Osteoporosis symposium

Question 1

What is a radiographic fracture?

Answer 1

Silent fracture that is only found on X-ray

Question 2

What are the reasons for broken bones?

Answer 2

Bone strength is reduced
- suboptimal peak bone mass
- reduced bone quality
They fall

Question 3

How can bone quality be reduced?

Answer 3

Reduced bone mineral (calcium)
Deteriorating architecture
Change in crystal size and composition
Abnormal collagen

Question 4

How can fractures be prevented?

Answer 4

Optimise peak bone mass in children, adolescents and young adults
Prevent deterioration of bone quality in adults
Prevent falls in adults
Identify elderly at high risk

Question 5

How can we identify fracture risk in the elderly?

Answer 5

History and examination
Increasing age
Previous fracture
Light weight (BMI 18)
Family history of osteoporosis 
Smoking
Alcohol
Many medical disorders

Question 6

What disorders can increase fracture risk?

Answer 6

Cushing's syndrome
Chronic inflammatory conditions 
Prostate cancer
Endocrine disorders:
- thyrotoxicosis
- hyperparathyroidism
- pituitary disease

Question 7

What types of nutritional deficiency can increase fracture risk?

Answer 7

Malabsorption conditions
Eating disorders
Alcoholism

Question 8

Why can prostate cancer increase fracture risk?

Answer 8

Prostate cancer is often treated with long-acting GnRH analogues which lower testosterone leading to loss of bone density

Question 9

What technology can be used to predict risk?

Answer 9

DEXA scan
Peripheral measurements to predict fracture
Heel ultrasound scanning device
WHO FRAX Risk calculator

Question 10

What are the objectives for drug treatment?

Answer 10

Prevent bone breakdown - inhibit osteoclasts
Stimulate bone build up
- stimulate osteoblasts
- modify osteocyte activity

Question 11

What do bisphosphonates do?

Answer 11

Inhibit osteoclast activity by inhibiting important enzyme

Question 12

What bisphosphonates can be given to prevent hip and spine fractures?

Answer 12

Alendronate

Risedronate

Question 13

What bisphosphonates will only prevent spine fractures?

Answer 13

Ibandronate

Question 14

How should bisphosphonates be taken?

Answer 14

In the morning with full glass of water and standing up
No food for 30min as this inhibits absorption
Can cause contact stomatitis or oesophageal ulcer if taken incorrectly

Question 15

What are the rare side effects of bisphosphonates?

Answer 15

Jaw osteonecrosis

Atypical femoral shaft fracture

Question 16

What is denosumab?

Answer 16

Fully human monoclonal antibody - IgG2 isotope
Binds to RANK ligand
- decoy receptor
- high affinity
- high specificity 
- no complement activation

Question 17

How is denosumab cleared?

Answer 17

By the reticuloendoethlial system

No renal excretion

Question 18

What is the anabolic treatment of osteoporosis?

Answer 18

S/C PTH 1-34 (teriparaide)
Abaloparatide - PTH / PtHRP analogue
Rososumab - antisclerostin antibody, increases Wnt signalling in bone

Question 19

What is raloxifene?

Answer 19

Selective oestrogen receptor modulator

Question 20

How can hypogonadism in men be treated?

Answer 20

Tostran

Nebido

Question 21

What dietary components are needed to maximise bone health?

Answer 21

Dairy products
- cow's milk
- soya milk
Magnesium & calcium
Protein intake
Vitamin D
PUFA
Gluten intolerance
Phytate
Oxalate

Question 22

Why is protein intake important for bone health?

Answer 22

Excess protein leads to a reduction of calcium

Improve bone healing in diets with high protein intake

Question 23

Describe the absorption of vitamin D

Answer 23

1st hydroxylation occurs in liver
- vit D –> 25-hydroxyvitamin D (calcidiol)
2nd hydroxylation occurs in kidney
- 25-hydroxyvitamin D –> 1,25-dihydroxyvitamin D

Question 24

Why is PUFA important in maximising bone health?

Answer 24

Ratio of N6-N3 is important
N6 is pro-inflammatory & can impact bone health
N3 can increase PGE3 concentration and metabolic acidosis

Question 25

What are the objectives when managing osteoporosis?

Answer 25

Maximise bone mass Reduce bone loss Encourage new bone growth

Question 26

How is osteoporosis managed?

Answer 26

``` Supplement with vitamin D Calcium Vitamin K Sodium Phyto-oestrogens Strontium EFA's ALA (omega 3) & LA (omega 6) ```

Question 27

What effect does sodium intake have on bone health?

Answer 27

High sodium intake leads to increased calcium loss in urine

Question 28

What effect does vitamin K have on bone health?

Answer 28

Effect on osteocalcin which is the protein involved in bone mineralisation. Enhances ability to bind calcium

Question 29

What effect does omega 3 have on bone reabsorption?

Answer 29

Reduces reabsorption

Question 30

What effect does omega 6 have on bone reabsorption?

Answer 30

Increases reabsorption

Question 31

What is the overall dietary advice for managing osteoporosis?

Answer 31

``` Avoid fizzy drinks Reduce intake of grains and protein Increase intake of fruits and vegetables Increase intake of N3 EFA found in fish and veg Calcium ```

Question 32

What is the objectives of physiotherapy in managing fractures?

Answer 32

Decrease pain Increase confidence Increase function Decrease risk of further fracture

Question 33

What are the impacts of fractures?

Answer 33

``` Pain Social - isolation Family Depression Body image Sleep deprivation General health - bowel, urine, swallowing, breathing ```

Question 34

What does physiotherapy provide?

Answer 34

``` Assurance Relaxation Education Empower patient, increase confidence Pain relief Hydrotherapy Walking aids Exercise classes Spinal supports Referrals ```

Question 35

What are the goals when prescribing exercise?

Answer 35

Decrease pain Decrease falls Increase bone loading

Question 36

What are some examples of weight bearing exercise?

Answer 36

``` Jogging Aerobics Racquet sports Tennis Dancing Stair climbing 30 min, 5X week ```

Question 37

What are some examples of strength training exercise?

Answer 37

``` Weights Therabands Resistance exercises Back reconditioning classes Pilates ```

Question 38

How can exercise prevent falls?

Answer 38

Posture Flexibility Co-ordination Balance