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MSK > Metabolic Bone Disease > Flashcards

Metabolic Bone Disease Flashcards

1
Q

What will insufficient vitamin D + calcium cause

A
  • Insufficient mineralisation (vit D stimulates Ca + phosphate absorption from gut)
  • Rickets in children
  • Osteomalacia in adults, when epiphyseal lines are closed
  • Muscle function also impaired in low vit D states
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2
Q

Appearance of Ricket’s

A
  • Large forehead
  • Odd curve to spine
  • Odd-shaped ribs + sternum
  • Large abdomen
  • Wide elbow, wrist and ankle joints
  • Odd-shaped leg
  • Stunted growth
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3
Q

Describe Paget’s disease

A

-Localised disorder of bone turnover
-Increased bone resorption followed by increased bone formation
-Leads to disorganised bone:
Bigger
Less compact
More vascular
More susceptible to deformity fracture

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4
Q

Cause of Paget’s disease

A
  • Strong genetic component

- Possibility of chronic viral infection within osteoclast

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5
Q

Symptoms of Paget’s disease

A
  • > 40 years
  • Bone pain
  • Bone deformity (occasionally)
  • Excessive heat over pagetic bone
  • Nerve deafness
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6
Q

Typical presentation of paget’s disease

A
  • Isolated elevation of serum alkaline phosphatase (commonest presentation)
  • Bone pain + heat
  • Hearing loss
  • Bone deformity or fracture
  • Osteosarcoma of affected bone (RARE)
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7
Q

Treatment of Paget’s disease

A

IV bisphosphonate therapy (one off IV zoledronic acid)

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8
Q

When and when not treat Paget’s diseases

A
  • Don’t treat asymptomatic paget’s disease unless involving skull or area requiring surgical intervention
  • Symptomatic paget’s disease requires treatment
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9
Q

What is Osteogenesis Imperfecta

A
  • Genetic disorder of connective tissue
  • Characterised by fragile bones
  • Fractures from mild trauma or acts of daily life
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10
Q

Clinical range of OI

A

Prenatally fatal to 40 year olds presenting with “early osteoporosis”

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11
Q

4 types of OI

A
  • Type 1 = Milder form, presents when child starts walking (can be present in adults)
  • Type 4 = Similar to type 1 but more severe
  • Type 11 = Lethal by age 1
  • Type 111 = Progressive deforming with severe bone dysplasia + poor growth
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12
Q

8 OI symptoms

A
  • Growth deficiency
  • Defective tooth formation (dentigenesis imperfecta)
  • Hearing loss
  • Scoliosis
  • Barrel chest
  • Ligamentous laxity
  • Easy bruising
  • Blue sclera
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13
Q

Management of OI

A
  • Surgical (treat #s)
  • Medical (prevent #s with bisphosphonates)
  • Social adaptions
  • Genetic (genetic counselling for parents + next generation)
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14
Q

Define osteoporosis

A

-Micro architectural deterioration of bone resulting in increased risk of fracture
or
-Thin bones with increased risk of low trauma fracture

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15
Q

What is fracture risk related to

A
  • Age
  • BMD
  • Falls
  • Bone turnover
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16
Q

T score of > -1, -1 - -2.5 and > -2.5 suggest what management

A
  • -1 = Reassure + Lifestyle advice
  • -1 to -2.5 = Lifestyle advice (treat if previous fracture)
  • > -2.5 = Lifestyle advice + offer treatment
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17
Q

2 fracture risk assessment tools

A
  • FRAX

- QFracture

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18
Q

When should a patient be referred for a DEXA scan

A

FRAX or QFracture score = >10% fracture risk at any site over next 10 years

19
Q

Treatment threshold for osteoporosis

A

~20% 10 year fracture risk

20
Q

What BMD T-score suggests osteopenia

A

-1 to -2.5

21
Q

3 risk factors for fracture

A
  • FHx (main)
  • Glucocorticoids
  • Prior fracture
22
Q

Limitations of FRAX

A
  • Does not account for all known risk factors (e.g. falls)
  • Lacks detail on some risk factors (dose response to glucocorticoids)
  • Model relevant only for untreated patients
23
Q

Describe the use of QFracture

A
  • Applicable for men + women aged 30-85

- Contains multiple variable (CVS risks, falls, TCA)

24
Q

Limitations of QFracture

A
  • Does not have the ability to add BMD

- Some variable and risks can not be altered by osteoporotic medications

25
Q

Causes of secondary osteoporosis

A
  • Amenorrhea
  • Drugs
  • Endocrine
  • Malabsorption
  • Malignancy
  • Rheumatic
26
Q

Amenorrhea causes of osteoporosis

A
  • Anorexia nervosa
  • Early menopause
  • Primary ovarian failure
27
Q

Drug causes of osteoporosis

A
  • Steroids
  • Heparin + warfarin
  • Anticonvulsants
  • PPIs
28
Q

Endocrine causes of osteoporosis

A
  • Hyperthyroid
  • Hyperthyroid + Hypothyroid
  • GH deficiency
  • Cushing’s
  • Hyperprolactinaemia
29
Q

Malignant causes of osteoporosis

A

Myeloma

30
Q

Malabsorption causes of osteoporosis

A
  • Coeliac

- CF

31
Q

Rheumatic causes of osteoporosis

A
  • RA
  • Ankylosing spondylitis
  • PMR
32
Q

How to prevent osteoporotic fractures

A
  • Minimise risk factors
  • Good Ca + Vit D status
  • Fall prevention strategies
  • Medications
33
Q

Treatment of osteoporosis

A
  • Bisphosphonates (oral) (first line)
  • Parathyroid Hormone Analog (teriparatide)
  • Monoclonal antibody against RANK ligand (Denosumab)
  • HRT
  • Selective oEstrogen Receptor Modulator (SERM)
34
Q

Side effect of HRT

A
  • Increased risk of blood clots
  • Increased risk of breast cancer with extended use in late 50s/early 60s
  • Increase risk of heart disease + stroke if used after large gap from menopause
35
Q

Side effects of SERMs

A
  • Hot flushes if taken close to menopause
  • Increased clotting risk
  • Lack of protection at hip site
36
Q

Problems with bisphosphonates

A

-Adequate renal function required
-Adequate Ca + Vit D required
-Good dental health + hygiene advised
Notify dentist about bisphosphonates + encourage regular check-ups and good fitting dentures

37
Q

How do nitrogen containing bisphosphonates work

A

They inhibit osteoclasts

38
Q

Side effects of bisphosphonates

A
  • Oesophagitis
  • Iritis/Uveitis
  • ONJ? + Atypical femoral shaft fractures?
39
Q

What is done to minimise the problems of patients taking bisphosphonates

A
  • Drug holiday for 1-2 years

- Usually after 10 years of oral bisphosphonates

40
Q

Side effect of teriparatide

A
  • Injection site irritation
  • Rarely hypercalcaemia
  • Allergy
  • COST
41
Q

Side effects of denosumab

A
  • Allergy/rash
  • Symptomatic hypocalcaemia if give when Vit D deplete
  • ?Atypical femoral shaft fractures
42
Q

How does denosumab work

A
  • Binds to RANK ligand

- Which inhibits osteoclast formation, function and survival

43
Q

Why use denosumab and how is it taken

A
  • Subcutaneous injection every 6 months

- Safer in patients with significant renal impairment than bisphosphonates

MSK (28 decks)

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