Problem 13 Flashcards
What is the definition of osteoporosis
a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
What are the most typical osteoporotic fractures
hip and vertebral
Anti-resorptive drug
so reduced remodelling
denosumab (RANK-L inhibitor) and bisphosphonates (Alendronate, risedronate, and zoledronic acid)
and SERM
Anabolic drugs
teriparatide stimulates modelling-based bone formation and remodeling with over-filling of remodeling units
In cortical bone, the effects vary according to site; increased total bone area, increased cortical porosity, and the formation of hypomineralised new bone can occur in the early stages of treatment, which results in little change, or a decrease in BMD at sites such as the hip and radius. However, increased bone strength has been reported with longer-term treatment in the hip, and cortical thickness mapping has shown localised increases at sites that are subjected to mechanical loading
Sclerostin
an osteocyte-derived inhibitor of bone formation. The anabolic effects of sclerostin inhibition are mediated through an early and transient increase in bone formation combined with a sustained decrease in
bone resorption.
Risk assessment
BMD strongly correlates with risk of fracture
age, sex, previous fractures
FRAX
important to identify patients that we want to treat
Prise en charge de l’osteoporose
-lifestyle measures: good nutrition, regular physical activity, avoiding harmful lifestyle habits
Comprehensive fall prevention programmes, including
exercise programmes for muscle strengthening, balance training, and correction of visual impairment, can reduce fall frequency but have not been shown to reduce fracture risk
-meds: for high risk patients
EI des biphosphonates
Common: upper gastrointestinal adverse reactions with oral dosing, acute phase reaction with intravenous dosing
uncommon: bone, joint and muscle pain
rare: eye inflammation, femoral shaft or subtrochanteric
fractures with atypical radiographic features, osteonecrosis of the jaw
EI denosumab
Uncommon: skin rash
rare: cellulitis, femoral shaft or subtrochanteric fractures with atypical radiographic features, osteonecrosis of the jaw
EI oestrogene
Breast pain, headache, oedema
EI selective oestrogen receptor modulator
Common; vasomotor symptoms, muscle cramps uncommon: venous thrombosis
EI PTH receptor agonist
Common: muscle cramps, increased serum or urine calcium or serum uric acid
uncommon: orthostatic hypotension
Example of SERM
raloxifene
What is sarcopenia
loss of muscle mass and function
associated with increased adverse outcomes including
falls, functional decline, frailty, and mortality
Symptoms of sarcopenia
falling, weakness, slowness, self-reported muscle wasting, or difficulties carrying out daily life activities
What score to use for sarcopenia
The SARC-F has a low sensitivity but high specificity. This screening instrument has five questions addressing strength, assistance in walking, rising from a chair, climbing stairs, and falls.
How to diagnose sarcopenia
- measuring muscle mass (DXA)
- measuring muscle strength (grip strength)
- measuring physical performance (timed up and go)
The 3 main differential diagnosis for sarcopenia
malnutrition (usually normal muscle strength but mass diminue)
cachexia (severe weight loss and muscle wasting associated with cancer, HIV and AIDS, or end-stage organ failure)
frailty
Pathophysiology of sarcopenia
Ageing appears to result in an imbalance between muscle protein anabolic and catabolic pathways, leading to overall loss of skeletal muscle. Cellular changes in sarcopenic muscle include a reduction in the size and number of myofibers, which particularly affects type II fibers. This is partly due to transition of muscle fibers from type II to type I with age, together with intramuscular and intermuscular fat infiltration (myosteatosis), and a decreased number of type II fiber satellite cells. Molecular changes in sarcopenic muscle involve alterations to the complex signalling pathway that includes insulin-like growth factor 1 and others. Deregulation in skeletal muscle gene expression, probably mediated through epigenetic changes and modulated via microRNAs.
ttt of sarcopenia
- non pharmacological: physical activity, vitamin D and nutrients, eating proteins
- pharmacological: vitamin D, ostrogen-progesteron, DHEA, GH, GHRH, IGF-1, testosterone…
Which meds if taken by patients are considered high risk and so have to take osteoporosis meds
corticoids
anti-aromatase
androgen suppression therapy
Meds for osteoporosis
-antiresorptives, namely, selective oestrogen receptor modulators (SERMs: raloxifene, basedoxifene), bisphosphonates (alendronate, risedronate, ibandronate, zoledronate)
and monocloncal antibodies (denosumab)
-bone forming agents (teriparatide)
-and, very recently approved in Switzerland, a new monoclonal antibody, romosozumab, with dual antiresorptive and anabolic effects.
Which med is in first line for high risk patients
anti-resorptive
Which med is in first line for very high risk patients
anabolic drugs
Risk stratification of patients
taking into consideration: -previous fractures -BMD -age and other risk factors FRAX \+ evaluation of risk of falls (parkinson, urinary incontinence, previous fall)
When are patients considered in imminent risk
recent osteoporotic fracture if they are >65 years
How to treat patients with imminent risk or very high risk with vertebral fracture
teriparatide followed by an anti-resorptive
we can give romosozumab (if no cardiac risks)
How to treat patients with imminent risk or very high risk with hip fracture
zoledronate if renal function is okay
if not, denosumab
we can give romosozumab (if no cardiac risk)
How to treat patients with high risk
anti-resorptive
not denosumab for corticoid induced osteoporosis
How to treat patients with moderate risk
SERM if they don’t take any hormonal replacement
biphosphonate
How to treat patients with low risk
lifestyle changes
vitamin D
calcium if necessary
What is Rhabdomyolysis
Rhabdomyolysis due to muscle ischemia can develop in persons who are unable to get up after a fall and are
“found down” after a long period
Risk factors for falls
- deficits in gait and balance
- medications
- alcohol
- visual deficits
- impairments in cognition and mood
- environmental hazards
- cardiovascular disease (syncope)
2 of the most at risk patients if they fall
osteoporitc
and patients on anti-coagulants (risk of bleeding)
When is a timed up and go test considered pathological
> 12 seconds
How to manage patients with a risk of falling
- exercise
- physiotherapy
- vision exams
- testing cognition
- reviewing their meds
- testing for orthostatic hypotension
- vitamin D
- ergotherapy
