Osteoporosis

?
  • Created by: LBCW0502
  • Created on: 31-01-19 10:09
What is osteoporosis? (1)
Progressive skeletal disorder characterised by low bone mass and structural deterioration of bone tissue leading to bone fragility and increase in fracture risk. Initially asymptomatic and often remains undiagnosed until a fragility fracture occurs
1 of 48
What is osteoporosis? (2)
Approximately 200,000 fractures per year are due to OP (no cure but treatments to manage condition/reduce rate of deterioration)
2 of 48
What are osteocytes?
Main cellular source of receptor activator of nuclear factor B-ligand (RANKL) - when activated stimulate osteoclasts
3 of 48
What are osteoclasts?
Responsible for bone reabsorption and the bone breaks down
4 of 48
What are osteoblasts?
Responsible for formation and mineralisation (calcification) of new bone matrix
5 of 48
Outline the pathophysiology of OP (1)
OP occurs when bone resorption > bone formation. Bone density increases rapidly until puberty and declines after 35 years, rapid decline after menopause. Asymptomatic until fragility fracture occurs (under diagnosed, only seen on X-rays/tests)
6 of 48
Outline the pathophysiology of OP (2)
0-30 years (bone formation > bone loss) and 30+ years (bone loss > bone formation)
7 of 48
Which hormones are involved in the bone remodelling process? (1)
PTH (stimulates bone resorption), glucocorticosteroids (stimulates bone resorption), thyroid hormones (stimulate bone resorption), calcitonin (inhibits bone resorption), insulin (stimulates bone formation), growth hormone (stimulates bone formation)
8 of 48
Which hormones are involved in the bone remodelling process? (2)
Vitamin D and circulating calcium (increase bone mineralisation), oestrogen (inhibit bone resorption), androgens (stimulate bone formation)
9 of 48
What are the risk factors for OP?
Age, female, early menopause, low BMI (<22 kg/m^2), excess alcohol, smoking, lack of exercise, drugs (corticosteroids, heparin), endocrine disease, hereditary, COPD, frequent falls, RA, anorexia nervosa, previous fractures, liver disease, transplants
10 of 48
OP fragility fractures are most common in which areas?
Hip, wrist and spine (vertebrae fractures) - cause disability, pain and reduced QOL. Occurrence of one fracture predisposes person to further fractures
11 of 48
What are the consequences of fracturing the hip?
Pain, unable to walk independently, unable to perform activities of daily living, increase mortality
12 of 48
What are the consequences of fracturing the vertebrae?
Pain, curvature of spine, loss of height, respiratory and GI problems, unable to perform activities of daily living, increased mortality
13 of 48
Which factors are involved when investigating if a patient has OP? (1)
High risk groups (women > 65 yrs, men > 75 yrs), if younger consider - previous fractures, falls, low BMI, smoker/alcohol, long-term steroids, early menopause
14 of 48
Which factors are involved when investigating if a patient has OP? (2)
Exclude other diseases e.g. met bone cancer, falls/fracture history, bone profile test (PTH, Vit D, cCa2+), dual energy X-ray-absorptiometry (DXA) scan to measure bone mineral density, FRAX/Qfracture online risk calculator (10-year risk)
15 of 48
Describe features of diagnosis of OP and the DEXA scan results (1)
Results expressed as T-score (number of s.d. below mean BMD of young adults at their peak bone mass. T score of > -1.0 (normal), -1 to -2.5 (osteopenia - not treated), < -2.5 (OP - needs treatment), > - 2.5 and 1+ fractures (severe OP - treatment)
16 of 48
Describe features of diagnosis of OP and the DEXA scan results (2)
For those where DEXA is not possible, assume OP in all women > 75 yrs with 2+ risk factors
17 of 48
The results from the DEXA scan are compared to what?
Results of a 30 year old male (healthy), compared to ‘perfect’ bone
18 of 48
What are the goals of therapy?
Modification of risk factors, adequate calcium and vitamin D intake, prevention (primary/secondary)
19 of 48
Give examples of medicines used in pharmacological management
Calcium and vitamin D, oral bisphosphonates, IV bisphosphonates, raloxifine, teriparatide (PTH), denosumab, HRT (given to women who start menopause early e.g. 40 years old)
20 of 48
Describe features of calcium and vitamin D (1)
Essential to ensure bone remodelling appropriate, lower levels increases risk of OP, usually poor diet intake in older people. Calcium absorption reduces as age increases so supplementation recommended unless dietary intake considerably high
21 of 48
Describe features of calcium and vitamin D (2)
Usually used combined produced e.g. Adcal D3. Check compliance. If calcium intake adequate (Rx 400 IU Vit D). If calcium intake inadequate (<700 mg/day) then Rx 400-800IU Vit D with 1000 mg calcium min (approx)
22 of 48
Describe features of calcium and vitamin D (3)
Possible to have loading doses of vitamin D (20,000-40,000/week). E.g. patient unable to swallow tablets
23 of 48
State features of bisphosphonates
Oral - alendronic acid, ibandronic acid, risendronate. IV - ibandronic acid and zoledronic acid (different doses/indications for men/women)
24 of 48
What does the NICE guidance state about primary prevention in post menopausal women? (1)
1st line (alendronic acid, 70 mg weekly). Consider risk factors e.g. age, alcohol intake, other conditions, T-scores
25 of 48
What does the NICE guidance state about primary prevention in post menopausal women? (1)
2nd line (risedronate 35 mg weekly), if patients cannot tolerate alendronate or C/I (but has similar side effects). Needs to meet requirements e.g. age, number of ICRF, different T-scores
26 of 48
What is the next option is alendronat and risedronate cannot be tolerated?
Denosumab for primary prevention - but also has to meet requirements e.g. age, number of ICRF, different T-scores
27 of 48
What does the NICE guidance state about secondary prevention in post menopausal women? (1)
Guidance if patient has had a fracture and T-score of < -2.5. 1st line (alendronic acid), 2nd line (risedronate), 3rd line (raloxifine), 4th line (denosumab or teriparatide) - ensure calcium/Vit D intake and address risk factors
28 of 48
What does the NICE guidance state about secondary prevention in post menopausal women? (2)
Bisphosphonates 1st and 2nd line therapy. Start with alendronate - risedronate 2nd line if conditions are met e.g. age and number of ICRF (different T-scores)
29 of 48
What does the NICE guidance state about secondary prevention in post menopausal women? (3)
Raloxifine, 3rd line, given age, number of ICRF and different T-scores
30 of 48
Describe features of teriparatide (PTH) for secondary prevention
Used when alendronate/risedronate produce an unsatisfactory response. But need to have fragility fracture, decline in BMD below pre-tx baseline after 1 year of tx and age/T-scores
31 of 48
Describe features of denosumab for secondary prevention
When the patient cannot take aldendronate, risedronate (e.g. GI upset, oesophagitis) - more commonly prescribed than PTH
32 of 48
Summarise the NICE treatments (1)
Primary/secondary treatment does not cover all cases e.g. those on long term corticosteroids. Men with OP (nil recommendations of treatment). NICE doesn't have guidance for IV therapies
33 of 48
Summarise the NICE treatments (2)
If DEXA scan shows reduced BMD limited guidance on switching (physician decision). How to decide between IV and subcut options - cost, practicalities, patient choice, renal impairment
34 of 48
What is the main action of bisphosphonates?
Inhibit bone resorption by inducing apoptosis of OC (anti-resorptive drugs). Prevent age related bone loss and deterioration of bone microarchitecture. Oral - alendronate, risedronate (once a week)
35 of 48
What are the counselling points for bisphosphonates? (1)
GI adverse effects (oesophagitis, gastritis, dyspepsia). Swallow hole, sit or stand upright, empty stomach at least 30 mins before food or other meds, upright for 30 mins post. IV - zoledronic acid (annually), ibandronate 3 monthly
36 of 48
What are the counselling points for bisphosphonates? (2)
Atypical fractures (femoral) especially in long term - occur after minimal or no trauma, prodromal pain, heal poorly, counsel patients. Osteonecrosis of jaw (greater risk with IV and long tx, counsel patient on jaw pain, swelling, loose teeth)
37 of 48
What are the counselling points for bisphosphonates? (3)
Need for dental health checks and to report symptoms. Often not tolerated by patients, not suitable for those with moderate to severe renal impairment
38 of 48
What is the main action of raloxifine?
Selective oestrogen receptor modulator (SERM). Inhibits bone resorption, reduces vertebral fractures only, once daily oral, increased risk of VTE - not recommended as primary treatment
39 of 48
HRT is used for which patients?
Restricted to younger postmenopausal women with OP and menopausal symptoms who are at high risk of fractures. Additional option - but increases risk of breast Ca, MI and VTE
40 of 48
What is the main action of denosumab? (1)
Monoclonal antibody reduces OC activity, reduces bone breakdown, blocks RANKL which is involved in stimulating bone resorption and inhibits OCs. Reduces risk of fractures. Subcutaneous injection 60 mg every 6 months
41 of 48
What is the main action of denosumab? (2)
Hospital administration or GP (high cost), NICE (post menopausal women). ADRs - diarrhoea, MSK pain, hypocalcaemia, ONJ, another option if unable to take oral therapy, can be used in renal impairment (creatinine clearance <35)
42 of 48
What is the main action of denosumab? (3)
Risk of hypocalcaemia afterwards (Ca blood test 2 weeks post injection)
43 of 48
What is the main action of teriparatide (PTH)? (1)
Recombinant fragment of PTH, regulates calcium, stimulates OBs/stimulating bone growth, reduces both vertebral and non-vertebral fractures, 20 micrograms, subcut daily for 2 years (cannot have further treatment/need alternative after 2 years
44 of 48
What is the main action of teriparatide (PTH)? (2)
Injection local s/e, side effects - nausea, headache, dizziness, limb pain
45 of 48
Describe features of the MHRA recommendations on drug holidays (1)
Bisphosphonates may cause atypical (thigh bone) fractures - increased risk if IV therapy/prolonged courses - may recommend drug holidays for patients or breaks in therapy
46 of 48
Describe features of the MHRA recommendations on drug holidays (2)
Osteonecrosis of the jaw, good dental hygiene advised for denosumab and bisphosphonates pts if invasive dental work recommend adequate healing time after
47 of 48
What are the pharmacological treatments for OP in men?
Alendronate, risedronate, zolendronic acid, teriparatide (licensed but no NICE guidance). Denosumab now licensed in men with OP, may be used if renal impairment
48 of 48

Other cards in this set

Card 2

Front

What is osteoporosis? (2)

Back

Approximately 200,000 fractures per year are due to OP (no cure but treatments to manage condition/reduce rate of deterioration)

Card 3

Front

What are osteocytes?

Back

Preview of the front of card 3

Card 4

Front

What are osteoclasts?

Back

Preview of the front of card 4

Card 5

Front

What are osteoblasts?

Back

Preview of the front of card 5
View more cards

Comments

No comments have yet been made

Similar Pharmacy resources:

See all Pharmacy resources »See all Osteoporosis resources »