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Q1: Definition and recognition (2 min)
Examiner: Define osteoporosis. How is it recognised, and why is it a problem?
Expected answer:
- Osteoporosis = a systemic skeletal disease of low bone mass and microarchitectural deterioration, increasing bone fragility and fracture risk.
- It is operationally defined by a DEXA T-score of minus 2.5 or less at the femoral neck, total hip or lumbar spine; osteopenia is minus 1.0 to minus 2.5.
- A low-trauma (fragility) fracture establishes the diagnosis regardless of the T-score.
- It is usually silent until a fracture. Hallmarks are fragility fractures of the hip, vertebrae and distal forearm, plus loss of height and thoracic kyphosis from vertebral collapse.
- It matters because hip fractures carry 20 to 30 percent one-year mortality and major loss of independence, yet the disease is largely preventable.
Q2: Investigations and risk (3 min)
Examiner: How do you investigate and risk-stratify a patient?
Expected answer:
- DEXA of the lumbar spine, total hip and femoral neck is the gold standard; report the T-score.
- FRAX integrates clinical risk factors (age, BMI, prior fracture, parental hip fracture, smoking, glucocorticoids, rheumatoid arthritis, secondary causes, alcohol) with or without femoral-neck BMD to give the 10-year probability of hip and major osteoporotic fracture and guide treatment, especially in osteopenia.
- Vertebral fracture assessment on DEXA or a lateral thoracolumbar spine X-ray finds silent vertebral fractures.
- Screen for secondary causes: calcium, phosphate, ALP, 25-hydroxy vitamin D, renal and liver function, TSH; in men add testosterone; consider PTH, 24-hour urinary calcium, protein electrophoresis, coeliac serology.
- A key discriminator: in osteoporosis calcium, phosphate and ALP are normal (unlike osteomalacia, myeloma, hyperparathyroidism, Paget disease).
Q3: Management (3 min)
Examiner: Walk me through the management.
Expected answer:
- Baseline for all: weight-bearing and resistance exercise, smoking cessation, limit alcohol, fall prevention, calcium 1000 to 1200 mg per day, vitamin D 800 to 1000 IU per day.
- First-line drug: a bisphosphonate - oral alendronate weekly or risedronate, or IV zoledronate annually; reduce vertebral, hip and non-vertebral fractures.
- Alternatives: denosumab (RANKL monoclonal antibody, subcutaneous every 6 months).
- Anabolic therapy - teriparatide (PTH 1-34) or romosozumab - for severe or very-high-fracture-risk disease, then followed by an antiresorptive.
- Glucocorticoid-induced osteoporosis needs prophylactic bisphosphonate plus calcium and vitamin D for prednisolone over 7.5 mg per day for over 3 months.
- Drug holiday after 3 to 5 years of a bisphosphonate in stable, lower-risk patients.
- Never stop denosumab without transitioning to a bisphosphonate (rebound vertebral fractures).
Q4: Complications and prognosis (2 min)
Examiner: What are the complications, and how do you counsel her on prognosis?
Expected answer:
- Fragility fractures: hip (high mortality and loss of independence), vertebral (pain, kyphosis, respiratory restriction), distal forearm.
- A prior fragility fracture roughly doubles the future fracture risk.
- Drug-related: rare atypical femoral fracture and osteonecrosis of the jaw with long-term bisphosphonate (balanced by a drug holiday); rebound fractures if denosumab is stopped without a transition.
- Teriparatide is avoided after prior skeletal radiation or malignancy (theoretical osteosarcoma risk).
- With treatment, vertebral fracture risk falls 40 to 70 percent and hip fracture risk 25 to 50 percent; non-adherence is the main real-world barrier, so review the DEXA every 1 to 3 years and reinforce adherence.