5. Osteoporosis MT1

Question 1

this is a fracture found at the front of a vertebrae; if a patient has one of these types of fractures, they may be seen as hunched forward

Answer 1

crush fracture

Question 2

true/false: osteoporosis can be primary or secondary

Answer 2

true

Question 3

osteoporosis can affect people at almost any age, it is most common among Canadians __ years of age or older

Answer 3

50

Question 4

a pathological fracture that results from minimal trauma (e.g. a fall from a standing height) or no identifiable trauma at all. The fracture is both a sign and a symptom of osteoporosis.

Answer 4

fragility fracture

Question 5

this comes from osteoclasts; when activated, it triggers bone remodeling. it is the target of denosumab

Answer 5

RANKL

Question 6

what are the two reasons that explain why osteoporosis is more common in females than males

Answer 6

• males have a higher peak bone mass at around 30 y/o
• females have a bone loss due to menopause (estrogen has a bone protective effect which is lost during menopause)

Question 7

is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones (fractures).

Answer 7

osteoporosis

Question 8

what are some indications for measuring bone mineral density

Answer 8

• age of 65 or older
• had fragility fracture after age 40 yrs
• prolonged used of prednisone
• use of other high risk medications (e.g. aromatase inhibitors or androgen deprivation therapy)
• history of parental hip fractures
• smoker
• high alcohol intake
• low body weight or major weight loss
• rheumatoid arthritis

Question 9

if a patient is younger than 50, what are some indications for measuring bone mineral density

Answer 9

• fragility fracture
• prolonged use of prednisone
• use of other high risk medications
• hypogonadism or premature menopause
• malabsorption syndrome (b/c can’t absorb vitamin D or calcium)
• primary hyperparathyroidism (b/c parathyroid hormone helps control bone reabsorption and turnover and therefore here there might be too much bone turnover)

Question 10

a bone mineral density test is done by DEXA which reports a t-score. the T score at _________ is used to estimate fracture risk

Answer 10

femoral neck

Question 11

osteoporosis is characterized by a T score less than or equal to ___ standard deviations below the mean for a young adult reference mean

Answer 11

2.5

Question 12

true/false: the risk of a vertebral fracture can be measured by height loss

Answer 12

true

Question 13

what are some aspects than can contribute to a fall risk assessment

Answer 13

• medications (drowsiness and dizziness)
• stairs/rugs at home
• live alone/what kind of supports they have
• poor vision

Question 14

basic bone health should be encouraged for all individuals over the age of 50. what may this basic bone health consist of?

Answer 14

• regular active weight bearing exercise
• calcium (diet and supplementation) 1200mg daily
• vitamin D 800-2000 IU

Question 15

these two tools provide an estimate of 10 year risk of major osteoporotic fracture; both use the T-score at femoral neck

Answer 15

CAROC (what we will use for exam) and FRAX

Question 16

what are some non pharmacological options for osteoporosis treatment

Answer 16

• regular exercise
• minimizing hazards for falling in home, assess drugs implicated in falls such as benzodiazepines and other psychotropics, improve strength and balance
• smoking cessation
• dietary measures: encourage adequate protein, calcium and vitamin D intake, avoid excessive alcohol intake (> 2 drinks/day) and caffeine (> 4 cups of coffee per day or equivalent)

Question 17

true/false: vitamin D2 (ergocalciferol) is preferred over vitamin D3 (cholecalciferol)

Answer 17

false - other way around! cholecalciferol seen more commonly in pharmacy

Question 18

what are some situations where 25-hydroxy vitamin D deficiency is suspected or where levels would affect response to therapy

Answer 18

• individuals with impaired intestinal absorption
• patients with osteoporosis requiring pharmacotherapy

Question 19

after a patient is started on vitamin D supplementation, when should the serum 25-hydroxy vitamin D levels be checked again

Answer 19

no sooner than 3 months after commencing an adequate supplementation dose

Question 20

true/false: monitoring routine supplement use of Vitamin D and routine screening of otherwise healthy individuals is unnecessary

Answer 20

true

Question 21

what are some side effects of vitamin D

Answer 21

• usually well tolerated
• possible side effects include hypercalcemia, hypercalcuria, renal calcification and renal stones (usually at high doses b/c fat soluble vitamin therefore we don’t pee out the extra if we get too much)

Question 22

true/false: supplementation doses of calcium > 500 mg/day should be in divided doses

Answer 22

true

Question 23

this type of calcium salt is preferred as it has the most elemental calcium; it requires an acidic media (stomach) thus may be more constipating

Answer 23

carbonate (e.g. tums, rolaids, caltrate)

Question 24

this type of calcium salt may be used if a patient has low stomach acid or is on a PPI as the preferred calcium salt requires an acidic media

Answer 24

calcium citrate (e.g. Citrical)

Question 25

what are some side effects of calcium supplementation

Answer 25

• constipation and nausea are the most common side effects
• hypercalcemia, hypercalcuria, renal calcification and renal stones
• may decrease absorption of bisphosphonates, ciprofloxacin, iron, levothyroxine, tetracycline (separate administration by 2h)

Question 26

if a patient is at a low risk of 10 year fracture, what should be the course of action for management

Answer 26

unlikely to benefit from pharmacotherapy therefore reassess in 5y

Question 27

if a patient is at a moderate risk of 10 year fracture, what should be the course of action for management

Answer 27

an x-ray of the spine may aid in the choice of pharmacological tx vs being reassessed in a few yrs. if old fractures are seen: they need pahrmacological tx

Question 28

if a patient is at a high risk of 10 year fracture or has had a prior fragility fracture of the hip or spine or >1 fragility fracture, what should be the course of action for management

Answer 28

good evidence that patient would benefit from pharmacotherapy

Question 29

what is the dose and duration of prednisone that would warrant a patient to high risk of 10 year fracture risk

Answer 29

at least 3 months cumulative therapy in the previous year at a prednisone equivalent dose of 7.5mg daily

Question 30

this treatment option only covers vertebral fractures and not hip or non-vertebral fractures

Answer 30

raloxifene

Question 31

this treatment option only covers vertebral and non-vertebral fractures and does not cover hip fractures

Answer 31

teriparatide

Question 32

this class of medication are the mainstay of osteoporosis treatment. they absorb to bone and form a coating over the bone therefore the osteoclasts are unable to adhere to bone surfaces

Answer 32

oral bisphosphonates

Question 33

in what situations would IV bisphosphonates be preferred over oral bisphosphonates

Answer 33

• those who cannot tolerate the GI side effects of oral agents
• when they cannot adhere to dosing instructions
• when it appears a patient is not responding to an oral agent

Question 34

true/false: adherence with oral bisphosphonates is a major problem

Answer 34

true

Question 35

should oral bisphosphonates be taken on an empty stomach or with food

Answer 35

poorly absorbed therefore should;d be taken on empty stomach (no juice, coffee, milk or mineral water)

Question 36

what are three main counselling points regarding Alendronate and Risedronate

Answer 36

• take on an empty stomach
• take with a full glass of water
• stay upright for 30 mins after taking

Question 37

what are the contraindications for oral bisphosphonates

Answer 37

• pts with hypocalcemia
• CrCl < 35ml/min

Question 38

this bisphosphonate is administered IV. vitamin D must be administered in appropriate doses for >2 weeks prior to the infusion. patients should be told that they may experience flu like symptoms and acetaminophen can be given prior to the infusion and up to 48 hrs after to minimize the severity of the reaction. elderly pts, those who are on diuretics and those who have impaired renal function should be encouraged to drink 500ml of water prior to or during the infusion

Answer 38

zoledronic acid

Question 39

what are some common side effects of bisphosphonates.

Answer 39

• GI symptoms
• altered taste
• nighttime leg cramps

Question 40

what are some rare but more serious more side effects of bisphosphonates

Answer 40

• reflux, esophagitis, esophageal ulcers
• osteonecrosis of the jaw (ONJ)
• “atypical” femoral shot fractures (reported an increase incidence with long term use of bisphosphonates)

Question 41

this medication my be used in postmenopausal women with a history of osteoporotic fracture, multiple risk factors for fracture or in those who have failed or are intolerant to other therapies.
this is a human monoclonal antibody that binds to the receptor activator of nuclear factor kappa-B ligand (RANKL) to habit binding with its receptor on the surface of osteoclast precursors and osteoclasts
it is an injection into the upper arm, thigh or abdomen q 6 months

Answer 41

denosumab (Prolia)

Question 42

true/false: Denosumab needs to be dose-adjusted in renal impairment

Answer 42

false

Question 43

what are some common side effects of denosumab

Answer 43

• flatulence, nausea, decreased Ca, injection site run, limb pain

Question 44

what are some rare side effects of denosumab

Answer 44

ONJ, atypical femur fracture

Question 45

what are contraindications for denosumab

Answer 45

• CrCl < 15ml/min
• pre-existing hypocalcemia

Question 46

this is a first line agent for menopausal females for prevention of vertebral fractures; usually used in breast cancer patients; it is a selective estrogen receptor modulator (SERM). it acts as an estrogen antagonist in breast and uterine tissue, but has estrogen-like activity in bone and lipid metabolism (bone-protective effect)

Answer 46

raloxifene

Question 47

what are some common, less serious side effects of Raloxifene

Answer 47

vasodilation (hot flashes), leg cramps, peripheral edema, flu-like symptoms

Question 48

what are some drug interactions with Raloxifene

Answer 48

• cholestyramine (decrease raloxifene)
• levothyroxine (space 12hr)
  -warfarin (decrease INR)

Question 49

what are some contraindications for Raloxifene

Answer 49

• pregnancy
• previous/active VTE (venous thromboembolism) disorder
• more than 65 y/o due to stroke and VTE risk

Question 50

this medication is first line for post menopausal osteoporosis for secondary prevention of vertebral and non-vertebral fractures with severe OP (decreased bone mineral density) & high fracture risk; is also an alternative if contraindication, failure or intolerance to oral bisphosphonate
- stimulates osteoblast function, increasing GI calcium absorption and increasing renal tubular reabsorption of calcium.

Answer 50

teriparatide

Question 51

what are some contraindications for teriparatide

Answer 51

• pregnancy/nursing
• pre existing increased Ca2+ or CrCl < 30ml/min
• metabolic bone disease (E.g. Pagets disease, hyperparathyroidism, bone metastases)

Question 52

these types of medications are no longer considered first choice for tx of osteoporosis. an increased risk for CVA and VTE significantly outweigh the benefits

Answer 52

hormone therapy (estrogen and progesterone)

Question 53

monitoring: once a pt starts tx for osteoporosis, how often should a repeat measurement of BMD be performed

Answer 53

initially performed after 1-3 years (closer to 1 year for severe pts)