Osteoporosis In Practice Flashcards
What are the most common osteoporotic fractures?
-hip
-wrist
-spine
If a patient is to experience a fracture how would we intervene ?
-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
What are the risk factors for osteoporosis?
-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
What is primary prevention in osteoporosis?
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.
What is secondary prevention?
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.
How does nice guidelines carry out fracture risk?
ALL OLDER PATIENTS:
->65 females
->75 male
Other patients with specific risk factors.
What risk assessment tools are available for assessing the risk of osteoporosis?
Frax and Qfracture
Once a risk assessment has been carried out what is there to do?
-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)
When can you use the FRAT tool and what result does it give?
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.
What drugs are available for the treatment of osteoporosis?
- 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
Why is patient information regarding treatment important?
-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
What is first line treatment for osteoporosis and what are some considerations that need to be evaluated before prescribing?
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
Who should we take care with when prescribing oral BPs ?
-eGFRs
-hyopcalcaemia ( low calcium)
-recent GI bleed (risedronate may cause fewer GI side effects)
When should we review a patient on oral BPs?
Every 5 years
How to advice a patient how to take oral BPs?
- 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.
When is it appropriate to giver a patient zoledronic acid?
Eligible for risk assessment and 10 year fracture risk is over 10% or over 15 if cannot tolerate oral BPs.
What dose of zoledronic acid is given?
5mg annual IV infusion over 15 minutes
What side effects do you experience with zoledronic acid?
-flu like symptoms
-hypocalemia
-rare osteonecrosis of the jaw
What is important to check when placing a patient on zoledronic acid ?
- Renal function
- Calcium
3.vitamin D before each infusion
HAVE REGULAR DENTAL CHECK UPS
WHEN DO WE REVIEW A PATIENT ON ZOLEDRONIC ACID?
Every 3 years
What dose of denosumab is given?
Given firstly by the hospital and then is given via the GP.
60mg SC injection 6 monthly
What needs to be checked before each injection of Denosumab?
-bloods
-renal (not renally excreted however take caution in renal impairment as can increase the risk of hypcalcaemia)
-calcium
-vitamin D
-hypocalemia risk
What does denosumab increase the risk of?
-Increased risk of UTIs
-increased risk of chest infections
-rashes
What is a rare side effect of denosumab?
Osteonecrosis of the jaw
-a patient should maintain a good dental hygiene and should report any groin, thigh or hip pain.
What is raloxifene?
SERM (SELECTIVE OESTROGEN RECPETOR MODULATOR)
It is used in post menopausal women
What risk is posed with taking raloxifene?
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.
When is HRT used in osteoporosis and why is not necessarily the best option?
It is used mainly for early menopausal women, however it does not offer bone protection but it is benefitical for the bones.
What medication is used if the patient has severe osteoporosis?
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
When a patient is on strontium what monitoring do we obtain?
-We would monitor the patients skin to observe any skin reactions
-review cardiovascular risk every 6-12 months
When is strontium contraindicated (who should not take strontium)?
-uncontrolled hypertension
-VTE
-CVD
-diabetes
-smoking
-angina
-stroke
-TIA
-immobilised patients
What side effects are associated with strontium?
-increased risk of heart disease
-blood clots
-allergic reactions
What is teriparatide?
This is a synthetic version of PTH (parathyroid hormone)
- activates osteoblasts and thus causes bone formation
What side effects can you obtain from teriparatide?
-limb pain
-nausea
-headache
-dizziness
-depression
-increased risk of hypercalcaemia
What dose is given for teriparatide?
It is a expensive, daily SC injection and it is a 2 YEAR course.
BLOOD MONITORING REQUIRED
Where is terperatide stored?
-stored in the fridge
WHAT IS ROMOSOZUMAB AND HOW DOES IT WORK?
This is a monoclonal antibody that works by inhibiting sclerostin ( this is a osteocyte derived glycoprotein).
-it stimulates osteoblasts and reduces osteoclast function.
What is a high risk problem with using ROMOSOZUMAB?
It runs a significant potential risk of cardiac adverse events
How is ROMOSOZUMAB prescribed and dosed?
Prescribed for 12 months and injections are given twice a month then followed by another treatment.
Other than the following medications mentioned, what other therapies should we give alongside?
Calcium and vitamin D
Recommended if a patients diet is low in calcium intake.
Why would we tend to not give calcium or vitamin D to patients who are currently taking teriparatide?
It displays evidence of having increased MI risk
What is a drug holiday? (For BPs)
Stop bisphosphonates usually for 1-2 years and then the patient is able to go back onto them.
What is one rule when starting a patient on BISPHOSPHONATES?
The patient must obtain good dental hygiene and should be maintained
What is a long term side effect to BISPHOSPHONATES?
Osteonecrosis of the jaw
Increased risk of atypical fractures
TO PREVENT THIS THE PATIENT SHOULD TAKE A BREAK FROM THIS MEDICATION AFTER BEING REVIEWED.
Why is denosumab not suitable for drug holidays and what would happen if the drug is stopped?
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
If a patient is to stop on denosumab what would need doing?
Consider maybe an alternative treatment such as bisphosphonates, as they stay in the bone for 10 years even after stopping the medication.
What markers are available for bone reabsorption and what do they do?
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.
What markers are available for bone formation?
-p1NP
-osteocalcin
-bone specific ALP
