W5 Clinical Assessment and Management of Osteoporosis (PD) Flashcards
Osteoporosis
definition?
features?
Skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture (Föger-Samwald et al. 2020)
- Low bone mass
- Abnormal bone architecture
- Structural deterioration in bone
- Reduced bone strength
- Increased bone fragility
- Increased fracture susceptibility
- Asymptomatic - not picked up until a fracture occurs
Osteoporosis Pathophysiology:
Imbalance in the process of bone remodelling by osteoclasts and osteoblasts
Osteoblasts form bone
Osteoclasts resorb/breakdown bone
Osteoporosis WHO definition:
Bone mineral density (BMD) 2.5 standard deviations below mean peak bone mass as measured by dual-energy X-ray absorptiometry (DEXA/DXA) applied to the femoral neck and reported as a T-score
i.e. T-score ≤ -2.5
Prevalence of Osteoporosis (for info)
- Increased risk in women – reduced oestrogen post menopause
- 2% prevalence at 50 years of age to circa. 50% at 80 years
- > 2 million women diagnosed in England and Wales
- Around 180k fractures annually due to osteoporosis
- 1 in 3 women and 1 in 5 men will get a fracture in life as a result of osteoporosis
- Higher risk of fractures in white men and women
Fractures
What is an osteoporosis fracture?
What is a fragility fracture?
Where do fractures usually occur?
Osteoporotic fracture – A fragility fracture that occurs as a result of osteoporosis
Fragility fracture – Fracture following a fall from standing height or less, or as a result of
routine activities
Characteristically, fractures occur in the wrist, spine, and hip, but they can also occur in the arm, pelvis, ribs, and other bones
Fracture Risk Factors
-Risk of fracture is dependent upon falls risk, bone strength (measured by BMD), plus other risk factors
-Factors that affect bone strength are split into those that reduce BMD and those that don’t reduce BMD
Fracture risk factors that
Reduce BMD:
Do not reduce BMD:
Falls risks:
- Endocrine disease – DM, hyperthyroid,
hyperparathyroidism - GI conditions – Crohn’s, UC, Coeliac, Chronic Pancreatitis
- Chronic diseases –CKD, Liver disease, COPD
- Menopause
- Immobility
- BMI under 18.5
Do not reduce BMD:
* Age
* Oral Corticosteroids
* Smoking
* Alcohol consumption
* Prev fragility fracture
* Rheumatoid Athritis
* Parental Hx of hip fracture
Falls risks:
* Impaired vision
* Neuromuscular weakness
* Cognitive impairment
* Alcohol and sedatives
* Polypharmacy
* Hypotension
* Frailty
Assessment of Fracture Risk – Who?
High risk groups?
Aim of Osteoporosis management is to assess fracture risk and prevent fragility fractures
Consider assessment of fracture risk in high-risk groups :
- Women over 65; Men over 75
- Woman aged 50-64/Men aged 50-74 with risk factors or secondary cause of osteoporosis
- Under 50s with: Current/frequent oral steroid use, untreated premature menopause, previous fragility fracture
- Under 40s with: Current/recent high dose oral steroid use (>7.5mg prednisolone daily for 3 months+), previous hx
spine, hip, forearm, proximal humerus fracture or multiple fractures - Consider in patients prescribed: SSRIs, carbamazepine, aromatase inhibitors, gonadotrophin-releasing hormone
agonists, PPIs, pioglitazone
National Osteoporosis Guideline Group UK
NICE guidelines 146
Assessment of Fracture Risk – How?
50+?
others?
assess for ? deficiency?
- Exclude non-osteoporotic causes for fragility fracture (e.g. metastatic bone disease) and secondary causes of osteoporosis
- For over 50 + Hx fragility fracture OR under 40 with major risk factor offer DEXA scan WITHOUT calculating
fracture risk - For others calculate 10-year fragility fracture risk – QFracture or FRAX – before arranging DEXA based on
identified risk - Assess for vitamin D deficiency and calcium intake
-Aged over 65 or not exposed to sunlight
-Calcium intake of at least 1000mg/day recommended for people at increased fracture risk
Identify any falls risk factors (e.g. age >65yrs with Hx of fall, cognitive impairment etc)
What is QFracture and FRAX?
- Web based calculators/risk tools – QFracture preferred by NICE
- Use to calculate risk of developing osteoporotic fracture through questionnaire
Amber zone: measure BMD through DEXA
Red zone: start treatment
Dark red zone: treat and consider referral to specialist
See tables on lecture slide
Management of Fracture Risk
High risk (Red) – Offer DEXA
* If T score is -2.5 or lower start bone sparing drug treatment
* If T-score > -2.5 modify risk factors, treat underlying conditions, repeat DEXA within 2 years
Intermediate risk (Amber)
* If risk is close to threshold with underestimated fracture risk factors, refer for DEXA then reassess
fracture risk
* Offer drug treatment if T score is -2.5 or lower
Low risk (Green) – Lifestyle advice, follow up within 5 years
Assessment of Fracture Risk
Secondary care specialist referral- who is eligible/considered? (7)
Very high-risk patients
Patients <40 yrs of age
Consideration of parenteral treatment
Vertebral fracture within the last 2 years
2 or more vertebral fractures
T-score < -3.5
Treated with high dose glucocorticoids
Clinical Management
Non-pharmacological/Lifestyle advice
- Healthy balanced diet
- Adequate calcium intake – minimum 700mg daily (diet or supplementation)
- Vitamin D – 800iu daily – From diet/supplement or prescribed if evidence of deficiency
- Regular weight-bearing and muscle strengthening exercise
- Smoking cessation
- Restrict alcohol to less than 2 units per day
- Maintain healthy normal weight – BMI 20-25
Pharmacological Management:
What are the main treatments?
Calcium & Vitamin D (Colecalciferol)
Bisphosphonates, alendronate, risedronate
Denosumab
Teriparatide
Romosozumab
Strontium Renelate
Raloxifene
Calcium and vitamin D exercise – using the BNF
Daily intake of at least 1g calcium and 400 units of vitamin D
Miss B. Summers (age 67) needs to be started on a calcium and vitamin D preparation
Use the BNF to identify a product that you could prescribe
Calcichew D3 chewable tablets
Adcal D3 chewable tablets
Accrete D3 film-coated tablets
Calcium and vitamin D
C/I?
Cautions?
Contraindications
* Conditions causing hypercalcaemia
and/or hypercalciuria
* Hyperparathyroidism
* Renal Stone Disease
* Hypervitaminosis D
* Stage 4 & 5 CKD
* Soya & Peanut allergy
Cautions
* Stage 2-3B CKD
* Mild Hypercalciuria
* CrCl below 30ml/min – adjust doses
* Hx renal stone disease
Bisphosphonates:
function?
examples?
Alter osteoclast activation and function
Absorbed onto hydroxyapatite crystals on bone slowing down their
growth and dissolution rate thus reducing the rate of bone turnover
Inhibit bone resorption, increase BMD
Alendronic Acid, Risedronate Sodium, Ibandronic Acid (All Oral)
Zoledronic Acid (Parenteral)
Bisphosphonates- Counselling and advice?
Take on an empty stomach before food
Swallow tablet whole with a glass of water
Stay upright for 30 minutes after taking
Take whilst standing or sitting upright
Do not take at bedtime or before getting up in the morning (take when youve started your day)
Once weekly- on same day each week
Not to be sucked or chewed- alendronic acid available as effervescent tablet
Report thigh, hip, groin pain and any ear pain or discharge
Maintain good oral hygiene, regular dental check-ups
BNF: Directions for administration, Patient and carer advice
Bisphosphonates- Adverse effects?
Atypical femoral fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory ear canal
Bisphosphonates- Drug interactions
Calcium and antacids – Reduced absorption of bisphosphonates- leave a 30 min gap between taking
Food and drink
* Coffee & orange juice reduce bioavailability by around 60%
* Leave 30 minutes before eating or drinking after taking bisphosphonate
NSAIDs – Use with caution due to GI irritation
* In practice you may see a lot of patients taking an NSAID & Bisphosphonate together (usually with a PPI too)
Denosumab (Prolia®)
Monoclonal antibody targeting RANKL
Inhibits osteoclast formation, function and survival
Reduced bone resorption
Administered subcutaneously to thigh abdomen or upper arm
60mg dose every 6 months
Calcium & vitamin D given alongside
Prescribed under shared care protocol
- Serum calcium and vitamin D levels checked
before starting and before each administration - Deficiencies to be corrected before treatment given
ADR- Osteonecrosis of the jaw was identified through the Yellow Card Scheme
Denomusab counselling:
- Report new or unusual thigh, hip or groin pain during treatment
- Maintain good oral hygiene
- Routine dental check ups
- Report oral/dental pain or swelling symptoms
- Report symptoms of muscle spasms, twitches, cramps, numbness/tingling of fingers, toes or around mouth – HYPOCALCAEMIA
Loads of drugs left on slides but it was skipped in the recording??
- Ask if we need to learn these or if its extra info
