Osteoporosis, Nutrition and Fragility Flashcards by David Houghton

What is osteoporosis?

means porous disease
systemic low bone density
characterised by micro-artictecture deterioration

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Before a fracture occurs, what are the common signs of osteoporosis?

1 - sore bones
2 - weak muscles
3 - no symptoms
4 - history of fractures

3 - no symptoms

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What is the most common metabolic bone disease, which are generally disorders of bone strength?

1 - osteoporosis
2 - RA
3 - osteoarthritis
4 - osteopenia

1 - osteoporosis

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There are 2 main categories of fractures, what are they?

1 - trauma and pathological (diseased bone)
2 - trauma and accidental
3 - pathological and physiological
4 - pathological and accidental

1 - trauma and pathological (diseased bone)

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Patients with osteoporosis are said to have fragility fractures. What are fragility fractures?

1 - fracture sustained through low energy trauma such as a fall from standing height
2 - fracture sustained through high energy trauma such as a fall from above 2m height
3 - fracture sustained through low energy trauma such as a fall from above 2m height
4 - fracture sustained through high energy trauma such as a fall from standing height

1 - fracture sustained through low energy trauma such as a fall from standing height

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Patients with osteoporosis are said to have fragility fractures, which are fractures sustained through low energy trauma, such as a fall from standing height of less. What are the 4 most common sites for fractures in osteoporosis

1 - PIP, DIP, proximal humerus and spine
2 - proximal humerus, hip/neck of the femur, spine, forearm
3 - proximal humerus, hip/neck of the femur, femur, forearm
4 - ankle, hip/neck of the femur, spine, forearm

1 - proximal humerus
2 - hip/neck of the femur
3 - spine
4 - forearm

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How can we diagnose osteoporosis?

1 - DEXA
2 - X-ray
3 - MRI
4 - ultrasound

1 - DEXA

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What is bone mineral density?

quantify of bone/unit of area

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Bone mineral density is the amount of bone contained with a unique area, which can only be quantified using a DEXA scanner. The DEXA scanner can generate a T score, what is a T score?

1 - score for patients BMD compared to peak of a 30 y/o female
2 - score for patients BMD compared against same gender and age
3 - score for patients BMD compared to peak of a 30 y/o male
4 - score for patients BMD compared against same age

1 - score for patients BMD compared to peak of a 30 y/o female

patients BMD is converted to a T score to standardise BMD scores
t score is then compared to the peak of a 30 y/ol female as SD either side of peak female T score

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Bone mineral density is the amount of bone contained with a unique area, which can only be quantified using a DEXA scanner. What is the Z score?

2 - score for patients BMD compared against same gender and age
- z score = patients BMD as a number of SD above or below people of the same gender and age

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What is osteopenia?

less severe form of osteoporosis

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The normal T score generated from a DEXA scan is <1. What is the diagnosis of osteopenia, the less severe form of osteoporosis?

1 = -1 to -2.5
2 = < -2.5
3 = < -2.5 with at least one fracture

1 = -1 to -2.5

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The normal T score generated from a DEXA scan is <1. What is the diagnosis of osteoporosis?

1 = -1 to -2.5
2 = < -2.5
3 = < -2.5 with at least one fracture

2 = < -2.5

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The normal T score generated from a DEXA scan is <1. What is the diagnosis of severe osteoporosis?

1 = -1 to -2.5
2 = < -2.5
3 = < -2.5 with at least one fracture

3 = < -2.5 with at least one fracture

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What proportion of >65 will fall in a year, and thus increase the risk of fractures?

1 - 33%
2 - 50%
3 - 70%
4 - 100%

1 - 33%

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Bone is described as anisotropic. What does this mean?

1 - material that can regenerate
2 - material that cannot be broken
3 - material that has different properties, depending on angle of measurement
4 - material that has different properties at different parts of it

3 - material that has different properties, depending on angle of measurement

material has different properties of obtaining different values when observing or measuring something from different directions
essentially stronger in certain planes rather than others

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What is the single most important risk fracture for a fragility fractures?

1 - exercise
2 - diet
3 - gender
4 - age

4 - age

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What is the most common fragility fracture?

1 - vertebral
2 - hip
3 - femur
4 - radius

1 - vertebral

- 70% go undiagnosed as they as asymptomatic

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Once an osteoporotic woman has had a 1st vertebral fracture, what % of the these women are likely to have another vertebral fracture within the next 12 months?

1 - 5%
2 - 10%
3 - 19%
4 - 33%

3 - 19%

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What is the most common fracture in young and older patients?

young = forearm (distal radius) fracture from falling over

- older = hips (fall directly onto the hips)

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What is an index fracture?

1 - risk of subsequent fractures following an initial fracture
2 - risk of 1st fractures
3 - risk of developing multipole fractures simultaneously

1 - risk of subsequent fractures following an initial fracture

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Are fragility fractures more common in men or women?

women

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What % of patients will die within 12 months of a hip fracture?

1 - 10-15%
2 - 15-20%
3 - 25-30%
4 -30-40%

3 - 25-30%

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Is the mortality higher in patients following a hip or vertebral fracture?

vertebral

- number of vertebral fractures increases mortality

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Fragility vertebral fractures are the most common type of fracture. Which part of the spine is most likely to be damaged in vertebral features?

- weight bearing thoracolumbar spine | - thoracic and lumbar regions

What are some common signs of a vertebral fracture? 1 - pain, height loss and hearing changes 2 - pain, height loss and change in posture 3 - height loss and change in posture 4 - height loss and change in posture

2 - pain, height loss and change in posture - pain is from compressed nerves - posture and height loss are due to damaged vertebrae creating a wedged vertebrae

We all have a degree of lordosis (outward curvature of the spine) and kyphosis (inward curvature of the spine) in a normal and healthy spine. Which segments of the vertebral spine are lordosis and kyphosis in normal spine? 1 - cervical and lumber = lordosis and thoracic = kyphosis 2- cervical and lumber = kyphosis and thoracic = lordosis 3 - cervical and thoracic = lordosis and lumbar = kyphosis 4 - thoracic and lumber = lordosis and cervical = kyphosis

1 - cervical and lumber = lordosis and thoracic = kyphosis

We all have a degree of lordosis (outward curvature of the spine) and kyphosis (inward curvature of the spine) in a normal and healthy spine. Patients with osteoporosis can present with excessive kyphosis. What happens here?

- excessive kyphosis is present in the thoracic region | - results in patients looking like they are bowing of bending over

Fragility vertebral fractures can cause kyphosis. What happens to the patients centre of gravity and what can this lead to? 1 - centre of gravity moves horizontally (backwards) increasing the risk of falls 2 - centre of gravity moves horizontally (backwards) increasing the risk of fractures 3 - centre of gravity moves horizontally (forwards) increasing the risk of falls 4 - centre of gravity moves horizontally (forwards) increasing the risk of fractures

2 - centre of gravity moves horizontally (backwards) increasing the risk of fractures

At what age does bone mass peak in our lifetime? 1 - 10-15 y/o 2 - 15-20 y/o 3 - 20-25 y/o 4 - 28-30 y/o

4 - 28-30 y/o

When does the majority of bone mass accumulate? 1 - when baby is a foetus 2 - early childhood 3 - puberty 4 - adulthood

3 - puberty

Is bone mineral mass affected by genetics?

- yes | - polygenic up to aprox 50-70%

What is key in terms of lifetime bone mass that we can modify?

- lifestyle through diet and exercise

What affect do inflammatory conditions have on bone mineral density?

- cytokines activate osteoclasts | - osteoclast begin bone breakdown and reabsorption

What are the key 2 key micronutrients that are essential for bone health? 1 - Ca2+ and Vitamin A 2 - Ca2+ and Vitamin K 3 - Folic Acid and Vitamin D 4 - Ca2+ and Vitamin D

4 - Ca2+ and Vitamin D Protein Micronutrients: Vitamin A, B Vitamins, Vitamin K, Magnesium and Zinc

Calcium and Vitamin D are 2 key micronutrients that are essential for bone health. What 3 other vitamins are important?

- vitamin A, D and K

Calcium and Vitamin D are 2 key micronutrients that are essential for bone health. What 2 other micronutrients are important?

- magnesium and zinc

99% of the bodies Ca2+is maintained within bones. But 1% is found within serum, Why is serum Ca2+ a bad marker for assessing overall Ca2+ absorption and consumption? 1 - slow to respond to pathology 2 - will be normal even if patient has osteoporosis 3 - assays have poor sensitivity 4 - assays have poor specificity

2 - will be normal even if patient has osteoporosis - even if patient has osteoporosis, PTH will ensure serum Ca2+ is maintained from bones stores - should measure Ca2+ and hormone levels as PTH could be high

What is the recommended intake of Ca2+? 1 - 100mg 2 - 1500mg 3 - >1000mg 4 - >3000mg

3 - >1000mg

In addition to dairy, what other sources of Ca2+ can we get?

- nuts (almonds) - broccoli - spinach - dairy substitutes

What is the most commonly prescribed for patients with low bone mineral density? 1 - magnesium and Ca2+ 2 - zinc and vitamin D3 3 - Ca2+ with vitamin D3 4 - Ca2+ and zinc

3 - Ca2+ with vitamin D3

What % of vitamin D is absorbed through sunlight? 1 - 10% 2 - 30% 3 - 55% 4 - 95%

4 - 95%

Order the process of how vitamin D is process to make active vitamin D using the labels below: - converted to 1, 25 hydroxyvitamin D (active vitamin D) - converted into calcifediol (25-hydroxycholecalciferol) in the liver - vitamin D3 or D2 absorbed through skin or diet, respectively

1st - vitamin D3 or D2 absorbed through skin or diet, respectively 2nd - converted into calcifediol (25-hydroxycholecalciferol) in the liver 3rd - converted to 1, 25 hydroxyvitamin D (active vitamin D)

What effect does vitamin D have on GIT and bone?

- increases Ca2+ absorption from enterocytes in GIT | - mobilises Ca2+ stores by acting like PTH

What affect can chronic liver disease affect vitamin D?

- vitamin D3 and D2 is not converted into 25 hydroxyvitamin | - so active vitamin D is not created

What affect can obesity affect vitamin D?

- impairs skins ability to absorb vitamin D

What affect can medications affect vitamin D?

- long term use of anti-epileptics or retrovirals impairs vitamin D synthesis

What affect can chronic kidney disease affect vitamin D?

- cannot re-absorb Ca2+ | - cannot convert 25 hydroxyvitamin D into 1,25 hydroxyvitamin D, which is the active form of vitamin D

Protein is important for bone health, why is this? 1 - amino acids are essential for bone matrix 2 - amino acids stimulate muscle growth and bone development 3 - amino acids are raised in puberty 4 - amino acids are released stimulating RANK-L release in bone

1 - amino acids are essential for bone matrix

The amino acids contained within protein are important for the matrix of bone. What else is protein important for in bone development? 1 - amino acids are essential for bone matrix 2 - stimulate the release of IGF-1 which stimulates osteoclasts 3 - stimulate the release of IGF-1 which stimulates osteoblasts 4 - stimulate the release of IGF-1 which stimulates osteocytes IGF-1 = insulin like growth factor

3 - stimulate the release of IGF-1 which stimulates osteoblasts

What affect does vitamin K have on bone health?

- crucial for making osteocalcin | - osteocalcin is secreted by osteoblasts and helps maintain bones metabolic regulation

Effects does magnesium have on bone health? 1 - inhibits osteoblasts proliferation 2 - stimulates osteoclasts proliferation 3 - stimulates osteocyte proliferation 4 - stimulates osteoblasts proliferation

4 - stimulates osteoblasts proliferation | - osteoblasts build new bone

What effect does zinc have on bone health? 1 - involved in bone deposition 2 - involved in osteoblasts development 3 - involved in osteoclasts development 4 - involved in bone mineralisation

4 - involved in bone mineralisation

How does a low BMI (<19) affect bone health? 1 - low vitamin D intake 2 - amenorrhea so no progesterone 3 - amenorrhea so no estrogen 4 - low Ca2+ intake

3 - amenorrhea so no estrogen - oestrogen inhibits osteoclasts - poor diet and reduced weight so reduced mechanical stress

Is obesity a risk factor for osteoporosis?

- yes - reduced bone size due to body mass and poor activity - poor vitamin D absorption

How does alcohol affect bone density? 1 - reduces hormones (testosterone and estrogen) 2 - impairs vitamin D metabolism 3 - impairs Ca2+ absorption 4 - inhibits osteoblasts

- 1 - reduces hormones (testosterone and estrogen) - suppresses osteoblasts differentiation - increases falls and fracture risk

How many units of alcohol p/w doubles the risk of bone fracture? 1 - 1 unit 2 - 1-2 units 3 - 3-4 units 4 - >4 units

3 - 3-4 units

The cumulative risk of bone fracture is dependent on what in smoking? 1 - amount smoked 2 - duration of smoking 3 - what is smoked 4 - amount and duration of smoking

4 - amount and duration of smoking

How much exercise should be done weekly and daily? 1 - 10 minutes a day/70 minutes/week 2 - 30 minutes a day/120 minutes/week 3 - 60 minutes a day/150 minutes/week 4 - 90 minutes a day/360 minutes/week

3 - 60 minutes a day/150 minutes/week

How does inflammatory disease, which has increased levels of TNF-a, IL-6 and IL-1 affect the risk of osteoporosis?

- inhibit osteoblasts | - increase RANK-L and activate osteoclasts activity

What is the FRAX tool?

- algorithm for the risk of fracture over 10 years

A 50 year old lady was referred to the RA clinic. She had the following on a medical history: - Family history maternal hip fracture - Coeliac Disease – strict gluten-free adherence - Lactose Intolerance - Family history breast cancer - Last menstrual period 49 yrs - Well, regular weight-bearing exercise - No history of falls - Never fractured - Never smoked - Alcohol 6U/wk - BMI 17.31 - paracetamol - no history of corticosteroids or PPIs Which of the above factors are risk factors for osteoporosis?

- Family history maternal hip fracture = high genetic association - Coeliac Disease – strict gluten-free adherence (poor Ca2+ absorption) - Lactose Intolerance (low Ca2+ intake) - Low BMI (high risk amenorrhea and low mechanical loading)

A 50 year old lady was referred to the RA clinic. She had the following on a medical history: - Family history maternal hip fracture - Coeliac Disease – strict gluten-free adherence - Lactose Intolerance - Family history breast cancer - Last menstrual period 49 yrs - Well, regular weight-bearing exercise - No history of falls - Never fractured - Never smoked - Alcohol 6U/wk - BMI 17.31 - paracetamol - no history of corticosteroids or PPIs This patient then has a DEXA, which gives a T score of -2.1. What does this score mean?

- patient is osteopenic -1 to -2.5 = osteopenic < -2.5 osteoporosis < -2.5 with at least one fracture severe osteoporosis

What is the goal of any treatment for osteoporosis?

- fragility fracture prevention

When we look at modifying patients lifestyle we need to reduce or stop known risk factors for RA. What are the 3 lifestyle factors, excluding diet that need modifying and how? 1 - smoking, alcohol, exercise 2 - medication, alcohol, exercise 3 - smoking, sleep, exercise 4 - sleep, alcohol, exercise

1 - smoking, alcohol, exercise - smoking = stop smoking - alcohol = reduce alcohol <4u/wk exercise = encourage weight bearing exercise

When we look at modifying patients lifestyle we need to reduce or stop known risk factors for RA. What are the 2 most important dietary changes that should be addressed?

1 - vitamin D supplementation (1000-2000 IU colecalciferol/day) 2 - Ca2+ if levels are low

Which cell within bones is responsible for mechanotransduction in bones, which is the mechanism by which cells convert mechanical stimuli into cellular responses to a variety of mechanical loads? 1 - osteons 2 - osteoclasts 3 - osteoblasts 4 - osteocytes

4 - osteocytes

There are only 2 ways that any osteotherapy drugs are able to target bones, what are they? 1 - inhibit osteoblasts and stimulate osteoclasts 2 - inhibit osteoblasts and osteoclasts 3 - stimulate osteoblasts and inhibit osteoclasts 4 - stimulate osteoblasts and osteoclasts

3 - stimulate osteoblasts and inhibit osteoclasts

When we talk about osteotherapy drugs we talk about antiresorptive and anabolic. What does antiresorptive and anabolic mean?

- antiresorptive = inhibit bone reabsorption | - anabolic = building, in this instance its bone rebuilding

What affect does estrogen have on bone health?

- inhibits osteoclasts formation by reducing RANK-L | - stimulates osteoblasts

If a clinician is considering prescribing hormone replacement therapy, specifically oestrogen for a female patient with osteoporosis, what must they ensure prior to prescribing them oestrogen? 1 - cervical cancer 2 - breast cancer 3 - osteosarcoma 4 - hepatocarcinoma

2 - breast cancer - oestrogen receptor positive breast cancer can increase the risk of breast cancer, so we wouldn't want to give this patient oestrogen

What are selective oestrogen receptor modulator medication that can be given to patients with osteoporosis? 1 - drugs that regulate non-estrogen receptors 2 - drugs that regulate all estrogen receptors 3 - drugs that regulate estrogen receptors on breast tissue only 4 - drugs that regulate estrogen receptors on bones only

2 - drugs that regulate all estrogen receptors | - inhibits/down regulates osteoclast activity

Selective oestrogen receptor modulator medication can be given to patients with osteoporosis, which are drugs that act on estrogen receptors. For example in bone they inhibits/down regulates osteoclast activity. Which of the following is the drug commonly used in the UK? 1 - Methotrexate 2 - Tamoxifen 3 - Raloxifene 4 - Prednisolone

3 - Raloxifene

Selective oestrogen receptor modulator medication can be given to patients with osteoporosis, which are drugs that act on estrogen receptors. For example in bone they inhibits/down regulates osteoclast activity, with Raloxifene being the key drug used in the UK. Although effective at reducing the risk of vertebral fracture, what are the most common adverse events that can occur with this drug? 1 - heart attack and strokes 2 - stroke and deep vein thrombosis 3 - stroke and breast cancer 4 - breast cancer and deep vein thrombosis

2 - stroke and deep vein thrombosis

If you have a patient that has previously had a fracture, is hormone therapy (HRT or Selective Oestrogen Receptor Modulators) going to be potent enough for treatment?

- no

If you have a patient that has previously had a fracture, hormone therapy (HRT or Selective Oestrogen Receptor Modulators) is not going to be potent enough for treatment. What is the 1st line treatment for patients who have previously had a fracture? 1 - antibiotics 2 - steroids 3 - bisphosphonates 4 - RANK-L medication

3 - bisphosphonates

1 - Alendronic acid 2 - Disodium pamidronate 3 - Zolendronic acid

If you have a patient that has previously had a fracture, hormone therapy (HRT or Selective Oestrogen Receptor Modulators) is not going to be potent enough for treatment. The 1st line treatment for patients who have previously had a fracture is bisphosphonates. The 3 drugs we need to know are: 1 - Alendronic acid 2 - Disodium pamidronate 3 - Zolendronic acid What is the basic mechanism of action of this group of drugs? 1 - induce osteoblast proliferation 2 - induce osteocyte proliferation 3 - induce osteoblast apoptosis 4 - induce osteoclasts apoptosis

4 - induce osteoclasts apoptosis - bisphosphonates have a similar structure to inorganic pyrophosphate - bisphosphonates are incorporated into bone matrix - bisphosphonates accumulates in osteoclasts and inhibits inhibit Farnesyl Pyrophosphate Synthase (FPS) - FPS inhibition induces apoptosis of osteoclasts

What is paget's disease?

- disease of bone - interferes with bones normal recycling process - bones become fragile and misshapen

If you have a patient that has previously had a fracture, hormone therapy (HRT or Selective Oestrogen Receptor Modulators) is not going to be potent enough for treatment. The 1st line treatment for patients who have previously had a fracture is bisphosphonates. The 3 drugs we need to know are: 1 - Alendronic acid 2 - Disodium pamidronate 3 - Zolendronic acid These drugs essentially cause apoptosis of osteoclasts. What 4 diseases have these drugs been licensed for?

1 - hypercalcaemia of malignancy 2 - metastatic bone cancer 3 - active pagets disease 4 - osteoporosis

If you have a patient that has previously had a fracture, hormone therapy (HRT or Selective Oestrogen Receptor Modulators) is not going to be potent enough for treatment. The 1st line treatment for patients who have previously had a fracture is bisphosphonates. The 3 drugs we need to know are: 1 - Alendronic acid 2 - Disodium pamidronate 3 - Zolendronic acid These drugs must be taken in a very specific way. How must they be taken?

- taken once a week in the morning - on a empty stomach with a full glass of water standing up - must not eat for 30 minutes

If you have a patient that has previously had a fracture, hormone therapy (HRT or Selective Oestrogen Receptor Modulators) is not going to be potent enough for treatment. The 1st line treatment for patients who have previously had a fracture is bisphosphonates, with the 3 core drugs being Alendronic acid, Disodium pamidronate and Zolendronic acid. What is the most common side effect of these drugs? 1 - rickets disease 2 - oesophagitis/gastritis (oral agents) 3 - osteonecrosis of the jaw (rare) 4 - atypical femoral fractures (rare)

2 - oesophagitis/gastritis (oral agents)

- renal impairment as excreted by kidneys - hypocalcaemia - upper gastrointestinal pathology eg peptic ulcer disease - dental disease

RANK-L is a protein that is a member of the protein family TNF-a, a cytokine. Once activated they stimulate osteoclasts to mature and begin bone re-absorption. What is the process by which RANK-L matures osteoclasts?

- RANK-L is expressed and released by osteoblasts - RANK-L binds to immature osteoclasts that then mature - RANK-L then signal osteoclasts differentiation and survival, essentially promoting bone re-absorption.

Osteoprotegerin is a inhibitory factor released by osteoblasts. What is the function of osteoprotegerin?

- binds RANK-L and inhibits RANK-L ability to bind with osteoclasts

Osteoprotegerin is a inhibitory factor released by osteoblasts. Osteoprotegerin binds RANK-L and inhibits osteoclasts maturation. There are synthetic forms of osteoprotegerin that can have the same effect, which are classed as RANK-L inhibitors. What is the core drug that we need to know that comes under this category? 1 - bisphosphonate 2 - denosumab 3 - estrogen 4 - triparitide

2 - denosumab | - very expensive

Osteoprotegerin is a inhibitory factor released by osteoblasts. Osteoprotegerin binds RANK-L and inhibits its ability to bind with osteoclasts. There are synthetic forms of osteoprotegerin that can have the same effect. Denosumab is the core drug that we need to know that comes under this category. How often and how is this drug administered?

- 6 monthly | - subcutaneous injection

What core drug do we need to know that is an anabolic (means to build things) drug that increases bone formation? 1 - bisphosphonate 2 - denosumab 3 - estrogen 4 - triparitide

4 - triparitide

Triparitide is a hormone regulator and is the core drug that we need to know that is an anabolic drug that increases bone formation. What is the mechanism of action of this drug? 1 - inhibits PTH 2 - induces constant secretion of PTH 3 - inhibits calcitonin and vitamin D 3 - induces a pulsatile secretion of PTH PTH = parathyroid hormone

- triparitide is a recombinant analogue of parathyroid hormone (essentially a copy of PTH) - forms pulses of PTH stimulating both osteoblasts and osteoclasts - BUT stimulates osteoblast more and increases bone formation

Triparitide is a hormone regulator and is the core drug that we need to know that is an anabolic drug that increases bone formation. It is a recombinant analogue of parathyroid hormone (essentially a copy of PTH) that stimulates osteoblasts preferentially over osteoclasts, thus increasing bone formation over bone re-absorption. How often and how is this drug administered?

- administered daily via subcutaneous injection

1 - patients with a cancer diagnosis

Osteoporosis, Nutrition and Fragility Flashcards

(91 cards)