the risk of any further fractures

Offer a DXA scan via the fracture liaison services.

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6
Q

How does nice guidelines carry out fracture risk?

A

ALL OLDER PATIENTS:
->65 females
->75 male
Other patients with specific risk factors.

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7
Q

What risk assessment tools are available for assessing the risk of osteoporosis?

A

Frax and Qfracture

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8
Q

Once a risk assessment has been carried out what is there to do?

A

-lifestyle advice only (limit smoking and alcohol, vitamin D and calcium, exercise)

-refer for a DXA scan or specialist review
Or
-start treatment ( for very high risk patients can refer them to a specialist)

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9
Q

When can you use the FRAT tool and what result does it give?

A

The FRAT tool is an online tool that can be used to assess fracture risk on patient between the ages of 40-90 years.
-gives the 10 year risk of osteoporotic fracture and the 10 year risk of a hip fracture.

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10
Q

What drugs are available for the treatment of osteoporosis?

A
  1. BISPHOSPHONATES
    -oral (alendronic acid,risedronate,ibandronic acid)
    -parenteral (zoledronic acid and ibandronic acid)

2.DENOSUMAB (subcutaneous injection)

3.HRT

4.RALOXIFIENE (serm and it is for specialist use only)

5.TERIPARATIDE ( daily injections but expensive)

6.STRONTIUM (this is discontinued due to increased cv risk

7.ROMOSOZUMAB

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11
Q

Why is patient information regarding treatment important?

A

-patients should be involved in treatment decision called the shared decision making process.

Explain to the patient:
-why they have been prescribed the following medication
-how it works
-benefits
-how to correctly take the medication
-side effects and how to manage them
-length of treatment
-check adherence to the medication

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12
Q

What is first line treatment for osteoporosis and what are some considerations that need to be evaluated before prescribing?

A

BISPHOSPHONATES -prescribe to patient if they have a risk of at least 1%.

-patient should avoid other medication for at least 30 minutes.
-avoid calcium supplements for at least 4hrs.

-eGFR of below 35 =alendronic acid
-eGFR of below 30= risedronate

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13
Q

Who should we take care with when prescribing oral BPs ?

A

-eGFRs
-hyopcalcaemia ( low calcium)
-recent GI bleed (risedronate may cause fewer GI side effects)

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14
Q

When should we review a patient on oral BPs?

A

Every 5 years

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15
Q

How to advice a patient how to take oral BPs?

A
  • this medication will help reduce your chances of breaking a bone by up to 50%.
    -you should only take it once a week
    -take 30 minutes before breakfast with a full glass of water then remain upright for 30 minutes after.
    -if you take calcium supplements wait up to 4hrs after taking the bisphosphonate.
    -the most common side effects include heartburn, indigestion etc
    -maintain good dental hygiene
    -report any thigh/hip or groin pain

SAME FOR IBANDRONATE EXCEPT IT IS TAKEN MONTHLY AND IT IS 1HR BEFORE BREAKFAST.

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16
Q

When is it appropriate to giver a patient zoledronic acid?

A

Eligible for risk assessment and 10 year fracture risk is over 10% or over 15 if cannot tolerate oral BPs.

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17
Q

What dose of zoledronic acid is given?

A

5mg annual IV infusion over 15 minutes

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18
Q

What side effects do you experience with zoledronic acid?

A

-flu like symptoms
-hypocalemia
-rare osteonecrosis of the jaw

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19
Q

What is important to check when placing a patient on zoledronic acid ?

A
  1. Renal function
  2. Calcium

3.vitamin D before each infusion

HAVE REGULAR DENTAL CHECK UPS

20
Q

WHEN DO WE REVIEW A PATIENT ON ZOLEDRONIC ACID?

A

Every 3 years

21
Q

What dose of denosumab is given?

A

Given firstly by the hospital and then is given via the GP.

60mg SC injection 6 monthly

22
Q

What needs to be checked before each injection of Denosumab?

A

-bloods
-renal (not renally excreted however take caution in renal impairment as can increase the risk of hypcalcaemia)
-calcium
-vitamin D
-hypocalemia risk

23
Q

What does denosumab increase the risk of?

A

-Increased risk of UTIs
-increased risk of chest infections
-rashes

24
Q

What is a rare side effect of denosumab?

A

Osteonecrosis of the jaw
-a patient should maintain a good dental hygiene and should report any groin, thigh or hip pain.

25
Q

What is raloxifene?

A

SERM (SELECTIVE OESTROGEN RECPETOR MODULATOR)
It is used in post menopausal women

26
Q

What risk is posed with taking raloxifene?

A

Increased risk of VTE
-leg cramps
-Hot flushes
-flu like symptoms

IF THIS IS TO OCCUR THE PATIENT SHOULD BE STOPPED ON THIS MEDICATION AND SECONDARY CARE TEAM SHOULD BE CONTACTED.

27
Q

When is HRT used in osteoporosis and why is not necessarily the best option?

A

It is used mainly for early menopausal women, however it does not offer bone protection but it is benefitical for the bones.

28
Q

What medication is used if the patient has severe osteoporosis?

A

STRONTIUM
This is used when the patient is not tolerant to other medication or if it is not working effectively enough.

PATIENTS WILL REQUIRE A PATIENT ALERT CARD WITH THIS MEDICATION

29
Q

When a patient is on strontium what monitoring do we obtain?

A

-We would monitor the patients skin to observe any skin reactions
-review cardiovascular risk every 6-12 months

30
Q

When is strontium contraindicated (who should not take strontium)?

A

-uncontrolled hypertension
-VTE
-CVD
-diabetes
-smoking
-angina
-stroke
-TIA
-immobilised patients

31
Q

What side effects are associated with strontium?

A

-increased risk of heart disease
-blood clots
-allergic reactions

32
Q

What is teriparatide?

A

This is a synthetic version of PTH (parathyroid hormone)
- activates osteoblasts and thus causes bone formation

33
Q

What side effects can you obtain from teriparatide?

A

-limb pain
-nausea
-headache
-dizziness
-depression
-increased risk of hypercalcaemia

34
Q

What dose is given for teriparatide?

A

It is a expensive, daily SC injection and it is a 2 YEAR course.

BLOOD MONITORING REQUIRED

35
Q

Where is terperatide stored?

A

-stored in the fridge

36
Q

WHAT IS ROMOSOZUMAB AND HOW DOES IT WORK?

A

This is a monoclonal antibody that works by inhibiting sclerostin ( this is a osteocyte derived glycoprotein).

-it stimulates osteoblasts and reduces osteoclast function.

37
Q

What is a high risk problem with using ROMOSOZUMAB?

A

It runs a significant potential risk of cardiac adverse events

38
Q

How is ROMOSOZUMAB prescribed and dosed?

A

Prescribed for 12 months and injections are given twice a month then followed by another treatment.

39
Q

Other than the following medications mentioned, what other therapies should we give alongside?

A

Calcium and vitamin D

Recommended if a patients diet is low in calcium intake.

40
Q

Why would we tend to not give calcium or vitamin D to patients who are currently taking teriparatide?

A

It displays evidence of having increased MI risk

41
Q

What is a drug holiday? (For BPs)

A

Stop bisphosphonates usually for 1-2 years and then the patient is able to go back onto them.

42
Q

What is one rule when starting a patient on BISPHOSPHONATES?

A

The patient must obtain good dental hygiene and should be maintained

43
Q

What is a long term side effect to BISPHOSPHONATES?

A

Osteonecrosis of the jaw
Increased risk of atypical fractures

TO PREVENT THIS THE PATIENT SHOULD TAKE A BREAK FROM THIS MEDICATION AFTER BEING REVIEWED.

44
Q

Why is denosumab not suitable for drug holidays and what would happen if the drug is stopped?

A

This is because it is not retained in the bone like bisphonates do

IF A PATIENT WAS TO STOP DENOSUMAB THERE WOULD BE AN INCREASED BONE REABSORPTION (WITHIN 3 MONTHS) AND DECREASED BONE DENSITY.

Increased risk of vertebral fractures

45
Q

If a patient is to stop on denosumab what would need doing?

A

Consider maybe an alternative treatment such as bisphosphonates, as they stay in the bone for 10 years even after stopping the medication.

46
Q

What markers are available for bone reabsorption and what do they do?

A

Test blood for markers such as CTX and NTX will show up in the blood if there is evidence of bone reabsorption.
CTX would disappear in the presence of a bisphosphonate and again would gradually increase if the bisphosphonate was to continue.

47
Q

What markers are available for bone formation?

A

-p1NP
-osteocalcin
-bone specific ALP

PHA332 (25 decks)

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