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IPT: MS > Block 2 > Flashcards

Block 2 Flashcards

(101 cards)

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1
Q

Which race and sex has highest fragility fracture rate via osteoporosis?

A

Caucasian/Hispanic women

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2
Q

What is a major predictor factor for osteoporosis?

A

Low bone mineral density

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3
Q

What do osteoclast and osteoblasts do?

A

Clast - resorption, dissolves mineral matrix

Blast - formation, synthesizes new bone in space

Bone loss exceeds formation in osteoporosis

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4
Q

Calcium homeostasis is maintained by what in bone mineral composition?

A

Vitamin D and PTH

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5
Q

Concentration of Vit. D depends on what?

A

Skin conversion

Diet

PTH

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6
Q

What is the most abundant source of Vitamin D?

A

Cholecalciferol (D3)

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7
Q

Conversion of cholecalciferol to calcidiol occurs where? From calcidiol to calcitriol?

A

Calcidiol forms in liver

Calcitriol forms in the kidney

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8
Q

How does estrogen affect BMD loss?

A

Proliferates osteoclasts

Increases calcium excretion and decreases calcium gut absorption

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9
Q

How does testosterone affect BMD loss?

A

Men as they age experience less free testosterone which leads to less estrogen conversion

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10
Q

Which medications are associated with increased bone loss?

A

Glucocorticoids, PPIs, LOOP diuretics (not thiazides)

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11
Q

How is osteoporosis classified?

A

Primary and Secondary

Primary has type I and II

I = Postmenopausal (vertebral and forearms)

II = age-related (>75, vertebral, hip, wrist)

Secondary has type III

III = any age (impaired osteoclast/blast), drug-induced

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12
Q

Lab findings of osteoporosis?

A

DXA = gold standard

T-score of -2.5 or less

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13
Q

Who should get screened for osteoporosis?

A

≥65yo women

Postmenopausal women >50yo

Not for men

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14
Q

What is the FRAX assessment tool? Who is it for?

A

Uses 11 RF and BMD at femoral neck to assess % of major osteoporotic and hip fracture in the next 10 years

Postmenopausal women OR men >50yo

Anyone w/ osteopenia (T score -1 to -2.5

Ppl who have NOT taken osteoporosis Rx

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15
Q

What is the difference between T and Z score?

A

T score is where there is significant difference when compared to young adult reference

Z score is the same except when compared to age matched reference

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16
Q

Bisphosphonates are analogs to what?

A

Pyrophosphate; a bone resorption inhibitor

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17
Q

Bisphosphonates MOA?

A

Stabilizes calcium phosphate

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18
Q

Key structure of bisphosphonates?

A

2 phosphorus groups with 2 alcohols and an oxygen surrounding 1 carbon with 2 R groups

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19
Q

What does R1, R2, and carbon do in bisphosphonates?

A

R1 = enhance binding to hydroxyapatite

R2 = anti-resorptive potency (more N or heterocyclic rings = more potent)

C = enhance stability

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20
Q

Oral bioavailability on bisphosphonates is good/bad?

A

Doodoo

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21
Q

Bisphosphonate AE?

A

GI effects

If inj then injection reactions

Osteonecrosis of jaw

Esophageal erosion

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22
Q

Bisphosphonate CI?

A

Esophageal abnormalities or hypocalcemia

Inability to stand up right for 30 min (60 for ibandronate)

Specific to zoledronic acid = renal impairment

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23
Q

Which RX is an RANKL inhibitor? How does it work?

A

Denosumab

Binds to RANKL which inhibits osteoclastogenesis and increases osteoclast apoptosis

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24
Q

Denosumab AE?

A

Skin infection, hypocalcemia, osteonecrosis of jaw, peripheral edema, HTN

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25
Core structure and side chain of SERMs?
2 aromatic rings connected by a few atoms; helps to mimic estrogen and to bind Flexible side chain which provides anti estrogen effects
26
What are the SERMs?
Raloxifene and Bazedoxifene
27
Whats the relationship between raloxifene and certain estrogen receptors?
Agonists on osteoblast and osteoclast estrogen receptors Antagonist on breast and uterine estrogen receptors
28
Indication of use for SERMs?
Prevents osteoporosis in postmenopausal women
29
SERMs AE?
Thrombosis of retinal vein
30
SERMs DDI?
Only Raloxifene has them Warfarin + Cholestyramine
31
SERMs CI?
Both = VTE, nursing mothers, pregnant Bazedoxifene = h/o uterine bleed, stroke, MI, breast carcinoma, hepatic impairment, thrombophilic disorders
32
Where is calcitonin metabolized?
Kidney
33
Calcitonin hormone mechanism?
Released from thyroid when calcium is elevated
34
Calcitonin CI?
Hypersensitivity to calcitonin-SALMO
35
Teriparatide MOA?
Stimulates Osteoblastic activity
36
Aspirin (reversibly/irreversibly) inhibits COX1/2
Irreversibly Other NSAIDs reversibly
37
Which AA does aspirin target?
Acetylates Serine 529
38
APAP and its metabolite info
APAP metabolized by CYP450 and its metabolite NAPQI is toxic Hepatotoxicity is associated with NAPQI
39
What is produced by COX 1+2 that contributes to CV AE?
COX 1 = TXA2; PLTS and vasoconstriction COX 2 = PGI2; inhibits PLTS and vasodilation Celebrex inhibits COX 2 and does the opposite^^
40
COX 1 or 2 inhibitors contribute more to renal AE
COX 2
41
COX 1 or 2 inhibitors contribute more to GI AE
COX 1
42
Which calcium products require it to be given w/ meals?
All of them except calcium citrate
43
Calcium AE?
Constipation
44
Goal of Vit. D levels?
30-50ng/mL
45
Indication of use for bisphosphonates?
Postmenopausal women (Ibandronate's only use) Male and/or glucocorticoid-induced osteoporosis
46
How should bisphosphonates be given?
Morning on empty stomach Dont administer w/ other supplements or medications
47
Alendronate Ibandronate Risedronate Zoledronic Acid Which one is CI if CrCl <35?
Zoledronic Acid
48
Alendronate Ibandronate Risedronate Zoledronic Acid Which one requires pt to be upright for 60 min after admin?
Ibandronate, the others require 30 min only
49
Alendronate Ibandronate Risedronate Zoledronic Acid Which one is just used for postmenopausal osteoporosis only?
Ibandronate
50
Alendronate Ibandronate Risedronate Zoledronic Acid Which one has IV formulation?
Ibandronate (quarterly use) Zoledronic (yearly)
51
Drug Holidays are used for which drug class?
Bisphosphonates; if used for 5+ years If used for 6-10 years or has h/o of fractures, consider drug holiday at 1-2 years but initiate non-bisphosphonate therapy
52
Can Denosumab be used safely in someone with renal impairment?
Yes
53
Denosumab dosing?
60mg SQ q6months
54
Denosumab CI?
Hypocalcemia Pregnancy
55
Treatment of duration for teriparatide?
2 years Same for abaloparatide
56
Teriparatide dosing?
20mcg SQ QD
57
Teriparatide AE?
HYPERcalcemia Same for abaloparatide
58
Abaloparatide dosing?
80mcg SQ QD
59
Indication of use for teriparatide and abaloparatide?
Teri - Postmenopausal women Male and/or glucocorticoid-induced osteoporosis Abal - postmenopausal women at high risk for fractures
60
Raloxifene vs Bazedoxifene Which one is used in combo with estrogen?
Bazedoxifene
61
Raloxifene vs Bazedoxifene Which one is used in postmenopausal women with a uterus?
Bazedoxifene
62
Romosozumab dosing?
2 consecutive inj of 105mg each
63
Romosozumab duration of Tx?
12 months
64
Calcitonin dosing?
IM/SQ 100u QD Intranasal 200u in one nostril QD
65
Calcitonin interactions and considerations?
Lithium Linked to malignancies Not preferred therapy
66
Which rx for osteoporosis is used for prevention?
Estrogen
67
Estrogen dosing?
0.3mg/day or cyclical
68
What is considered a high risk osteoPENIA pt?
T score -1 to -2.5 AND 10yr % of hip fracture ≥3% OR 10yr% of major osteoporosis related fracture ≥20%
69
When should a pt be considered calcium/vit D supplementation when on steroid therapy?
After ≥3 months of use. Highest bone loss is in the first 3-6 months
70
What is osteoarthritis?
Progressive destruction of articular cartilage usually in older adults ≥65yo
71
Patho behind osteoarthritis?
Damage to articular cartilage leading to increased chondrocyte activity
72
What inflammatory agents have been found in synovial fluid of OA?
IL-1, PGE2, TNF-alpha, NO Crystal or cartilage shards also found in synovial fluid
73
Changes in bone look like what in OA?
Denuded bones from eburnation (dense, smooth and glistening)
74
Where does the pain occur from in OA?
Due to nociception from mechanical and chemical irritants
75
How is OA classified?
Primary (most common and no identifiable cause) Secondary (inflammation, trauma, disease)
76
OA is (symmetrical/asymmetrical)
Asymmetrical
77
NSAIDs are recommended for OA patients that are affected in which region of the body?
Knee, hip, hand (strongly recommended APAP is only conditionally recommended
78
Corticosteroids are recommended for OA patients that are affected in which region of the body?
Strongly recommended for knee or hip OA, conditionally for hand
79
Capsaicin is recommended for OA patients that are affected in which region of the body?
Conditionally for knee CI to hypersensitivity to menthol Dont use the patch for more than 5 consecutive days
80
Duloxetine is recommended for OA patients that are affected in which region of the body?
Conditionally for knee, hip, or hand CI to MAOi within 14 days, zyvox, or methylene blue
81
Tramadol is recommended for OA patients that are affected in which region of the body?
Conditionally for knee, hip or hand
82
End of Life, where do most people want to die vs where do they actually die?
Prefer at home But they mostly die in hospitals
83
Key areas highlighted from SUPPORT Study?
Pt wishes frequently not followed Pain was common 53% of physicians did not know if pt preferred to avoid CPR
84
Palliative Care vs Hospice
Hospice = specialized type of palliative care, reserved for final 6 months Palliative = for serious illness, focuses on managing sx, QOL, provided throughout course of illness
85
Treatment of choice for Dyspnea? General strategies?
Opioids Upright position, leaning position, increase air flow to fae, reduce anxiety Oxygen is NOT helpful in treating sx
86
Dyspnea Opioid Naive pt, MILD pain
Hydrocodone 5mg or Codeine 30mg PO q4h
87
Dyspnea Opioid Naive pt, SEVERE pain
Morphine or Oxycodone 5mg PO q4h or Hydromorphone 1mg PO q4h
88
Dyspnea Opioid Tolerant treatment?
Increase baseline dose by 25-50%
89
Dyspnea breakthrough sx treatment?
Give equivalent dose q1-2hrs PRN and titrate by 50-100% every 24hrs If severe pulmonary disease, start at 50% and titrate at 25%
90
What can be used as adjuncts to dyspnea?
BZDs such as alprazolam and lorazepam (due to short t1/2) DO NOT USE as first line Tx
91
Treatment of choice for constipation?
Stimulants
92
Anorexia and cachexia info?
NOT reversible w/ improved nutrition. It's usually due to disease process
93
Meds to treat the anorexia/cachexia?
Progestins (megestrol, medroxyprogesterone), corticosteroids, cannabinoids
94
Progestin info and AE?
Improves appetite quickly (~1wk) and delayed weight gain Thrombotic events
95
Corticosteroid info?
May improve appetite only, no weight gain
96
Cannabinoid info?
Improves mood and appetite, no effect on weight gain
97
Terminal secretion meds and strategies?
DOC: glycopyrrolate, hyoscyamine Only use suctioning IF absolutely necessary, d/c IV hydration and tube feedings, avoid increasing oral intake
98
Weakness and fatigue Tx?
Corticosteroids, methylphenidate d/c unnecessary rx that worsen fatigue.
99
Which route is used for MAID? Which med are given?
Oral or feeding tube ONLY ``` Barbiturates*Gold standard* (Secobarbital; 9g) BZDs BB Opioids Digoxin ```
100
What are the 2 regimens used in MAID?
DDMP 1 or 2 Diazepam 500 or 1g Digoxin 25 or 50mg Morphine 10 or 15g Propranolol 2g
101
What are the adjunct agents for MAID?
Metoclopramide 20mg; start 1 day prior and again 1hrs prior Zofran or haldol

IPT: MS (3 decks)

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