Pharmaceutical Care of Osteoporosis

Question 1

What is osteoporosis?

Answer 1

Progressive, systemic skeletal disorder characterised by loss of bone tissue + disruption of bone micro architecture
= increased fragility + fracture

Question 2

What are the stages of osteoporosis?

Answer 2

Normal bone density
Osteopenia
Osteoporosis
Severe osteoporosis

Question 3

What is osteopenia?

Answer 3

Loss of bone mass + density BUT bone loss is not yet severe

Question 4

What builds bones?

Answer 4

Osteoblasts

Question 5

What crushes bones?

Answer 5

Osteoclasts

Question 6

What are osteocytes?

Answer 6

Former osteoblasts that lie in the matrix they form

Question 7

What are the non-modifiable risk factors?

Answer 7

Previous fractures
Parental history
Early menopause

Question 8

What are the modifiable risk factors?

Answer 8

Low BMI
Smoking
Low BMD
Alcohol intake

Question 9

What are the coexisting diseases that contribute?

Answer 9

Diabetes
RA
IBD/malabsorption
Moderate-severe CKD

Question 10

What drug therapies contribute?

Answer 10

Long-term antidepressants
Antiepileptics
Aromatase inhibitors
PPIs
Oral corticosteroids

Question 11

What are the complications?

Answer 11

Fractures
= often result from low-level trauma

Question 12

Where are fractures most common?

Answer 12

Spine (vertebral)
Hip
Wrist

Question 13

What are the causes?

Answer 13

Primary = multifactorial = idiopathic
Secondary = conditions

Question 14

What is the initial investigations for diagnosis?

Answer 14

Blood tests = vitD, thyroid test, U+Es
DXA scan
X-ray = suspect fracture

Question 15

How do you assess fracture risk?

Answer 15

QFracture
FRAX score

Question 16

When do you consider a fracture assessment?

Answer 16

In all women aged 65 years + over + in all men aged 75 years + over
In all women under 65 + men under 75 with risk factors

Question 17

When do you warrant for investigation for QFracture + FRAX?

Answer 17

When score is over 10%

Question 18

What is DXA scan?

Answer 18

Dual x-ray
Measures bone mineral density

Question 19

When does the DXA scan warrant for investigation?

Answer 19

T Score
Osteopenia =-1-2.5
Osteoporosis = less than -2.5
Severe = Less than -2.5 + fracture

Question 20

How do you target reversible risk factors?

Answer 20

Exercise = outdoors, strength training, balance of exercises
Diet
Smoking cessation
Alcohol intake limited

Question 21

If calcium + VitD inadequate what is given?

Answer 21

Ca = 1000mg
VitD = 800 units
BUT double if house bound or in nursing home

Question 22

What do bisphosphonates do?

Answer 22

Bind to, + stabilise bone by inhibiting osteoclast activity

Question 23

What needs to be monitoring with bisphosphonates?

Answer 23

Kidney function = renally excreted

Question 24

What are the drug choices for bisphosphonates?

Answer 24

Alendronic acid
Risedronate

Question 25

What are the counselling points for bisphosphonates?

Answer 25

Take once weekly Take with plenty of H2O Take whilst standing up Take on empty stomach Remain upright for 30mins after taking Do not take at night Do not crush

Question 26

What are the side effects of bisphosphonates?

Answer 26

Oesophageal reactions = counselling points Atypical fractures Osteonecrosis

Question 27

How do you manage osteonecrosis of the jaw?

Answer 27

Report any oral symptoms Encourage good oral hygiene Increased risk with IV formulations + malignancies

Question 28

How do you manage osteonecrosis of the ear?

Answer 28

Report any ear pain, discharge or infections Associated with long term use

Question 29

What is denosumab?

Answer 29

Monoclonal Ab S/C injection given for 6 months

Question 30

When is denosumab given?

Answer 30

When patient cannot tolerate bisphosphonate therapy

Question 31

What must be ensured before starting denosumab?

Answer 31

Ca + VitD levels are adequate

Question 32

What are the side effects of denosumab?

Answer 32

Osteonecrosis jaw + ear Atypical fractures Increased risk of infections at injection site Hypocalcaemia

Question 33

What is Raloxifene?

Answer 33

Selective oestrogen receptor modulator (SERM)

Question 34

What does Raloxifene do?

Answer 34

Partial agonists of oestrogen receptors within bone tissue = induce osteoblast activity

Question 35

What is Raloxifene licensed for?

Answer 35

Postmenopausal osteoporosis

Question 36

What is an example of a parathyroid hormone analogue?

Answer 36

Teriparatide Daily S/C injection

Question 37

What does Teriparatide do?

Answer 37

Mimic effects of PTH = increase bone formation pathway

Question 38

What must be ensured first before starting Teriparatide?

Answer 38

Adequate Ca + VitD levels

Question 39

What are the side effects of Teriparatide?

Answer 39

Post doe orthostatic hypotension

Question 40

How long is PO bisphosphonate treatment?

Answer 40

5 years Then assess if improvement if no longer above treatment threshold = "bisphosphonate holiday" Then review after 2 years