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PHAR 255 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Cortical bone description?

A

80% of bone wt
dense outer shell

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2
Q

Cancellous bone description?

A

20% bone wt
porous interior structure

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3
Q

Osteoblast?

A

build bone through synthesis of collagen matrix

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4
Q

group of osteoblasts?

A

hydroxyapatite

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5
Q

Osteoclast?

A

reabsorbs bone
homeostasis control of acid-base, Ca, and PO4

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6
Q

Osteocyte?

A

regulate rate of bone mineralization

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7
Q

What happens when remodeling balance becomes negative?

A

BMD declines

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8
Q

what does Vit D regulate?

A

Ca

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9
Q

what does osteocyte death lead too?

A

increased surface remodeling
replacement with weaker mineralized connective tissue
disruption in repair signaling
decrease in bone vascularity

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10
Q

most common fracture?

A

vertebral fracture followed by hip then distal forearm

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11
Q

Risk factors for osteoporosis?

A

age
race
Ca intake during growth
menopause
family history
sex
small stature
wt
medications, lifestyle, previous falls and fractures

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12
Q

Medical condition risk factors for osteoporosis?

A

oophorectomy
hypogonadism or premature menopause
hyperparathyroidism
hyperthyroidism
cushings
multiple myeloma
malabsorption sydromes
chronic inflammatory disease

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13
Q

Drug risk factors for Osteoporosis?

A

androgen deprivation therapy
anticoagulants
antidepressants
antiepileptics
antineoplastics
antiretrovirals
calcineurin inhibitors
glucocoticoid therapy > 3 months
loop diuretics
PPIs
thyroid supplementation excess
Vit A excess/ retinoids
SGLT2i
thiazolidinediones

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14
Q

Presentation of osteoporosis?

A

no symptoms until fracture occurs
unexplained pain and height loss idicative of vetebral fracture

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15
Q

Diagnosis of osteoporosis?

A

vetebral compression fracture , hip fracture, > 1 fragility fracture over 50 years of age.

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16
Q

Differentiation of osteopenia and osteoporosis?

A

osteoporosis: BMD T-score <= 2.5 SD normal peak
osteopenia: BMD T-score -1–2.5 SD normal peak

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17
Q

Who should be screened for osteoporosis?

A

over 50
low risk reassessment in 5 years
moderate risk reassess in 1-3 years

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18
Q

what to assess for fracture risk and osrteoporosis?

A

history
physical exam
biochemical tests
BMD in some
Risk assessment tools
Vertebral imaging for some

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19
Q

Major wt loss %?

A

> = 10% of wt at age 25

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20
Q

Biochemical tests to be done?

A

Ca, corrected for albumin
PO4
SCr
alkaline phosphatase
TSH
23-OH-D

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21
Q

tool used to measure BMD?

A

dual-energy X-ray absorptiometry (DXA)

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22
Q

What age to use T score vs Z score?

A

under 50 Z score
over 50 T score

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23
Q

Who is indicated for a BMD test?

A

postmenopausal women
over age 70
over age 65 w/ 1 clinical risk factor
age 50-64 w/ previous osteoporotic related fractures or 2+ clinical risk factors for fractures

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24
Q

risk factors indicated for BMD?

A

previous fracture after age 40
glucocorticoid use > 3 months in last year
falls >= 2 in last year
BMI of <20
smoker
alcohol use of >=3 drinks/d

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25
Q

what dose of prednisone is a risk factor for osteoporosis?

A

> 5mg/d

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26
Q

Risk assessment tools used in Canada?

A

CAROC
FRAX

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27
Q

How is CAROC stratified? what is it assessing?

A

3 zones;
low: <10%
moderate
High >20%
10 year risk of fracture

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28
Q

Non-pharm strategies to prevent fracture?

A

Lifestyle modification:
- exercise
- fall prevention
- smoking cessation
- alcohol reduction
- reduced caffeine
- Ca
- Vit D

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29
Q

Pharmacological options for osteoporosis?

A

Primary: Bisphosphonates, Denosumab
Secondary: Raloxifene, Teriparatide, Hormone THerapy
Last options: Calcitonin, combo therapy

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30
Q

Calcium daily intakes for men and women?

A

Men:
51-70: 1000mg/d
>70: 1200mg/d
Women:
>50: 1200mg/d

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31
Q

Ca supplement %’s?

A

Carb: 40%
Citrate: 21%
Lactate: 13%
gluconate: 9%

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32
Q

WHat Ca supplement is prefered if pt on a PPI?

A

citrate

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33
Q

Dosing of Ca w/ potential saftey issues?

A

over 2000mg/d
associated w/ CVD, dyspepsia, constipation, nephrolithiasis

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34
Q

Vit D daily intake?

A

Men and women:
<= 70: 600 IU/d
>70: 800 IU/d

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35
Q

Is routine monitoring of Vit D needed?

A

No

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36
Q

When is pharmacotherapy recommended flr females and males above 50 yrs old for fracture risk?

A

if high risk (>20%) or
T-score <= -2.5 and older than 70

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37
Q

How to bisphosphonates work?

A

bind strongly to hydroxyapatite undergoing remodeling; inhibt osteoclast activity, second gen promote osteoclast apoptosis

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38
Q

Are bisphosphonates covered?

A

EDS drugs

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39
Q

What is the difference between Fosamax and Fosavance alendronate?

A

Fosavance has Vit D

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40
Q

WHich bisphosphonate is administered via IV oncer yearly?

A

zoledronic acid, 5mg/100mL

41
Q

Dosing of alendronate?

A

10mg OD or 70mg once weekly

42
Q

Dosing for risedronate?

A

5mg OD
35mg once weekly or
150mg once a month

43
Q

How do you take IR bisphosphonate tablets?

A

spaced from all other meds b/c low F,
take w/ one cup of water before food, other liquids, and meds and remain upright for 30 minutes

44
Q

How do you take DR bisphosphonate tablets?

A

spaced from all other meds b/c low F, take w/ one cup of liquid right after breakfast and remain upright for 30 minutes

45
Q

How is zoledronic acid given?

A

once yearly via 15 minute IV infusion

46
Q

Onset of bisphosphonates?

A

weeks to see bone changes, years to obseve clinical benefit

47
Q

SEs of bisphosphonates?

A

GI, abdominal pain, NDC, dyspepsia, headache, dizziness, musculoskeletal pain

48
Q

Difference in SEs with zoledronic acid?

A

infusion reaction, NO GI issues

49
Q

What does bisphosphonate do to Ca?

A

transient decrease in blood Ca levels

50
Q

Major jaw SE w/ bisphosphonates?

A

Osteonecrosis of the jaw
Usually seen in cancer pts, immunocompromised, high dose zoledronic acid, invasive dental procedures, smokers, daibetes

51
Q

Serious SE of bisphosphonates seen around 7 years of therapy?

A

Atypical sub-trochanteric fractures

52
Q

Other serious SEs of bisphosphonate?

A

severe musculoskeletal pain
AKI
Afib
esophagitis, reflux, and ulcers
esophageal cancer

53
Q

Precautions w/ bisphosphonates?

A

pregnancy –> can accumulate in fetal bones

54
Q

CI’s of bisphosphonates?

A

esophageal abnormalities
inability to stand/sit for 30 minutes
hypocalcemia
CrCl under 35mL/min

55
Q

Duration of therapy for bisphosphonates?

A

3-6 years suggested but, needs to be individualized

56
Q

What kind of drug is denosumab? (prolia)

A

biologic

57
Q

Role of denosumab?

A

when pts can’t adhere to bisphosphonates
Intolerant to oral bisphosphonate
Severe renal impairment

58
Q

Onset of denosumab?

A

maximal reduction at 1 month, some seen at day 3

59
Q

Duration of therapy for denosumab?

A

indefinite b/c benefits lost rapidly upon d/c of drug

60
Q

Dosage form of denosumab?

A

pre-filled SQ syringes

61
Q

At what GFR is denosumab not used?

A

not recommended below 15mL/min

62
Q

SE to worry about for denosumab?

A

hypocalcemia; drug causes a major transient decrease of Ca levels

63
Q

Serious SEs of denosumab?

A

osteonecrosis of the jaw
atypical fractures
Rebound fracture risk upon d/c

64
Q

CI’s of denosumab?

A

hypocalcemia
Pregnancy and lactation

65
Q

difference between bisphosphonate and denosumab efficacy?

A

similar efficacy but, A/E risk slightly higher with denosumab

66
Q

Raloxifene MOA?

A

selective estrogen receptor modulator

67
Q

Raloxifene onset and duration?

A

Years to observe maximum BMD changes
lifelong therapy usually

68
Q

Dosing for Raloxifene?

A

Tablet once daily, cautioned in under 50mL/min

69
Q

SE’s of Raloxifene?

A

flushing, flu-like, leg cramps, peripheral edema, increase in triglycerides

70
Q

Serious SEs of Raloxifene?

A

Venous thromboembolism, Stroke

71
Q

Highest risk for thromboembolism with raloxifene?

A

in first 4 months of therapy

72
Q

CI w/ raloxifene?

A

pregnancy
history of clots

73
Q

Raloxifene DI’s?

A

decreases absorption of levothyroxine
bile acid sequesterants decrease absorption of raloxifene

74
Q

Monitoring for raloxifene?

A

same as bisphosphonates
+ lipid profile to monitore hypertriglyceridemia

75
Q

Who is raloxifene ineffective in?

A

premenopausal women

76
Q

Duration of therapy for raloxifene?

A

longterm

77
Q

What is the place for hormone therapy?

A

to prevent menopausal associated bone loss

78
Q

Dosing forms for hormone therapy?

A

oral, patch

79
Q

Risks w/ hormone therapy?

A

increased endometrial/ breat cancer risk
clots
CHD risk increase
stroke risk
urinary incontinence

80
Q

Why is teriparatide not 1st line?

A

very expensive

81
Q

When is teriparatide used?

A

very low BMD
prior fragility fractures who continue to have fractures w/ other therapies
BMD continues to decrease w/ other treatments

82
Q

dosage form of teriparatide?

A

SQ injection once daily in thigh or abdomen

83
Q

length of therapy for teriparatide?

A

2 years –> but recently changed by FDA

84
Q

SEs of teriparatide?

A

Nausea
dizziness
leg cramps
orthostatic hypotension

85
Q

Serious SEs of teriparatide?

A

hypercalcemia
hypercalciuria
osteosarcoma

86
Q

Precautions of teriparatide?

A

history of renal stones
moderate renal impairment
pre-existing orthostatic hypotension

87
Q

CI’s of teriparatide?

A

pre-existing hypecalcemia
severe renal dysfunction
hyperparathyroidism
history of bone cancers
pergnancy or lactation

88
Q

Monitoring of teriparatide?

A

Ca, SCr, PO4, ALP,
Ca monitored every 3-6 months

89
Q

Romosozumab dosage form?

A

SQ injection monthly

90
Q

duration of therapy for romosozumab?

A

12 months

91
Q

When is romosozumab used?

A

for men and women with highest fracture risk

92
Q

SE’s of romosozumab?

A

musculoskeletal/ joint discomfort
headache
injection site pain

93
Q

serious SEs of romosozumab?

A

osteonecrosis of the jaw
atypical fractures
MI
stroke

94
Q

CI’s of romosozumab?

A

pre-existing hypocalcemia
pregnancy and lactation

95
Q

What needs to be monitored w/ romosozumab?

A

Ca

96
Q

What benefits does combo therapy provide?

A

provides benefits to BMD but not to additinal fracture benefit

97
Q

what may the combo of estrogen and bisphosphonate increase?

A

risk of atypical fractures

98
Q

Main thing to assess for with treatment failure?

A

adherence

99
Q

when is BMD testing repeated when a pt is on pharmacotherapy?

A

3 years

PHAR 255 (14 decks)

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