Bones Flashcards
Osteopersosis
- Fragility of skeleton due to loss of bone architecture
- Most common in post menopausal women [primary or type I osteoporosis]
- Can also be seen from other disease states—hyperthyroidism, use of steroids, anti-seizure or blood thinning agents [secondary osteoporosis]
Type I Osteoperosis
caused by post menopause-cause by bone resorption that is out of proportion to bone formation
Therapy for osteoperosis
• Adequate dietary Calcium and Vitamin D
• Weight bearing exercise [it stimulates bone growth]
• Smoking cessation; avoidance of ETOH [both mute bone formation]
• Avoid [if possible] drugs that increase bone loss—steroids, anti-psychotics, anti-epileptic agents, others
• When these drugs must be used—baseline DEXA should be done and then yearly while on these
medications
Secondary osteoperosis
is defined as bone loss that results from specific, well-defined clinical disorders. Many times reversible, secondary causes of bone loss are not considered in a patient with low bone mineral density (BMD).
Difference between osteopenia and osteoporosis
Bone density of -1.0 to -2.5 is osteopenia
Bone density of -2.5 or below is osteoporosis
Bone Density (DEXA scan)
• Compares thickness of bones to a normal
• In young adults, compared to an aged matched control and Z score is evaluated
• In middle aged and older adults, compared to a 35 y/o adult, same gender, comparable height, weight and
race and T score is evaluated
• Patient’s score [Z or T] is used to decide if
treatment needed—a score of -2.5 or
more standard deviations below normal
is osteoporosis
What do bisphosphonates do?
decrease osteoclast bone resorption
FRAX score (fracture risk assessment tool)
A FRAX score indicates the risk of a fracture in a person with osteoporosis. Doctors can use it to determine the best measures to prevent fractures and treat the condition.
BISPHOSPHONATE:
Drug name: Alendronate
Brand Name: Fosamax and Binosto
Can be given daily or weekly
• Binosto is an effervescent tablet
• Given in AM with 4-8 ounces of water 30-60” AC breakfast [no recumbancy for 30-60”]
• Thought to have worst GI side effect profile
• Approved for prevention and treatment of osteoporosis of hip and spine
• Rapidly cleared from plasma—binds to hydroxyapalite in the bone; once bound they are
cleared over months to years; renally eliminated [cannot be given in severe renal disease—
GFR <35 cc/min]
• ADE—GI distress, esophagitis, osteonecrosis of jaw [associated with high doses over long
periods3 consecutive years]; atypical fractures [seen with long term use]
BISPHOSPHONATE
Drug name: Risedronate
Brand name: Actonel, Atelvia Route: PO Approved use for: hip and spine disease DOSAGE: 35 mg (weekly) PO 150mg (monthly) PO 35 mg pc (weekly)
BISPHOSPHONATE
Drug name: Ibandronate
Brand name: Boniva
Route: PO or IVP
Approved use for: spine disease
BISPHOSOPHONATE
Drug name: Zoledronic acid
Brand name: Reclast, Zometa
Route: IV infusion YEARLY
Approved use for: hip and spine disease
*contraindication: heart issues or high risk for a fib ; can have some flu like symptoms
second line agents for osteoperosis
- estrogens
- younger, healthy women for short amount of time - selective estrogen receptor blockers
- given for people intolerant to bisphosphonates, hx breast cancer, contraindicatated for women with hx of DVT, stroke, etc
SE: hot flashes
Selective Estrogen Receptor Blockers
Drug name: Raloxifene (EVISTA)
Brand name: Evista
- Oral daily agent – used for women intolerant to bisphosphonates
- It has estrogen like effects on bone and estrogen antagonistic effects on breast and endometrium
- This agent also lowers LDL cholesterol
- CONTRAINDICATED in women with prior history of thromboembolic disease [DVT, stroke, etc.]
- Main SE—HOT FLASHES!! MAJOR! 35% IN WOMEN
Selective Estrogen Receptor Blockers
Drug name: DUAVE (Bazedoxifne/conjugated estrogens)
Brand name: Duavee
• 0.45/20 [1] tab daily
• Approved for vasomotor sx of menopause and osteoporosis prevention
• Estrogen + SERM—CANNOT be used in those with INTACT UTERUS; hx of breast, endometrial, ovarian cancers
- ADE—thromboembolism
- Same precautions as for estrogens & Evista
Drug name: Duavee: Bazedoxifne/conjugated estrogens
Brand name: Duavee
• 0.45/20 [1] tab daily
• Approved for vasomotor sx of menopause and osteoporosis prevention
• Estrogen + SERM—cannot be used in those with intact uterus; hx of breast, endometrial, ovarian cancers
• ADE—thromboembolism
• Same precautions as for estrogens & Evista
Drug name: Calcitonin (miacalcin)
Brand name: miacalcin
- ANTIRESPORPTIVE
- MAINLY USE TO HELP WITH PAIN AFTER A FX
- Can be used for acute pain after a fracture
- Approved to treat osteoporosis in women who are at least 5 year postmenopausal
- Can be used in patients with vertebral osteoporosis – NOT effective for HIP disease
- Nasal spray used every day [alternate nostrils]
- ADE—nosebleeds and rhinitis
Drug name: Teriparatide (Forteo)
Brand name: Forteo
-for men and women with severe disease and can not take anything else
-synthetic form of parathyroid hormone which stimulates bone formation
Only agent that will build bone by stimulating osteoblasts
- Approved for men and women with severe disease or those in need of treatment that cannot take the other agents
- SC injection daily for 2 years; then off – best option is to follow this therapy with bisphosphonate or Prolia [so patient will not lose new bone that they have built] *****
- Contraindicated in patients who have had skeletal XRT
ONLY DRUG THAT BUILDS BONE
Drug name: Denosumab (Prolia)
Brand name: Prolia
RANKL (receptor activator of nuclear factor kappa B) ligand inhibitor; prevents bone loss by blocking a certain receptor in the body to decrease bone breakdown
- Indicated for post-menopausal women with osteoporosis at high risk for fracture or patients who have failed/cannot tolerant other available therapies
- In post-menopausal women agent reduces the incidence of vertebral, non-vertebral, and hip fractures
- SQ injection twice per year
- Targeted for women and men with renal insufficiency **
- ADE—dermatological reactions, hypocalcemia (will need to monitor calcium!)
Osteomalacia
• Soft or “mushy” bone
• Bone architecture is intact, but strength is impaired
• Most common cause is Vitamin D deficiency
• In children – known as Rickets
• Recent studies tell us that Vitamin D deficiency is rampant in healthy younger adults +
other groups that have long been known to be high risk—those that are ill, frail and older
• By far, Vitamin D deficiency is the most common cause
• Other causes – primary hyperparathyroidism, secondary hyperthyroidism from renal disease
• Deficiencies of Ca++, PO4
• Tumor induced
• Patients with long standing low levels of Vitamin D can develop a secondary
hyperparathyroid state [that corrects itself with Vitamin D replacement]
Normal range for 25 vitmainD
20-20 mM/L; min. acceptable norm is 40
Treatment for osteomalacia
• Replenish with OTC Vitamin D3 [start with 800 IU daily] + daily sun exposure of 25-
30′′ [morning sun] 5-6 days/week without sunscreen]
What is the inactive form of 25 Vitamin D?
vitamin D2 (from plants)
- 50,000 units per day, week, or monthly until dose is acceptable
- close monitoring of Ca++, PO4, and vit D levels if used
Paget’s Disease
- Disorder of bone remodeling leading to disorganized bone formation—usually limited to one or a few bones—skull, upper extremity involvement common
- Patient’s with Paget’s disease will have bone pain, deformities and/or fractures
- Alkaline phosphatase is elevated, as is urine and serum pyridinoline and hydroxyproline
- Calcium Carbonate 500 mg BID with Vitamin D3 400 units daily
