Rheuma

Question 1

Diagnosis criteria of OP

Answer 1

Any of the following

(1) fragility fracture hip or spine
(2) low BMD < 2.5
(3) high FRAX score and T score < -1
(4) fragility fracture and T score

Question 2

Dx criteria of osteopenia

Answer 2

T score -1 to -2.5

Question 3

Initial investigations after diagnosis of OP

Answer 3

1) Calcium corrected with albumin
2) CBC
3) creatinine
4) Alkaline Phosphatase
5) TSH

#### 
SPEP - if vertebral fracture 
- Vit D (25-Hydroxy) level 
- phosphate 
- albumin 
- LFTs 
- PTH
- anti-TTG

Question 4

SSx to suspected vertebral fractures

Answer 4

1) Height loss: prospective > 2cm or historical > 6cm
2) rib to pelvis < 2cm or 2 fingerbreadths
3) Kyphosis: occiput-to-wall > 5 cm
=> management: lateral thoracic + lumbar spine x-ray

Question 5

Indication of lateral thoracic + lumbar spine x-ray

Answer 5

1) SSx suspicious of vertebral # OR

2) moderate risk CAROC or FRAX

Question 6

Indications for BMD if < 50 y/o

Answer 6

• fragility fracture
• prolonged glucocorticoid use (total 3 mon > 7.5mg/d)
• high risk meds (aromatase inhibitor, androgen deprivation therapy, anti-convulsnts)
• hypogonadism or premature menopause ( < 45 y/o)
• malabsorption syndrome
• primary hyperparathyroid
• other disorders associated with bone loss # (RA)

Question 7

Indications for BMD if > 50 y/o

Answer 7

• > 65 y/o
• parental hip #
• vertebral #/ osteopenia
• current smoker
• high EtOH intake > 3 /day
• low body weight < 60kg or major weight loss > 10% at 25 y/o

Question 8

Indications to consider pharmacotherapy for OP

Answer 8

(1) moderate risk of # (10-20% in 10 yrs) + risk factors
(2) high risk of # (>20% in 10 yrs) - ased on CAROC or FRAX
(3) prior hip or spine fracture or >=2 fragility fracture

Question 9

1st line pharmacotherapy for OP in menopausal women

Answer 9

1) bisphosphonate
1) Denosumab 60mg subcutaneous every 6 months
1) Very high risk: abaloparatide, teriparatide x 2yr then bisphosphonate

Question 10

Risk factors to consider pharmacotherapy with moderate fracture risks (10-20%)

Answer 10

• additional vertebral fracture
• previous wrist fracture in > 65 y/o and T score <2.5
• lumbar spine T-score «_space;femoral neck T-score
• long-term/repeated systemic glucocorticoid use
• recurrent falls
• rapid bone loss

Question 11

How to monitor patients with low risks of OP

Answer 11

reassess FRAX/ BMD in 5 years

Question 12

How to monitor pt with moderate /severe risks of OP

Answer 12

repeat BMD q1-3 years until stable, and reassess risk factors

Question 13

Secondary cases of OP

Answer 13

Endocrine»_space; acromegaly, DM, Cushing’s, hyperparathyroidism, hyperthyroidism, hypogonadism, prophyria, pregnancy

GI/ nutrition»_space; alcoholism, anorexia, calcium/vit D deficiency, chronic liver disease, malabsorption (celiac, Crohn’s, CF, gastric bypass)

Drugs: anti-epileptic, medroxyprogesterone, glycocorticoids, GnRH, lithium, aromatase inhibitor, PPI, SSRI, heparin, TZD, SGLT2i

Others: EtOH, AIDS/HIV, hypercalciuria, MDD, myeloma, CKD, RA, thalassemia

Question 14

prevention of OP

Answer 14

• exercise - weight bearing
• smoking cessation
• EtOH < 2/day
• avoid high sodium + high protein
• home safety assessment/ fall risk reduction, consider PT
• cataract removal
• hip protectors in LTC