Exam 4 Flashcards
(143 cards)
1
Q
What are the vasomotor symptoms of menopause?
A
hot flashes and night sweats
2
Q
What are the three indications for menopausal hormone therapy?
A
vasomotor symptoms, vulvovaginal atrophy, osteoporosis prevention
3
Q
What are some contraindication to menopausal hormone therapy?
A
pregnancy, estrogen-dependent malignancies (endometrial and breast cancer)m stroke, thromboembolic disorders, liver disease
4
Q
Estrogen monotherapy is only for women (with/without) a uterus
A
without
5
Q
What are the three forms of oral estrogen monotherapy?
A
Premarin, Estrace, and Menest (PEM)
6
Q
What are the six transdermal monotherapy products?
A
Alora, Climara, Menostar, Minivelle, Vivelle, Vivelle-dot
7
Q
What are the two topical products for estrogen monotherapy?
A
Topical Gel (EstroGel, Divigel, Elestrin) and Topical Spray (Evamist)
8
Q
What are the four intravaginal products for estrogen monotherapy?
A
Vaginal cream (Estrace, Premarin), vaginal insert (Imvexxy), Vaginal tablet (vagifem, yuvafem), vaginal ring (Estring, Femring)
9
Q
Which intravaginal product has vasomotor symptoms?
A
Femring (the ring is bigger than the string)
Needs progesterone in intact uterus
10
Q
What type of product should be prescribed for women exclusively experiencing vulvovaginal atrophy?
A
Topical vaginal products- minimizes systemic effect
11
Q
Why should women with intact uterus be prescribed a progestin in addition to estrogen?
A
Decrease risk of endometrial hyperplasia and cancer
12
Q
In the WHI study, what major clinical outcomes were increased risk with use of Estrogen and Progesterone (intact uterus)?
A
heart attacks, strokes, venous thromboembolism, and invasive breast cancer
13
Q
In the WHI study, what major clinical outcomes were increased risk with use of Estrogen alone (hysterectomy)?
A
Increase stroke and venous thromboembolism.
14
Q
What were the two critical factors in determining whether hormone therapy reduces or increases risk of CHD?
A
Time since menopause (within 10 yrs of last period) and age of initiation (<60)
15
Q
Which age range and group (estrogen only vs E+P) had favorable outcomes for absolute risk of health outcomes by the WHI?
A. 40-49yrs
B. 50-59y
C. 60-69y
A
B. Estrogen only
16
Q
Women with intact uterus was significantly associated with a (higher/lower) risk of breast cancer
A
higher
17
Q
Women with prior hysterectomy had (higher/lower) risk of breast cancer
A
lower
18
Q
What drugs are associated with continuous cyclic therapy?
A
Premphase (oral) and Combipatch (Transdermal)
19
Q
How does continuous cyclic therapy (Sequential treatment) work? How is it viewed?
A
Estrogen admin daily, progesterone 12-14 days of 28 day cycle
Scheduled withdrawal bleeding- not favorable
Preferred in recently menopausal women (not long term)
20
Q
How does continuous long cycle therapy (cyclic withdrawal) work? How is it viewed?
A
Estrogen daily, Progesterone 12-14 days every other month
Limited safety data and endometrial protection unclear, RARE
21
Q
How does continuous combines therapy work? How is it viewed?
A
Daily E+P: Preferred!
Stops bleeding, recommended for women >2 yrs post-final period, long term endo protection
22
Q
What are the 6 continuous combined E+P oral drugs?
A
Prempro, Angeliq, Activella, Amabelz, Mimvey, Bijuva, Fyavolv, Jinteli
(PAAAM Be for Jim -Michael Scott Tarzan voice)
23
Q
What are the 2 continuous combined E+P transdermal products?
A
ClimaraPro and Combipatch
24
Q
How does intermittent combined (pulsed-progesterone) work? How is it viewed?
A
3 days estrogen, 3 days E+P
Pulse prevents progesterone receptors, endo protection unknown
25
What drug is used for intermittent combined E+P?
Prefest-Oral
26
What oral E+P is best for endometrial protection?
Medroxyprogesterone (Provera), Norethindrone acetate (Aygestin), and micronized progestin (Prometrium) (PAP)
27
What vaginal/intrauterine E+P is best for endometrial protection?
levonorgestrel (Mirena IUD) and progesterone gel (Crinone)
28
What drug is used for Estrogen+SERM? What are the side effects?
Duavee-oral
GI track disrders, muscle spasm, neck pain, dizziness, oropharyngeal pain
29
What SSRI is FDA approved for hot flashes?
Paroxetine
30
What drug is used for bio-identical hormone replacement therapy? How is it viewed?
Bijuva-oral
Minimal insurance coverage and questionable safety
31
What is the first line treatment for Genitourinary Syndrome of Menopause? Second line?
First line: non-hormonal (Lubricants and vaginal moisturizers)
Second line: estrogen (topical, low dose oral contra)
32
What drug is used in the treatment of mod-severe dyspareunia using SERM? What are important clinical pearls?
Ospemifene (Osphena)
Black box: endo cancer, stroke, VTW
In postmenopausal women
SE: endo hyperplasia and hot flashes
33
What drug is used in the treatment of mod-severe dyspareunia using DHEA? What are important clinical pearls?
Prasterone (Intrarosa)
Postmenopausal women
Contraindicated for undiagnosed vaginal bleeding
Avoid with history of breast cancer
Costly
34
Hormone produced by C-cells that help regulate calcium and phosphate levels in the blood
calcitonin
35
Main hormone secreted from thyroid gland into the blood stream, controlling basal metabolic rate
Thyroxine
36
Which is more potent: T4 or T3?
T3
37
Which is produced more: T4 or T3?
T4
38
How is thyroid biosynthesized? (Iodide to T3 and T4)
Iodide in blood pairs with sodium to go through Na/I symporter into thyroid follicular cell
In follicular cell, iodide is pushed through pendrin to follicle colloid, meanwhile thyroglobulin is taken from the ER of cell and undergoes exocytosis into follicle colloid
In follicle colloid, Iodide gets oxidized and attaches to the aromatic rings of thyroglobulin
Once attached, complex undergoes endocytosis where it goes through proteolysis which separates into T3 and T4 in transport of follicular cell
Cell goes back into blood stream with T3 and T4
39
What makes T3 and T4 from MIT and DIT?
MIT + DIT= T3
DIT + DIT= T4
40
What hormone is released between the hypothalamus and anterior pituitary?
A. TSH
B. T4 and T3
C. TRH
C. TRH
41
What hormone is released between the anterior pituitary and thyroid gland?
A. TSH
B. T4 and T3
C. TRH
A. TSH
42
What hormone is secreted from the thyroid gland to cause physiological functions?
A. TSH
B. T4 and T3
C. TRH
B. T4 and T3
43
What condition can result from iodine deficiency?
Goiter- enlarged thyroid due to rise in TSH
Cretinism- stunted physical and mental growth
44
What are the three transport proteins of thyroid in plasma?
TBG, TTR, and albumin
45
Transport proteins have greater affinity to (T3/T4)
T4
46
(T3/T4) has a longer half life than (T3/T4), and (T3/T4) has a more rapid onset
T4 has a longer half life than T3, and T3 has a more rapid onset
47
Name the compound
T4
48
Name the compound and its activity
T3- active
49
Name the compound and its activity
rT3- inactive
50
Name the compound and its activity
3,3-T2 inactive
51
Thyroid condition characterized by decrease in metabolic rate, bradycardia, hypoglycemia, and drooping of eyelids
hypothyroidism
52
One of the most common thyroid autoimmune disease that destroys the thyroid gland
Hashimotos
53
Thyroid condition characterized by increased BMR, tachycardia, hyperglycemia, and retraction of upper lids (exophthalmos)
hyperthyroidism
54
One of the most common thyroid autoimmune diseases that cause enlargement of the entire thyroid gland
Graves' disease
55
What are the 4 common thyroid hormone replacement options for hypothyroidism?
natural thyroid hormone preparations, Levothyroxine, Liothyronine, and Liotrix
56
Which hypothyroid medication is a T4 characterized by slow onset, long half life, and 6-8wk for steady state levels?
Levothyroxine
57
Which hypothyroid medication is a T3 characterized by rapid onset, short duration of action, requiring multiple daily doses.
Greater risk of cardiotoxicity
Liothyronine
58
Which hypothyroid medication is a 4:1 mixture of T4 and T3?
Liotrix
59
What are the two common treatment methods for hyperthyroidism?
Thioamides and radioactive iodine (131I)
60
What is the TSH reference range?
0.5-5.0 mlU/L
61
What is the free T4 range?
0.7-1.9 ng/dL
62
What are the three tests of autoimmunity for thyroid testing
ATgA, TPO-Ab, and TRAb
63
Which autoimmunity test is positive for autoimmune thyroid diseases and undetectable during remission?
ATgA
64
Hyper or Hypo thyroidism: Lab finding of high TSH and low FT4, decreased HR and increased BP
Hypothyroidism
65
Hyper or Hypo: Lab findings of low TSH and high FT4, Increased HR
hyperthyroidism
66
What 4 drugs induce hyperthyroidism?
Iodinated compounds, Amiodarone, interferons, and lithium
67
What 2 drugs are thioamides used for hyperthyroidism treatment?
Propylthiouracil (PTU) and methimazole
68
PTU or Methimazole: longer half life
Methimazole
69
PTU or Methimazole: less daily dosing
PTU- 2-3x day
Methimazole- daily
70
PTU or Methimazole: Blocks T4 to T3 conversion
PTU- YES
Methimazole- NO
71
PTU or Methimazole: Which trimester of pregnancy
PTU- 1st (less placental crossing)
Methimazole- 2nd + 3rd
72
PTU or Methimazole: Can take during lactation
PTU- No
Methimazole- Yes (Preferred)
73
PTU or Methimazole: Black box warning
PTU- Yes: hepatic failure
Methimazole- No: acute pancreatitis
74
What is the initial, maintenance, and max dosing range for Methimazole?
Initial:
Free T4 1-1.5x, 5-10 mg/day
Free T4 1.5-2x: 10-20 mg/day
Free T4 >2x: 30-40 mg/day
Maintenance: 5-15 mg/day
Max: 60 mg/day
75
What is the initial, maintenance, and max dosing range for PTU?
Initial: 50-150 mg TID
Maintenance: 50mg BID or TID
Max: 1200 mg/day
76
Which rash requires stopping thioamides and going to RAI or surgery?
A. Maculopapular
B. Wheals, hives, SOB
B. Wheals, hives, SOB
77
Which thioamide adverse effect leads to severely low white blood cell count?
agranulocytosis
78
How often are lab test checked with thioamides until euthyroid?
every 4-8 weeks
79
Short-term use of Beta blockers to alleviate symptoms are seen in (hyper/hypo)thyroidism
hyperthyroidism
80
Can a patient with hyperthyroidism be placed on a cardio-selective beta-blocker with a HR of 105?
Yes
81
What is the therapy dosing for levothyroxine and when should they take it?
1.6 mcg/kg/day on an empty stomach (60 min before breakfast or 4 hours after dinner)
82
A patient who recently became pregnant was taking levothyroxine for hypothyroidism. Can she continue her meds?
Yes, adjust dose every trimester
83
What are three reasons a patient has high or fluctuating TSH despite high levothyroxine dose?
Poor adherence, drug-food interaction, and drug-drug interaction
84
What are the four drug interaction effects commonly seen in thyroid treatment?
Decreased T4 absorption, increased T4 requirement, increased serum TBG, and disease-drug interactions (warfarin)
85
What is the calcium in bone's crystalline formation called?
hydroxyapatite
86
Bone forming cell that incorporates calcium and phosphate from plasma into bone
osteoblasts
87
Bone resorption cells that release calcium and phosphate from bone into plasma
osteoclasts
88
Regulates the release of osteoblast/clast activity in bone
osteocytes
89
Increased BMD with increased load stimulates osteo(blast/clast) activity, while decrease BMD with decreased load stimulates osteo(blast/clast)
Increased BMD with increased load stimulates osteoblast activity, while decrease BMD with decreased load stimulates osteoclast
90
Deletion from what amino acids in the parathyroid hormone eliminates activity?
Deletions 1&2
91
Describe the effect of PTH and Ca sensor activity
When Ca sensor is low, PTH is secreted in blood
Increase in Ca bone resorption, kidney Ca reabsorption, and kidney dihydroxyl vit D occur.
An increase of Ca occurs, causing a negative feedback inhibiting PTH
92
What is the first step of vitamin D synthesis?
Provitamin D is converted to cholecalciferol from UV irradiation of skin or diet
93
Describe Vit D synthesis
Vit D3 is hydrophobic, needing a Vit D binding protein through liver
Processed to 25 hydroxyvitamin D3 which can undergo two pathways in kidney:
1.) 1-alpha-hydroxylase- stimulated by PTH leads to 1,25 Dihydroxy Vit D3, active form of Ca absorbing from the intestines
2.) 24-hydroxylase- PTH is not being released
24,25 Dihydroxy Vit D3, less active form of Ca uptake from intestine
94
What are the actions of Vit D on calcium and phosphate (4)?
1. increase calcium and phosphate absorption from small intestine (rapid effect on brush border)
2. increase calcium and phosphate reabsorption
3. indirect (slow) effects on cells (calbindins, Vit D binding proteins)
4. Feedback inhibition of PTH
95
Describe the absorption of Ca from the intestine (TrpV6, Calbindin, Ca-ATPase)
TrpV6 brings in calcium, which is transported in the cell by calbindin to the Ca-ATPase that pumps into serosal membrane
96
What is the "phosphate specialist" that stimulates phosphate excretion, inhibits dihydroxyl Vit D synthesis, and inhibits PTH secretion?
FGF23
97
What conditions occur from high FGF23 levels?
Poor prognosis in CKD patients on dialysis
Autosomal dominant hypophosphatemic rickets
98
Which of the following inhibit PTH secretion?
I,25-(OH)2 Vit D3
FGF23
Low Ca
High Ca
I,25-(OH)2 Vit D3, FGF23, and High Ca
99
How is calcitonin a negative regulator of serum calcium?
1. Inhibits osteoclastic bone resorption
2. Increase calcium and phosphate loss in urine (less reabsorbed)
100
Calcitonin is stimulated by (low/high) serum calcium levels
high
101
Disease of uncontrolled osteoclastic bone resorption and secondary bone formation (high calcium turnover) resulting in bone pain, deformities, and loss of hearing, hypercalcemia.
Pagets disease
102
What is used to suppress osteoclastic activity in Paget's disease?
Bisphosphonates
103
What part of the bone can obvious deterioration be found in osteoporosis
trabecular bone
104
What two conditions are responsible for hypercalcemia?
Hyperparathyroidism and malignant tumors
105
What condition is associated with hypocalcemia?
Rickets
106
What drug combo with Vit D is taken as a supplement with osteoporosis?
Vit D + Ca
107
What drug combo with Vit D is taken as a supplement with hypo-calcemia/parathyroidism?
Vit D + Ca + rPTH
108
What drug combo with Vit D is taken as a supplement with hyperparathyroidism?
Vit D analogs (suppress PTH)
109
What bisphosphates are approved for Paget's and cancer, NOT osteoporosis?
Alendronate
Etidronate
Ibandronate
Pamidronate
Risedronate
Zoledronate
Pamidronate and Etidronate (PE)
110
What bisphosphates are approved for building bone mass in osteoporosis?
Alendronate
Etidronate
Ibandronate
Pamidronate
Risedronate
Zoledronate
Alendronate, Ibandronate, Risedronate, Zoledronate
111
What drugs are approved for high risk fracture?
Teriparatide and abaloparatide
112
What neutralizes RANKL in osteoclast differentiation?
OPG- Osteoprotegerin
113
Should PTH in teriparatide be exposed intermittent or continuously?
Intermittent
114
What is the max amount of years for Teriparatide?
2 years- black box bone cancer
115
Which drug for osteoporosis binds to RANKL and prevents activation of RANK on osteoclast precursors?
Denosumab or Romosozumab
Prolia (Denosumab)
116
Which drug for osteoporosis is a monoclonal antibody against sclerostin?
Denosumab or Romosozumab
Evenity (Romosozumab)
117
Sclerostin (incre/decre) osteoblasts and (incr/decre) osteoclasts
Sclerostin decreases osteoblasts and increases osteoclasts
118
Which part of sclerostin regulation is attacked to prevent loss of osteoblastic differentiation?
Inhibiting SOST (sclerostin) from binding to LRP 5/6
119
What are clinical uses for calcitonin?
Paget's disease, hypercalcemia
120
What drug is used to provide calcitonin and what is its response to osteoclastic activity and renal reabsorption of phosphate and calcium
Salmon (Miacalcin)
Decrease osteoclast activity and block renal reabsorption
121
What drug for calcium receptor sensitization is used for treatment of secondary hyperparathyroidism?
Cinacalcet (sensipar)
122
Cinacalcet binds to the receptor as (this) being more responsive to calcium and inhibiting PTH secretion
PAM
123
What drug is used for treatment of secondary hyperparathyroidism in CKD with dialysis?
Etelcalcetide (Parsabiv)
124
What are the two phosphate binders and their effects on Ca and PO42-
Lanthanum Carbonate (Fosrenol)- decreases phosphate and calcium levels
Sevelamer (Renagel, Renvela)- decrease serum phosphate levels selectively
125
What are contraindications for bisphosphonates?
Hypocalcemia, renal insufficiency, pregnancy
126
T/F: Bisphosphonate should be taken on an empty stomach
True
127
Which bisphosphates reduce vertebral, hip, and non-vertebral fractures?
Alendronate, Risedronate and Zoledronic acid
128
Ibandronate reduces which fracture?
Vertebral, Hip and/or Non-vertebral
Vertebral
129
What are counseling points for bisphosphonates?
Must take on empty stomach, take with full glass of plain water, do not lie down for at least 30 min and wait at least 30 min to eat
130
What should be avoided with bisphosphonates?
Mineral water with high Ca content, do not chew, discontinue if heartburn, avoid antacids, increased GI effects with NSAIDs
131
Which bisphosphonates can be used with glucocorticoid-induced osteoporosis?
Ibandroante
Zoledronic acid
Alendronate
Risedronate
Risedronate and Zoledronic acid
132
Which fracture risk reduction is associated with menopausal hormone therapy?
Vertebral, hip, non-vertebral
Vertebral, hip, non-vertebral
133
What are the two drugs used as Selective estrogen receptor modulators in fracture prevention and what do they reduce?
Vertebral, Hip, Non-vertebral
Raloxifene and Bazedoxifene
Vertebral
134
What are black box warnings for raloxifene? Side effects?
increase risk of DVT, PE and stroke
SE: hot flashes
135
Internasal Calcitonin effects what is fracture prevention?
Vertebral, Hip, Non-vertebral
Vertebral
136
Denosumab decreases fracture risk in which
vertebral, hip, non-vertebral
vertebral, hip, non-vertebral
137
What are denosumab's clinical pearls?
Rebound effect: increase risk of vertebral fracture with discontinuation
Consider indefinite treatment of denosumab, bisphosphonate after discontinuation of denosumab
138
How is denosumab administered?
60mg SQ q6 months
139
What two drugs are associated with parathyroid hormone osteoporosis treatment?
Teriparatide and Abaloparatide
140
Teriparatide and abaloparatide affect which fracture risk reduction?
Vertebral, Hip, Non-vertebral
Vertebral, Non-vertebral
141
How is Teriparatide and Abaloparatide administered?
Teri: 20 mcg SQ daily, only 2 yrs
Abalo: 80 mcg SQ daily, only 18 mon
142
What drug uses monoclonal anti-sclerostin antibody for osteoporosis treatment? Where (Vertebral, Hip, non-vertebral)
Romosozumab
Vertebral, Hip, non-vertebral
143
Summary
