OSTEOPOROSIS

Pathophysiology
An imbalance in bone resorption and creation occurs due to a number of factors increasingly so in
advanced age that causes a net loss of bone mass, leading to decreased cortical mass, and loss of
internal microarchitecture (the trebeculae and shit).
Overall this causes increased vulnerability to minimal impact fractures (from standing height etc.) and
compression fractures of the spine manifesting as kyphosis
The disability and morbidity associated is extremely significant, if I fix this, Im going to be a billionaire
CF

Mostly asymptomatic
Minimal trauma fracture
Height loss and kyphosis due to compression fractures of the spine
Presents as acute severe back pain
More than 3cm in loss of height is significant
DDx: acute nerve root compression, pathological fracture (MM)

Risk Factors
Primary risk factors
Secondary risk factors
Lifestyle
Immutable
Endo: hyperpara/hyperthyr/hypogonadism/Cushings
Lack of exercise/immobile
PHx fractures
GI: malabsorption from gut
Smoking
Age >55yo
MM, Leukaemia, Lymphoma
Poor nutrition/Ca intake/BMI
Female (Post-menopausal)
CTD (due to steroid use)
Vitamin D deficient
FHx, Maternal
Drugs: steroids, alcohol, anticonvulsants, antisex
Alcoholism
CKD
Weight loss >10%/
Anorexia nervosa
Frax score
Corticosteroids cause a worse form of disease than the DEXA may indicate, loss of microarchitecture
Investigations
Diagnosis of osteoporosis can be made as a clinical diagnosis, if the patient has presented with one of the fractures
above and has appropriate demographics covered.
DEXA bone scan
Measures the density of the bone
Used to aid diagnosis of osteoporosis, assess risk of fracture and ALSO for ongoing
monitoring/assessment with medications
Measurement is by standard deviations away the mean of a healthy 30yo healthy woman = T Score
o
0 is normal
o
-1 is osteopaenia
o
-2.5 is osteoporosis
o
Severe OP if -2.5 AND a fracture has occurred
The Z score is measured against the mean of healthy people in your age group and of the same sex
o
Used as a more appropriate measurement of advanced OP (likely secondary)
Xray
-

CXR/Spinal
o
anterior wedge compression fracture
o
loss of bone mass
Heel, Wrist, Hip

Routine Bloods
FBE, UEC, LFT
CMP
o
Calcium may be normal
Vitamin D
PTH: may be normal

Hip fracture 20-30% dead after one year, only 20% make it back to their own home after a hip fracture
Management
Non-pharmacological
Diet: plenty calories (good BMI) and calcium rich
Exercise: regular weight ebaring
Smoking
Medications: avoid glucocorticoids
Calcium and vitafmin D supplements
Assess and minimise falls risk
o
BP (Postural HoTN)
o
Visual, vestibulocochlear, neuropathy, gait issue
o
PHx fractures, FHx
o
Chronic disease:
o
Medications and drugs and alcohol
o
Cognitive status and behaviour
Pharmacological
Bisphosphonates (may cause oesophagitis, osteonecrosis of the jaw)
o
Alendronate (oral, daily/wkly)
o
Risendronate (oral, wkly/mnthly)
o
Zoledronic acid (IV, Annual)
Hormonal
o
Reloxifene: Selective oestrogen receptor mod drugs: for younger menopausal women b/c of
reduced Breast Ca risk

Causes hot flushes, increased risk of VTE

o
Regular Oestrogen-Progesterone

Not used much b/c risk of VTE, stroke, breast Ca etc.

Only used if other medications havent worked

Other
o
Denosumab: MAB, subcut every 6mos
o
Parathyroid once daily pulses in severe refractory OP

Differentiation
Multiple myeloma

Bone pain+Anaemia+Renal failure

Osteomalacia

More painful, RFs, much lack of sunlight,

too much sunscreen

Primary parathyroidism
Metastatic bone disease

Hypercalcaemia:A/N/C/Abdo pain
PHx of malignancy
Fracture may be in unusual spot
Unusual demographic for OP?
PHx CKD

CKD BMD

Something something pyroclastic eruption opinion

OSTEOPOROSIS Hx

Urine electrophoresis: bencejones proteinuria

SPEP: monoclonal gammopathy
Whack Ix results:
Low Ca, PO4, Vit D
High ALP
2* HyperPTH
Serum PTH elevated
Bone scan may show multiple
hot spots
CT may show primary tumour
Raised PTH and Creatinine