Osteoporosis

Question 1

What is osteoporosis?

Answer 1

Reduction in bone density

Question 2

How does osteoporosis appear on an x-ray?

Answer 2

Osteopenia (reduction in bone density)

Question 3

What investigation is used to diagnose osteoporosis?

Answer 3

DEXA scan

Question 4

How does the DEXA scan work?

Answer 4

The femoral neck is scanned and the T-score is calculated

Question 5

What is considered a normal T score?

Answer 5

More than -1

Question 6

What is considered osteopenia on a DEXA scan?

Answer 6

T score -1 to -2.5

Question 7

What is considered osteoporosis on a DEXA scan?

Answer 7

T score LESS than -2.5

Question 8

What is considered severe osteoporosis on a DEXA scan?

Answer 8

T score less than -2.5 + a fracture

Question 9

What are the risk factors for osteoporosis?

Answer 9

Age
Post-menopausal women
Reduced mobility
Low BMI
Low calcium or Vit D
Alcohol and smoking
CKD
Long term corticosteroids
Certain medications

Question 10

What medications increase the risk of of osteoporosis?

Answer 10

Long term corticosteroids
SSRIs
PPIs
Anti-epileptics
Anti oestrogens

Question 11

Why are post menopausal women at risk of osteoporosis?

Answer 11

Oestrogen is protective
It stimulates osetoblast activity so when its production ceases there will overall be more osteoclast activity

Question 12

What treatment can you offer to post menopausal women to help prevent osteoporosis?

Answer 12

Selective Oestrogen Receptor Modulator (SERM)
Raloxifene or Tamoxifen

Question 13

What is the alternate use of tamoxifen?

What is its down side?

Answer 13

Treats Breast cancer

But increases risk for endometrial cancer

Question 14

What investigations would you do for a patient who you think might have osteoporosis?

What scoring system would you use to determine likelihood of osteoporosis?

Answer 14

Vitamin D
Serum calcium
ALP
Thyroid function
Testosterone (men)

WHO FRAX score

Question 15

What is the use of the WHO FRAX score?

Answer 15

Measures 10year risk of a major osteoporotic hip fracture

Can be used to guide whether to start treatment for osteoporosis before a DEXA scan

Question 16

What patients can you start osteoporosis. Treatment for without a DEXA scan?

Answer 16

If they had a vertebral fracture

Question 17

What patients should you question osteoporosis?

Answer 17

Long term corticosteroids
Previous fragility fracture
50+ with risk factors
Women 65+
Men 75+

Question 18

What are lifestyle modifications that can be done for osteoporosis?

Answer 18

Inc physical activity
Healthy weight
Smoking cessation
Alcohol reduction
Increase calcium intake
Improve vitamin D intake

Question 19

How much calcium should a patient aim for in a day?

Answer 19

1000mg

Question 20

How many units of vitamin D does a patient need?

Answer 20

400-800 IU

Question 21

What is the first line medical treatment for osteoporosis?

Answer 21

Bisphosphonates

Question 22

How do bisphosphonates work?

Answer 22

Reduces osteoclast activity

Question 23

What are the side effects of bisphosphonates?

Answer 23

Oesophagitis
Osteonecrosis of the jaw
Osteonecrosis. Of the external auditory canal
Atypical

Question 24

How must oral bisphosphonates be taken?

Answer 24

Empty stomach with full glass of water

Should remain upright for 30mins before moving to reduce risk of GORD and oesophagitis

Question 25

What are the 2 main bisphosphonates used for osteoporosis?

Answer 25

Alendronate Zolendronic acid

Question 26

What dose of alendronic acid does a patient take and how often?

Answer 26

70mg once weekly

Question 27

How much zolendronic acid is given to a patient? How is it taken? How frequently is it given?

Answer 27

5mg IV Once yearly

Question 28

What are some specialist medications that can be given to treat osteoporosis if bisphosphonates aren’t suitable?

Answer 28

Denosumab Rommosozumab HRT Raloxifene Strontium ranelate

Question 29

What is an adverse effect of strontium. Ranelate?

Answer 29

Increases risk of VTE and MI

Question 30

How does Raloxifene differ to tamoxifen? What are its adverse effects?

Answer 30

It doesn’t stimulate receptors in the uterus so doesn’t increase the risk of endometrial cancer. Increases its risk of VTE

Question 31

Why are patients at risk of osteoporosis with CKD?

Answer 31

Kidneys unable to activate vitamin D Means poor absorption of calcium in the gut (renal bone disease)