16 - Orthogeriatrics

Question 1

When do Ps have Sx of osteoporosis?

Answer 1

At first fracture

Question 2

How is osteoporosis defined in terms of SDs?

Answer 2

Is defined as less than 2.5 SD away from the mean

Question 3

DEXA scans produce T and Z scores - what do these mean?

Answer 3

T score = mean bone density compared to general population

Z score = mean bone density compared to their age

Question 4

What are the commonest fragility fractures?

Answer 4

NOF
Vertebral
Pubic rami
Colleys
NOH (humerus)
Ribs

Question 5

What is a fragility fracture defined as?

Answer 5

Question 6

What is the most common reason for emergency surgery in elderly Ps?

Is also the commonest cause of death following a fall.

Answer 6

Hip fracture

Question 7

What percentage of Ps will die within 12 months of a hip fracture?

Answer 7

26%

Question 8

When is peak bone mass reached?

Answer 8

30s

Question 9

In which bone is remodelling most active?

Answer 9

Trabecular bone

Question 10

Overproduction of which cell membrane protein is linked to osteoporosis?

Answer 10

RANKL

Question 11

How does oestrogen deficiency affect bones?

Answer 11

Deficiency = inc bone resorption and therefore bone loss.

Question 12

How can Vit D deficiency affect bones?

Answer 12

Can cause secondary hyperparathyroidism => inc bone turnover and reduced Ca absorption

Question 13

How do steroids affect bones?

Answer 13

Inc PTH secretion
Reduced oestrogen
Impairs Vit D absorption
-> acute suppression of osteoblasts & stimulation of osteoclasts

Question 14

What are the RF for osteoporosis?

Answer 14

Question 15

Which diseases inc the risk of osteoporosis?

Answer 15

Diseases that affect absorption
Diseases that inc steroids (either endogenously or exogenously)

Question 16

Which drugs increase the risk of osteoporosis?

Answer 16

Steroids
PPI
Anti-epileptics
Depot Provera
Hormone Deprivation Therapy
SSRIs
Heparin
Anti-retrovirals

Question 17

Which tool is used to assess for fragility fracture risk?

Answer 17

FRAX Tool

Question 18

What diseases other than osteoporosis can cause fragility fractures?

Answer 18

Metastatic bone disease
Multiple myeloma
Osteomalacia
Paget’s disease

Question 19

What is the daily calcium intake of calcium?

Answer 19

700-1200mg, preferably through diet

Question 20

In postmenopausal women, how much Vitamin D should they take if supplementation is needed?

Answer 20

1000 IU - 2000 IU

Question 21

What lifestyle measures should Ps at risk of osteoporosis take?

Answer 21

Smoking cessation
Reduce alcohol
Do regular weight bearing and muscle strengthening exercises

Question 22

What exercises should Ps at risk of osteoporosis not undertake?

Answer 22

Forward flexion
Side bending
Heavy lifting

Want to avoid compressing the spine = can lead to fractures

Question 23

Which Rx is first line for treatment of osteoporosis?

Answer 23

Alendronic acid (70mg OW)

Question 24

When is Alendronic acid not recommended?

Answer 24

If eGFR is less than 35ml/min

Question 25

What are the SEs of Alendoronic acid?

Answer 25

Upper GI Sx Bowel disturbance Headaches MSK pain

Question 26

How should alendrotnic acid be taken?

Answer 26

After overnight fast - 30 mins before any food/water. Take sitting up, dont lie down for 30 mins after taking. Swallow whole with glass of water.

Question 27

How is Zolendronic acid given?

Answer 27

IV once a year - 5mg

Question 28

What are the side effects of Zolendronic acid?

Answer 28

Poss acute phase reaction Can poss inc AF Dont use if creatinine clearance <35ml/min

Question 29

What drug is a RANK-L inhibitor that is used for osteoporosis?

Answer 29

Denosumab

Question 30

Can Denosumab be used with renal failure?

Answer 30

Yes

Question 31

What are the SEs of Denosumab?

Answer 31

Abdominal discomfort Cataracts Constipation Hypocalcaemia Inc risk of infection Pain Sciatica Skin reactions

Question 32

Which drug is a PTH analogue that is used for osteoporosis?

Answer 32

Teriparatide

Question 33

When is Teriparatide used?

Answer 33

When Ps cannot tolerate or have failed with bisphosphonates + have severe osteoporosis