Osteoporosis

Question 1

Define osteoporosis

Answer 1

A condition in which the bones become brittle and fragile from reduced bone density and loss of micro-architecture

SIDE NOTE
Etymology
Osteo (G) = Bone
Poros (G) = Passage, pore

Question 2

How does osteoporosis present?

Answer 2

Often asymptomatic

Bone fractures (this is when most patients first present)

Question 3

What are the different Bone Mineral Density (BMD) categories provided by the WHO?

Answer 3

Normal - T score ≥ -1

Low bone mass (osteopenia) - T score < -1 but > -2.5

Osteoporosis - T score ≤ -2.5

Severe osteoporosis - T score ≤ -2.5 PLUS fracture

Question 4

What are the risk factors for osteoporosis?

Answer 4

A LOT

Female

Pre-existing conditions e.g., Rheumatoid, malabsorption syndrome (e.g., in CF)

Menopause

Malnutrition/poor dietary intake

Low BMI (<19kg/m2)/ anorexia nervosa

FHx

Corticosteroid therapy (esp. long term)

Cushing’s syndrome

Osteogenesis imperfecta

Primary hyperparathyroidism

Prolonged immobilisation/sedentary lifestyle

CKD

Post transplantation

GI diseases e.g., IBD, coeliac

T1DM

Question 5

What investigations would you do for osteoporosis?

Answer 5

Bloods - FBCs, Us&Es, LFTs, TFTs, bone profile (Ca2+, phosphate, aspartate transaminase), inflammatory markers, testosterone + gonadotrophins in men, serum immunoglobulins and paraproteins, urinary Bence-Jones proteins (this is for multiple myeloma - CRAB)

Imaging - DEXA scan

Question 6

What tools can be used to help determine risk of fracture?

Answer 6

QFracture (for people aged 30-84 years)

FRAX (for people aged 40-90 years)

Question 7

Which risk factors does FRAX underestimate?

Answer 7

Regular use of corticosteroids ≤ 5 mg prednisolone daily.

Use of corticosteroids ≥ 7.5 mg prednisolone daily for more than 3 months.

Hx of multiple fragility fractures.

High alcohol intake.

Heavy smoking

Question 8

What score is considered high risk?

Answer 8

QFracture > 10%

FRAX in red zone

Question 9

What score is considered intermediate risk?

Answer 9

QFracture close to but below 10%

FRAX in orange zone

Question 10

What score is considered low risk?

Answer 10

QFracture < 10%

FRAX in green zone

Question 11

What is the management of osteoporosis

Answer 11

Low risk of fracture = lifestyle advise e.g., exercise, stopping smoking, balanced diet etc + follow up in 5 years

Intermediate risk = arrange DEXA scan, offer Tx if T-score is -2.5 or lower

High risk = DEXA scan, offer Tx if T-score is -2.5 or lower
If T-score > -2.5 modify risk factors + repeat DEXA at appropriate intervals dependent on the individual’s risk profile and clinical judgement

Question 12

What are the pharmacological Tx of osteoporosis?

Answer 12

Calcium + Vit D supplements

Bisphosphonates - alendronic acid, zoledronic acid, risedronate (for men)

RANK-L inhibitors - denosumab (used in postmenopausal osteoporosis in women and in men at increased risk of fractures)

Parathyroid hormone (PTH) analogues - Teriparatide (used in postmenopausal osteoporosis in women and in men at increased risk of fractures)

Question 13

Sources

Answer 13

https://patient.info/doctor/osteoporosis-pro

https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/management/management/

https://westessexccg.nhs.uk/your-health/medicines-optimisation-and-pharmacy/clinical-guidelines-and-prescribing-formularies/06-endocrine-system/88-osteoporosis-guidance/file