All::Rheumatology::Diseases::Osteoporosis
Intro
What are major risk factors for osteoporosis?
Advancing age, female sex, glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture, low BMI, current smoking.
Important FRAX risk factors?
Glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture, low BMI, current smoking.
Other osteoporosis risk factors?
Sedentary lifestyle, premature menopause, ethnicity (Caucasians, Asians), endocrine disorders, multiple myeloma, gastrointestinal disorders, chronic kidney disease.
Medications worsening osteoporosis?
SSRIs, antiepileptics, proton pump inhibitors, glitazones, long-term heparin therapy, aromatase inhibitors.
Why further investigations for osteoporosis patients?
Exclude mimicking diseases, identify causes, assess fracture risk, choose appropriate treatment (NOGG recommendations).
NOGG recommended investigations?
History, physical exam, blood tests (CBC, ESR/CRP, calcium, etc.), and DXA.
Minimum blood tests for all patients by NOGG?
CBC, electrolytes, liver function, bone profile, CRP, thyroid function.
NICE guidelines for postmenopausal women?
Treat with confirmed osteoporosis, offer vitamin D, calcium, and consider alendronate as first-line.
First-line treatment for osteoporotic fragility fractures?
Alendronate.
Alternatives for alendronate-intolerant patients?
Risedronate or etidronate per treatment criteria.
What are the key considerations for treatment when patients cannot tolerate alendronate?
Consider age, T-score, and specific risk factors (parental hip fracture, alcohol intake, rheumatoid arthritis). Second-line drugs are risedronate or etidronate.
What are the T-score criteria for strontium ranelate or raloxifene if alendronate, risedronate, or etidronate cannot be taken?
Strict T-score criteria, e.g., a 60-year-old woman would need a T-score < -3.5.
Which drug has the strictest criteria among alternative treatments according to the text?
Denosumab.
What is the licensing status of alendronate, risedronate, and etidronate for osteoporosis treatment?
All three are licensed for prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis.
What are some key points about ibandronate, a bisphosphonate mentioned in the text?
Ibandronate is a once-monthly oral bisphosphonate, and evidence suggests it reduces the risk of vertebral and non-vertebral fractures.
Strontium ranelate's dual action in bone?
Boosts new bone, inhibits bone resorption.
Strontium ranelate precautions?
Prescribed by specialists, limited use, contraindicated in cardiovascular/thromboembolic history, may cause skin reactions.
Denosumab's action and frequency?
Inhibits osteoclast maturation, 6-month subcutaneous injection.
Teriparatide role in osteoporosis?
Increases bone density, role unclear.
Why is HRT not recommended for osteoporosis prevention?
Concerns about cardiovascular disease, breast cancer unless vasomotor symptoms.
Who should be assessed for osteoporosis according to NICE guidelines?
Women ≥65, men ≥75, or younger with specific risk factors.
Recommended methods for risk assessment by NICE?
Use FRAX or QFracture for 10-year fracture risk estimation.
Key points about FRAX?
Estimates 10-year risk, ages 40-90, international data, factors in various risks.
Key points about QFracture?
Estimates 10-year risk, ages 30-99, UK primary care dataset, broader risk factors.
When does NICE recommend BMD assessment?
Before treatments affecting bone density or in <40 with major risk factors.
What defines high-dose systemic glucocorticoids?
More than 7.5 mg prednisolone or equivalent per day for 3 months or longer.
How are FRAX results interpreted without BMD measurement?
Low risk: reassure and advise, intermediate risk: offer BMD test, high risk: offer bone protection treatment.
How are FRAX results interpreted with BMD measurement?
Reassure, consider treatment, or strongly recommend treatment.
How does QFracture differ in risk categorization compared to FRAX?
QFracture provides raw data on 10-year fracture risk; interpretation requires local or national guidelines and age consideration.
When does NICE recommend reassessing a patient's risk using FRAX/QFracture?
If the original risk was near the intervention threshold for treatment, after a minimum of 2 years, or when there's a change in risk factors.
What is a significant risk factor for osteoporosis according to the text?
Use of corticosteroids, as emphasized in the 2002 RCP guidelines on glucocorticoid-induced osteoporosis.
When does the risk of osteoporosis significantly rise with prednisolone use?
Equivalent of 7.5mg/day for 3 or more months, and anticipatory management is recommended.
What's the approach to bone protection for patients with polymyalgia rheumatica on prednisolone?
Start bone protection immediately if it's likely they'll take steroids for over 3 months.
How is the management of fragility fractures different for patients aged ≥75 and <75?
For those ≥75, start first-line therapy (oral bisphosphonate) without DEXA. For <75, arrange a DEXA scan and use FRAX for ongoing fracture risk assessment.
According to NOGG guidelines, when should treatment start for women after a fragility fracture?
In all women over 50 who've had a fragility fracture, although BMD measurement may be appropriate, especially in younger postmenopausal women.
Example of management for a 79-year-old woman with a Colles' fracture?
Presumed osteoporosis, start oral alendronate 70mg once weekly without arranging a DEXA scan.