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Flashcards in Disorders of bone health including osteoporosis Deck (68):
1

What is osteoporosis?

Progressive skeletal disease characterised by low bone mass and microarchitectual deterioration of bone structure

2

Which sex gets osteoporosis more commonly?

Women

3

How does osteoporosis present?

Asymptomatic until fractures

4

Over which age is osteoporosis frequent?

50

5

What are the common osteoporotic fracture sites?

Neck of femur
Vertebral body
Distal radius
Humeral neck

6

What is the domino effect in relation to osteoporosis?

An increasing number of vertebral fractures due to osteoporosis causing progressive curvature of the spine

7

Where does bone remodelling occur?

Bone remodelling units

8

Describe bone remodelling

Osteoclasts begin to reabsorb bone at specific sites >
Osteoclasts replaced by osteoblasts which lay down osteoid >
Osteoid undergoes mineralisation to bone >
Resorptive cavity completely filled with new bone

9

How is bone remodelling altered in osteoporosis?

Reabsorption of bone occurs more than formation

10

How is osteoporotic bone architecture different from normal bone?

Large spaces and breaks
Weakened

11

Which factors are important in bone density?

Body weight
Genetics
Sex hormones
Diet
Exercise

12

Which factors contribute to bone density loss?

Lowered sex hormones (menopause)
Low body weight
Poor genetics
Calcium deficient diet
Immobility
Disease affecting bones
Drugs (e.g steroids)

13

How does bone density change with age?

Bone density increases until around 30
After 40 it begins to decline slowly
During and after menopause bone density loss is rapid and oestrogen deficiency can further perpetuate this

14

What are the non-modifiable risk factors for fragility fractures?

Age
Gender
Ethnicity
Previous fracture
Family history
Early menopause (

15

What are the modifiable risk factors for fragility fractures?

Bone mineral density
Alcohol
Low weight
Inactivity
Diet
Smoking
Pharmacological (steroids)

16

Which diseases increase the risk factor for an osteoporotic fragility fracture?

Rheumatoid arthritis
Hyperthyroidism
Chronic liver disease
Hypogonadism
Diabetes
Dementia

17

Who should be risk assessed?

Patients over 50 with risk factors
Patients under 50 with serious risk factors (steroids, early menopause)

18

Who should be referred for a dexa bone scan?

High risk patients

19

How is bone mineral density measured?

DEXA bone scan

20

Is bone mineral density a dependent or independent risk factor for fragility fractures?

Independent

21

What is osteopenia?

Low bone density above 1 standard deviation below expected

22

What is osteoporosis?

Low bone density over 2 and a half standard deviations below expected

23

What is severe osteoporosis?

Low bone density over 2 and a half standard deviations below expected + fragility fracture

24

How can osteoporosis be classified in patients younger than 20?

Using the z score

25

As bone mineral density increases what happens to the risk of fracture?

Decreases

26

How should suspected osteoporosis be investigated?

U&E
LFT
Bone biochemistry
FBC
PV
TSH
Protein electrophoresis/bence jones proteins (myeloma)
Coeliac antibodies
Testosterone levels
Vitamin D
Parathyroid hormone

27

List some secondary causes of osteoporosis

Hyperthyroidism
Hyperparathyroidism
Cushing's disease
Coeliac
IBD
Chronic liver disease
Chronic pancreatitis
Cystic fibrosis
COPD
Chronic kidney disease

28

What lifestyle changes can be helpful in the management of osteoporosis (not diet)?

Risk assessment for falls and prevention
High intensity strength training
Low intensity weight bearing
Smoking cessation
Avoidance of alcohol excess

29

What diet changes can be helpful in the management of osteoporosis?

2-3 portions of milk/dairy per day (700g)
3-4 portions of milk/dairy per day (1000g) post menopausal
Non dairy sources (bread, fortified cereal, fish w/ bones, green veg, beans)

30

When are calcium and/or vitamin D supplements indicated?

Considered as risk reduction of non-vertebral fracture in patients at risk of deficiency due to diet or limited sunlight (housebound, cultural garb)

31

When should calcium not be taken?

Within two hours of oral biphosphonates

32

When would vitamin D alone be indicated?

When oral calcium intake is adequate

33

How do biphosphonates work?

Anti-resorptive agents - analogues of pyrophosphate that get absorbed onto bone and eaten by osteoclasts causing cell death and less reabsorption

34

Give two examples of biphosphonates

Alendronate
Risedronate

35

What do biphosphonates reduce the risk of?

Spine and hip fractures

36

When are biphosphonates indicated?

T score less than -2.5
Existing fragility fracture

37

How long should biphosphonates be given for?

5 yr +
10 yr + if vertebral fracture

38

What are the risks of long term biphosphonate use?

Osteonecrosis of the jaw
Oesophageal carcinoma
Atypical fractures

39

How is zoledronic acid given?

Once yearly IV infusion (5mg in 100ml NaCl) for 5 years

40

What is a common side effect of zoledronic acid and how can this be treated?

Influenza like symptoms (acute phase reaction)
Paracetamol

41

How does denosumab work?

Human monoclonal antibody targeting RANKL - inhibiting activation, development of osteoclasts and decreased reabsorption so increased density

42

How is denosumab administered?

Subcutaneous injections 6 monthly

43

Which osteoporosis drug can be administered in severe renal failure?

Denosumab

44

What are the side effects of denosumab?

Hypocalcaemia
Eczema
Cellulitis

45

What is strontium ranelate?

Antireabsorptive agent

46

When is strontium ranelate contraindicated?

Thromboembolic disease
Ischaemic heart disease
Peripheral artery disease
Uncontrolled hypertension

47

When is strontium ranelate indicated?

When there is no other option

48

What is teriparatide?

Recombinant parathyroid hormone

49

How does teriparatide work?

Stimulates bone growth

50

When is teriparatide indicated?

Over 65 with T score -3.5 plus 2 fragility fractures
55-64 with T score

51

When should patients be treated for osteoporosis?

Anti-resorptive therapy T score 7.5 for 3 months or more OR prevalent fracture and T score

52

What are the direct and indirect effects of corticosteroids on bone?

Direct - reduced osteoblast activity, suppression of osteoblast growth and reduction in calcium absorption
Indirect - reduced gonadal and adrenal hormones

53

Are the fracture risks of glucocorticoids dose dependent?

Yes but no safe dose

54

What is Paget's disease?

Abnormal osteoclast activity followed by increased osteoblast activity resulting in weakened bone and increased fracture risk

55

What is the term for paget's at a single site? What about at multiple sites?

Monostotic
Polystotic

56

What is the aetiology of Paget's?

Unknown

57

Which bones does Paget's affect?

Long bones
Pelvis
Lumbar spine
Skull

58

Which age group is affected by Paget's?

Over 55

59

How does Paget's disease present?

Bone pain
Deformity
Deafness
Compression neuropathies

60

What is a rare complication of Paget's?

Osteosarcoma

61

How can Paget's be investigated?

X-ray
Isotope bone scan
Isolated raise on alkaline phosphate
Normal LFTs

62

How is Paget's treated?

Analgesia +/- biphosphonates if not responding

63

What is osteogenesis imperfecta?

Group of autosomal dominant genetic conditions arising from mutations in type 1 collagen

64

How many types of osteogenesis imperfecta are there?

8 types
Neonatal lethal - type 2
Very severe - type 3 and 4
Mild - type 1

65

What is osteogenesis imperfecta associated with?

Blue sclera
Dentinogenesis imperfecta

66

How do severe forms present?

Childhood fractures

67

How is osteogenesis imperfecta treated?

Fixation
Surgery for deformity
Biphosphonates

68

What is osteogenesis imperfecta an important differential of?

Non-accidental injury

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