Osteoporosis-1

Mrs. Patel is a frail (BMI 18) lady of 72 years with well-controlled asthma using
high dose steroid inhalers and occasional oral courses during an exacerbation. She
came in to show you her wrist, which is in a plaster cast. She wants your opinion as
the orthopedic consultant has said she has got osteoporosis and wants to send her
for a special X-ray and start treatment.
1. How is osteoporosis characterized?
- Decreased bone mineral density / increased skeletal fragility /
increased risk of fractures.
2. What are the risk factors for this condition, and which of these is
relevant to Mrs. Patel?
- Modifiable: Low calcium intake/Excessive alcohol intake/Cigarette
smoking/Sedentary lifestyle/Low mobility.
- Non-modifiable: Advanced age/Female sex/Caucasian or
Asian/Family history/Small stature/Early menopause/Immobility.
- Related to Mrs. Patel: advanced age 72 years/high doses of inhaled
corticosteroid and occasional oral doses.
3. What is the special X-ray and what do the results indicate?
-DXA (Dual-energy X-ray absorptiometry), indicates the risk of
fracture.
4. What are the goals of therapy in this case?

- Preventing fractures and their complications / Maintaining or

increasing BMD / Preventing secondary causes of bone loss /
Reducing morbidity and mortality associated with osteoporosis.

5. What drug treatments are available? Comment on their advantages

and disadvantages with regards to Mrs Patel, using the latest evidence.
- Bisphosphonates (alendronate)
- Advantages: increases BMD / decreases fracture
- Disadvantages: High incidence of GI side effects e.g., Esophageal /
gastric / duodenal irritation / perforation / ulceration / bleeding,
Complicated dosing requirement.
6. What monitoring would be required if Mrs. Patel was prescribed
alendronate 70 mg weekly?
- Efficacy: BMD & fractures.
- Safety: side effects.
7. What other measures would patients with this condition need to take?
- Pharmacologically: Calcium and vitamin D.
- Non-pharmacologically: exercise / balanced diet.
 Osteoporosis-2
Mrs TY is a 77-year-old woman who has been admitted to the orthopaedic ward
where you work as the clinical pharmacist. She slipped on the wet floor in a
supermarket and has been diagnosed with a fractured hip. She is normally fit and
well and doesn’t take any regular medication or have any relevant past medical
history. She is 157 cm tall and weighs 49 kg. She lives alone, has never smoked
and drinks a small glass of wine most nights. Mrs TY is in considerable pain
(given 5 out of 10 on the pain scale) from her fracture.
1a What recommendations could you make to help manage her pain?
- Moderate pain (5/10 on scale): paracetamol + codeine.
1b What are the contraindications and cautions for the analgesics you are
recommending?
- Paracetamol: liver hepatotoxicity
- Codeine: Dependence / respiratory depression / constipation.
- Caution in asthma & COPD patients.
1c Are there any adjunctive treatments you would recommend to the doctor
that can be prescribed?
- Counter irritants (Capsicum).
1d What parameters would you monitor in this patient?
- Osteoporosis: BMD.
- Pain: pain relieved / respiratory function / signs of dependence /
bowel movement.
2a Later in the week Mrs TY has surgery to repair her hip fracture. She is
also diagnosed with osteoporosis. What is osteoporosis?
- Is a metabolic bone disease characterized by increased skeletal
fragility and thus exposing the patients to fractures arising from
trivial activities.

2b What is the difference between primary and secondary osteoporosis?

- Primary: unknown cause.
 - Secondary: caused by drugs or other diseases / found in elderly and
postmenopausal women.
2c Which drugs may be implicated in the development of osteoporosis?
- Thyroid drugs / antiepileptics / NSAIDs.
2d What are the signs and symptoms of osteoporosis?
- Asymptomatic.
2e What are the risk factors for osteoporosis and which does Mrs TY have?
- Advanced age / female / postmenopausal.
2f What lifestyle advice could you offer to Mrs TY?
- Diet should be high in vitamin D and calcium / exercise / low caffeine
/ reduce or stop alcohol.
3 Discuss the options for the treatment of osteoporosis and decide which you
think would be the most suitable for Mrs TY.
- Bisphosphonates (Alendronate) / calcium and vitamin D.
4a On discharge, Mrs TY was prescribed alendronate 70 mg once weekly &
calcium and vit. D preparation, 1 tablet twice a day. What are the indications
for alendronate?
- For osteoporosis.
4b How does alendronate work?
- Increases BMD / decreases fractures.
4c What are the side-effects of alendronate?
- GI side effects e.g., Esophageal / gastric / duodenal irritation /
perforation / ulceration / bleeding, Complicated dosing requirement.
4d What advice would you give to Mrs TY regarding the taking of her
alendronate?
- Drug must be taken whole on an empty stomach with a full glass of
water and in upright position for 30 minutes after taking the
medication to improve absorption and reduce the risks of esophageal
reactions.
 5 Mrs TY tells you that she has heard of a new treatment called teriparatide
from a friend who came to visit her in hospital. She wonders if it would be
good for her. Discuss whether this would be a suitable option for her. How
would you answer Mrs TY’s question?
- Teriparatide is only prescribed if the response to bisphosphonates is
insufficient.
 Rheumatoid Arthritis-1
Mrs. PJ is a 67-year-old woman who has recently attended the hospital’s
rheumatology clinic. She has been diagnosed with rheumatoid arthritis. She has
come to the community pharmacy where you work to collect her prescription for
methotrexate and diclofenac.
1. What is rheumatoid arthritis?
- Is a chronic, progressive inflammatory disorder of unknown etiology
characterized by polyarticular symmetric joint involvement and
systemic manifestations.
2. What are the risk factors for developing rheumatoid arthritis?
- Age (35-50) / Gender (Female more) / smoking / stress / family
history.
3. What are the clinical features of rheumatoid arthritis?
- Pain / morning stiffness.
4. What investigations are performed to help confirm a diagnosis of RA?
- Positive rheumatoid factor / elevated ESR / elevated C-reactive
protein / CBC.
5. The major treatments for rheumatoid arthritis include NSAIDs and
DMARDs.
6. What do the abbreviations NSAID and DMARD stand for &what is the
difference?
- NSAID (Nonsteroidal anti-inflammatory drugs), provide
symptomatic treatment only and doesn’t work on the disease or its
progression, used in case of inflammation, used in bridging therapy
for its fast onset of action.
- DMARD (Disease-modifying antirheumatic drugs), act on the disease
by delaying its progression / delaying joint damage, it has a potent
effect, used in case of NO inflammation, has slow onset.
7. State the common side-effects of methotrexate. How would you monitor
it?
 - Side effects: folic acid deficiency / anemia / elevation in liver function
test.
- Monitoring: LFT / renal function test.
8. List the formulations of methotrexate that are currently available.
- Oral and injections.
9. When you hand Mrs PJ her dispensed prescription, what information
or help would you give her to ensure that she knows how to use her
medications appropriately?
- MTX (Once weekly) / Folic acid (Once weekly) / NSAIDs decrease
the secretion of MTX so separation between two drugs must be done
(12h before / 12h after = total 24h).
 Rheumatoid Arthritis-2
Mrs MT is a 67-year-old woman with rheumatoid arthritis. Her current prescription
includes: methotrexate 15 mg once weekly, folic acid 5 mg once weekly,
diclofenac 50 mg 3x daily, paracetamol 1 g up to 4x daily PRN. She collected her
first prescription 10 days ago. She has returned to the pharmacy and asks to speak
to you. She has several problems with her medication which she wishes to discuss.
First, she complains that her medication is not working properly as she has not
noticed any benefit from it. She asks you whether you think she should make an
appointment with her GP to discuss this.
1. How is the dose of methotrexate normally initiated and titrated?
- Once weekly (maximum 20mg).
2. Why is the dose increased gradually?
- To improve the response to oral MTX.

3. Why was the patient prescribed folic acid?

- To prevent folate depleting reactions (stomatitis, diarrhea, nausea,
alopecia, myelosuppression, and elevations in LFTs).

4. What advice would you give Mrs. PJ in answer to her question?

- Delay in response to drugs because DMARD have slow onset of
action (2-3 weeks).
5. Mrs MT also mentions that she must go to her practice nurse for some
blood tests. What are these tests & why they are performed?
- LFTs (Hepatotoxicity) / RFTs (Drug is excreted renally) / CBC
(Myelosuppression).
6. Should the diclofenac be continued forever since the disease is chronic
and why?
- NO, because diclofenac is NSAIDs which provide only symptomatic
relieve, and associated with GI and cardiovascular side effects.
Six months later, Mrs MT returns to your pharmacy. She says that she still has not
had much benefit from her treatment despite the fact that her dose has been titrated
to an appropriate level.
7. What are the goals of therapy when treating rheumatoid arthritis?
- Reduce or eliminate pain / Protect articular structures / Control systemic
complications / Prevent loss of joint function / Improve or maintain quality of
life.

8. List other treatment options that may be used in the management of RA

in Mrs. PJ and briefly discuss when an alternative treatment would be
used.
- DMARDs (MTX) / Leflunomide / Hydroxychloroquine /
sulfasalazine
- Alternatives: combination of (MTX + Leflunomide) / (Leflunomide +
Hydroxychloroquine)
- Biologics are given only in case of failure response to 1st line drugs.
 Osteoarthritis
Mrs KR is a 70-year-old woman who weighs 80 kg and is 162 cm tall. Her BMI is
30 kg/m2. Mrs KR lives alone and has no immediate family in this country. Her
past medical history includes osteoarthritis and hypertension. Her medication
includes: lercanidipine 10 mg daily, bendroflumethiazide 2.5 mg daily, diclofenac
50 mg 3x daily, paracetamol 1 g 4x daily. Her BP is 138/85 mmHg and her
haemoglobin is 13.1 g/dL (12–18 g/dL). She has been admitted to hospital
complaining of abdominal pain and chest pain. After an ECG, which is normal and
various other tests, a cardiac problem is excluded and it is decided that she requires
endoscopy.
1. Why do you think endoscopy might be being performed?
- Patient may have a peptic ulcer.
2. Mrs KR has had her BP & Hb level checked, why is that?
- Hb: might have GI bleeding (blood in urine).
- BP: could be affected by NSAIDs and cause GI bleeding.
3. Mrs KR is subsequently diagnosed with gastritis. Which of her
medicines may have caused this?
- Diclofenac.
4. What advice would you give regarding the management of this
problem?
- Take diclofenac after food / stop it and take alternative (Celecoxib).
5. Mrs KR is taking analgesics to manage the symptoms of her
osteoarthritis. What is osteoarthritis?
- Is a chronic, progressive condition, primarily affecting women, that
causes loss of articular cartilage in the hands, knees, hips, and
cervical and lumbar spine.

6. What are the signs and symptoms of osteoarthritis?

- Joint pain / reduced range of motion / brief joint stiffness after
period of inactivity.
 7. What risk factors may predispose patients to getting osteoarthritis and
which risk factors does Mrs KR have?
- Modifiable risk factors: obesity / joint trauma.
- Non-modifiable risk factors: advanced age / gender / genetics.
- Metabolic conditions.
8. What non-drug recommendations could you give her regarding the
management of osteoarthritis?
- Education / exercise / weight loss / cognitive behavior intervention.
9. Mrs KR is using diclofenac, an NSAID to manage the symptoms of her
osteoarthritis. How do NSAIDs work in the treatment of osteoarthritis?
- Diclofenac is a only symptomatic pain reliever, used only in case of
inflammation / in case if no benefit from paracetamol.
10. What are the contraindications and cautions for the use of diclofenac?
- CI in Peptic ulcer disease patients.
- Caution in renal impairment patients.
11. Critically appraise the alternative treatments available for
osteoarthritis?
- Opioids (oral / transdermal), used cautiously if failure to 1st line
agents (dependence)
- Capsicum.

A year later, the GP refers Mrs KR to her consultant as she has been having
difficulty walking and severe pain in her knee joint. The consultant discusses her
condition and mentions the possibility of surgery as the joint is badly affected.
12. What are the surgical options available for Mrs KR?
- Joint replacement surgery.
13. What are the options available for relieving Mrs KR post-operative pain?
- Patient controlled analgesia (PCA), morphine is the typical agent in PCA
with 10 minutes lock out interval.