Osteoporosis

Question 1

What is osteoporosis?

Answer 1

Osteoporosis is a skeletal disorder characterised by low bone mass and microarchitectural deterioration leading to increased bone fragility and risk of fragility fractures.

Question 2

How is osteoporosis diagnosed according to WHO?

Answer 2

A DEXA T-score of less than −2.5 SD at the hip or lumbar spine.

Question 3

What is a fragility fracture?

Answer 3

A fracture resulting from low-energy trauma that would not normally cause a fracture, typically indicating underlying osteoporosis.

Question 4

Which patients should be clinically assessed for osteoporosis risk without waiting for symptoms?

Answer 4

All women aged ≥65 years and all men aged ≥75 years.

Question 5

What are the six major FRAX risk factors for osteoporosis?

Answer 5

Glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture, low BMI, smoking.

Question 6

Which lifestyle factors increase osteoporosis risk?

Answer 6

Smoking, sedentary lifestyle, alcohol consumption above 14 units/week for women or 21 units/week for men, low BMI.

Question 7

Which endocrine disorders increase osteoporosis risk?

Answer 7

Hyperthyroidism, hypogonadism, hyperparathyroidism, growth hormone deficiency, diabetes mellitus.

Question 8

Name two haematological disorders associated with osteoporosis.

Answer 8

Multiple myeloma and lymphoma.

Question 9

Which gastrointestinal disorders increase osteoporosis risk?

Answer 9

Inflammatory bowel disease, malabsorption including coeliac disease, chronic pancreatitis, gastrectomy, liver disease.

Question 10

Which medications (other than steroids) worsen osteoporosis risk?

Answer 10

SSRIs, antiepileptics, PPIs, glitazones, long-term heparin, aromatase inhibitors.

Question 11

Which blood tests are recommended by NOGG for secondary osteoporosis?

Answer 11

Full blood count, U&E, LFTs, bone profile, CRP/ESR, thyroid function tests.

Question 12

Which further investigations may be indicated in suspected secondary osteoporosis?

Answer 12

Serum 25OHD, PTH, serum testosterone/FSH/LH in men, prolactin, coeliac antibodies, urinary calcium excretion, protein electrophoresis and Bence-Jones proteins.

Question 13

Which imaging helps identify vertebral fractures in osteoporosis?

Answer 13

Lateral spine X-ray or DXA-based vertebral fracture assessment.

Question 14

What is the purpose of FRAX and QFracture?

Answer 14

To estimate a patient’s 10-year risk of fragility fractures based on clinical factors with or without bone density.

Question 15

In which patients should risk be reassessed using FRAX/QFracture?

Answer 15

When the original risk was near treatment threshold (after at least 2 years) or when risk factors change.

Question 16

When should a DEXA scan be offered without calculating fracture risk?

Answer 16

Patients >50 with fragility fracture, patients <40 with major risk factors, and before initiating treatments causing rapid bone loss (e.g. hormone deprivation therapy).

Question 17

When does QFracture indicate DEXA scan?

Answer 17

When 10-year fracture risk ≥10%.

Question 18

What is the T-score threshold for diagnosing osteoporosis?

Answer 18

≤ −2.5 SD.

Question 19

What is the purpose of DEXA in patients ≥75 with fragility fractures?

Answer 19

To provide a baseline only; treatment should be initiated regardless of T-score.

Question 20

Which sites are measured in a DEXA scan?

Answer 20

Hip and lumbar spine.

Question 21

What lifestyle advice should be given to all patients with osteoporosis or at risk?

Answer 21

Adequate calcium and vitamin D intake, regular weight-bearing and muscle-strengthening exercise, healthy diet, reduced alcohol, smoking cessation.

Question 22

What is the first-line pharmacological treatment for osteoporosis?

Answer 22

Oral bisphosphonates such as alendronate or risedronate.

Question 23

When is IV zoledronate first-line?

Answer 23

After a hip fracture in older adults, according to NOGG.

Question 24

Which treatment is generally used second-line after bisphosphonates?

Answer 24

Denosumab.

Question 25

How do bisphosphonates work?

Answer 25

They bind to hydroxyapatite and inhibit osteoclast-mediated bone resorption.

Question 26

What counselling is required for oral bisphosphonate administration?

Answer 26

Take on an empty stomach with water, remain upright for 30 minutes, avoid other medications/food for 30 minutes.

Question 27

What are common adverse effects of bisphosphonates?

Answer 27

Oesophagitis, oesophageal ulcers, hypocalcaemia, acute phase reaction, atypical femoral fractures, osteonecrosis of the jaw.

Question 28

What pre-treatment step is required before prescribing bisphosphonates?

Answer 28

Correct hypocalcaemia and vitamin D deficiency.

Question 29

What is denosumab and how is it administered?

Answer 29

A monoclonal antibody against RANK-L, given as a subcutaneous injection every 6 months.

Question 30

What is raloxifene?

Answer 30

A selective oestrogen receptor modulator that reduces vertebral fracture risk but not non-vertebral fracture risk.

Question 31

Why is strontium ranelate rarely used?

Answer 31

Increased risk of cardiovascular events, VTE, and serious skin reactions; reserved for specialist use when no alternatives exist.

Question 32

What is teriparatide?

Answer 32

Recombinant PTH that increases bone density; used in severe osteoporosis.

Question 33

What is romosozumab?

Answer 33

A monoclonal antibody inhibitor of sclerostin that increases bone formation and reduces resorption.

Question 34

At what steroid dose and duration does osteoporosis risk significantly increase?

Answer 34

Prednisolone ≥7.5 mg/day for ≥3 months.

Question 35

What is the management approach for patients >65 or with previous fragility fracture starting long-term steroids?

Answer 35

Start bone protection immediately.

Question 36

How should patients <65 starting long-term steroids be managed?

Answer 36

Arrange DEXA; management depends on T-score.

Question 37

What is first-line treatment for glucocorticoid-induced osteoporosis?

Answer 37

Alendronate.

Question 38

How should a fragility fracture in a woman ≥75 be managed regarding DEXA?

Answer 38

Start bisphosphonate therapy without requiring a DEXA scan.

Question 39

Which symptoms may indicate vertebral osteoporotic fractures?

Answer 39

Acute back pain, height loss, kyphosis, reduced lung capacity, or asymptomatic incidental findings.

Question 40

What is the male-to-female ratio of vertebral osteoporotic fractures?

Answer 40

1:6.

Question 41

What is the first-line investigation for suspected vertebral fracture?

Answer 41

Spine X-ray to detect wedge compression fractures.

Question 42

Which groups should routinely receive vitamin D supplementation?

Answer 42

Pregnant/breastfeeding women, children 6 months–5 years, adults >65, and people with little sun exposure.

Question 43

Who should have vitamin D levels tested?

Answer 43

Those with bone diseases treatable by vitamin D, before IV zoledronate/denosumab, or with symptoms suggestive of deficiency such as bone pain.

Question 44

Are vitamin D tests required before treating osteoporosis?

Answer 44

Not routinely; supplementation is advised regardless unless deficiency is clinically suspected.

Question 45

How long should oral bisphosphonates be prescribed before reassessment?

Answer 45

At least 5 years.

Question 46

How long should IV bisphosphonates be given before reassessment?

Answer 46

At least 3 years.

Question 47

When may bisphosphonate therapy be discontinued at 5 years?

Answer 47

Patient <75, femoral neck T-score > −2.5, and low fracture risk on FRAX/NOGG.