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Adv. Immunology > Osteoporosis > Flashcards

Osteoporosis Flashcards

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1
Q

What is osteoporosis?

A
  • Progressive systemic disease (once it occurs, it won’t stop)
  • Low bone mass + impaired bone architecture + decreased bone strength = increase fracture risk + increased morbidity, mortality, decreased quality of life
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2
Q

What are some lifestyle risk factors for Osteoporosis?

A

o Diet (Ca and Vit D)
o Low physical activity
o Smoking
o Alcohol
o Caffeine

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3
Q

What are some diseases or conditions that are risk factors for osteoporosis?

A

o Menopause
o RA & other inflammatory dx
o Organ transplant
o Diabetes
o Malabsorptive states (Chron’s, celiac disease)
o Hyperthyroidism
o CKD
o Genetic Disorders

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4
Q

What are some patient characteristic risk factors for osteoporosis?

A

o Female sex
o Low bone mineral density
o Low body weight (<127 lbs)
o Hormonal status
o Parenteral history of hip fracture

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5
Q

What are some medications that could be risk factors of osteoporosis?

A

o Corticosteroids
o Long-term PPI use
o Heparin/LMWH
o Calcineurin inhibitors (cyclosporin, tacrolimus)
o GnRH Agonists (leuprolide, goserelin)
o Anticonvulsants
o Aromatase inhibitors
o Oral diabetes (SGLT2i, TZD)

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6
Q

Who do you screen for osteoporosis?

A
  • ALL women > 65 yo, men > 70
  • Post-menopausal women < 65, men 50-69 screen in high-risk patients
    • Glucocorticoid therapy (oral prednisone ≥ 5 mg/day, ≥ 3 months)
    • Recent low-trauma fracture
      • Other: Lifestyle, PMH, medication use, patient characteristics, low body weight, parental history of hip fracture, smoking
  • USPSTF recommends use of Clinical Risk Assessment Tools for post-menopausal women < 65
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7
Q

What indicates treatment for osteoporosis?

A

Any T-score ≤ -2.5 at the lumbar spine, femoral neck, or hip as determined by DXA

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8
Q

What indicates treatment for osteopenia?

A

FRAX score with 10-year risk for hip fracture ≥ 3% or for major osteoporotic fracture ≥ 20%

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9
Q

What is considered corticosteroid-induced osteoporosis?

A

ALL adults taking prednisone ≥ 2.5 mg/day for ≥ 3 months

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10
Q

When should osteoprophylaxis be considered in patients taking chronic steroids (≥ 5 mg/day prednisone ≥ 3 months)?

A

With any of the following:
o T-score between -1 and -2.5 (osteopenia)
o 10-yr risk of major osteoporotic fracture of 10-19%
o 10-yr risk of hip fracture between >1% and <3%
o Very high doses of steroids (e.g., > 30 mg/day prednisone)

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11
Q

What is the osteoporosis prophylaxis?

A

Oral biphosphonates

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12
Q

What are some alternatives to oral bisphophonates?

A

 IV bisphosphonates
 Denosumab
 Teriparatide
 Raloxifene

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13
Q

What is the recommended daily intake of calcium?

A

19-50 years: 1,000 mg

≥ 51 years: 1,200 mg

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14
Q

What is the daily intake of Vitamin D?

A

≥ 50 years: 800-1,000 IU

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15
Q

What is the repletion dosing of Vitamin D?

A

50,000 IU weekly for 8-12 weeks

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16
Q

Which calcium supplementation is the cheapest?

A

Calcium carbonate

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17
Q

Which calcium supplementation must be taken with meals?

A

Calcium carbonate

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18
Q

Which calcium supplementation is better absorbed?

A

Calcium citrate

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19
Q

What is the safe daily upper limit of Vitamin D supplementation?

A

ages 9+: 4,000 IU (100 mcg)/day

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20
Q

What are some possible adverse effects of Vitamin D supplementation?

A

hypercalcemia, soft tissue calcification, kidney stones, renal failure

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21
Q

What are some secondary causes of osteoporosis?

A
  • Hyperthyroidism
  • Hyperparathyroidism
  • Rheumatoid arthritis
  • Multiple sclerosis
  • Severe liver disease
  • Celiac disease
  • Adrenal insufficiency
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22
Q

Bisphosphonates

A

-Inhibits osteoclast
-Mimic pyrophosphonate: an endogenous bone resorption inhibitor
-First line

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23
Q

Name the Bisphosphonates

A

-Alendronate (Fosamax)
-Risedronate (Actonel, Atelvia)
-Zoledronic Acid (Reclast)
-Ibandronate (Boniva)

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24
Q

What are the indications for Alendronate (Fosamax)?

A

Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures

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25
What are the typical dosing of Alendronate?
70 mg PO weekly or 10 mg PO daily
26
What are the indications for Risedronate (Actonel, Atelvia)?
Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures
27
What are the typical dosing of Risedronate (Actonel, Atelvia)?
35 mg PO weekly or 150 mg PO monthly
28
What is the indication for Zoledronic Acid (Reclast)?
Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures
29
What is the typical dosing of Zoledronic Acid (Reclast)?
Treatment: 5 mg IV yearly Prevention: 5 mg IV every 2 years
30
What is the typical dosing of Ibandronate (Boniva)?
Postmenopausal: treat and prevent vertebral fractures (does not treat hip fractures)
31
What is the typical dosing of Ibandronate (Boniva)?
Oral: 150 mg once monthly IV: 3 mg every 3 months
32
What is the bioavailability of bisphosphonates?
oral bioavailability <1% (very poor), reduced up to 60% with coffee or orange juice (take 30 min before food)
33
What is the half-life of bisphosphonates?
~10 years
34
What are some common adverse effects of bisphosphonates?
-esophagitis (b/c of chemical irritant in bisphosphonates) or acid reflux -hypocalcemia -abdominal pain -constipation -diarrhea
35
What are some rare adverse effects of bisphosphonates?
atypical femur fracture, osteonecrosis of the jaw (ONJ)
36
What are some risk factors of Osteonecrosis of the Jaw?
-Presence of malignancy -Use of chemotherapy and corticosteroids -Age ≥ 65 -H/o periodontal and dental abscesses -Bacterial infections -Dental procedures (e.g. tooth extractions) -Use of IV bisphosphonates
37
What are some signs and symptoms of osteonecrosis of the jaw?
* Tissue loss, exposed bone, jaw pain, odontalgia, and welling
38
What are some prevention strategies of Osteonecrosis of the Jaw?
* Regular dental hygiene and routine dental exams * Assessment of patients for risk factors * Completion of anticipated dental procedures prior to initiating bisphosphonates * Examine mucosa of patients with full or partial dentures
39
What are some counseling points of Bisphosphonates?
 Must be taken on empty stomach, with full glass of water, upright for at least 30 minutes  Avoid in patients that may have trouble following administration instructions  Should be used with caution in patients with active esophageal disease or hypocalcemia  Do not take with any other medications  Supplemental calcium + vitamin D if inadequate diet/deficiency  Consider weekly dosing over daily dosing
40
Denosumab (Prolia)
- Human monoclonal antibody: binds to RANKL (precursor to osteoclast activity) which inhibits osteoclastogenesis and increases osteoclast apoptosis
41
What are the indications for Denosumab (Prolia)?
Postmenopausal, males, and glucocorticoid-induced: Treat and prevent vertebral, nonvertebral, and hip fractures
42
What is the typical dosing of Denosumab (Prolia)?
60 mg subQ every 6 months Administration by healthcare professional
43
What is the half-life of Denosumab (Prolia)?
~25 days
44
What are some common adverse effects?
Nausea, diarrhea, constipation, fatigue, asthenia, and arthralgia
45
What are some serious adverse effects?
Hypocalcemia, serious skin infections, osteonecrosis of jaw, and atypical femur fractures
46
Parathyroid Hormone & Analogs
o SECOND LINE o Stimulate osteoblast function, increasing gastrointestinal calcium absorption, and increasing renal tubular reabsorption of calcium
47
What is the indication for Teriparatide (Forteo)
Postmenopausal, males: Treat and prevent vertebral, nonvertebral
48
What is the typical dosage of Teriparatide (Forteo)?
20 mcg SQ daily
49
What is the indication for Abaloparatide (Tymlos)?
Postmenopausal, males: Treat and prevent vertebral, nonvertebral
50
What is the typical dosing of Abaloparatide (Tymlos)?
80 mcg SQ daily
51
When are parathyroid hormone (PTH) & Analogs used in?
-Severe osteoporosis (T-score of ≤ 3.5 even in the absence of fractures, or T-score of ≤ 2.5 plus a fragility fracture) -Unable to tolerate bisphosphonates or who have contraindications to oral -Fail other osteoporosis therapies (fracture with loss of BMD in spite of compliance with therapy)
52
What are some common adverse effects of Parathyroid hormones & analogs?
Hypercalcemia -Orthostatic hypertension -Arthralgia -Asthenia -GI -Dyspepsia
53
What are some contraindications of parathyroid hormones & analogs?
Metastases, history of skeletal malignancies, hypercalcemia
54
What are some counseling points of parathyroid hormones & analogs?
 Rise slowly from sitting position  Rotate injection sites with each dose
55
What is the duration of therapy of parathyroid hormones & analogs?
Should NOT exceed 2 years (due to risk for osteosarcoma)
56
Romosozumab (Evenity)
 Monoclonal antibody; binds to sclerostin, an inhibitor of bone formation  SECOND LINE
57
What is the indication for Romosozumab (Evenity)?
* Postmenopausal: Treat vertebral, nonvertebral, and hip fractures * Used in postmenopausal women at high risk for fracture OR intolerant to or who have failed other osteoporosis therapy
58
What is the typical dosage of Romosozumab (Evenity)?
2 consecutive subQ injections (105 mg each) for a total dose of 210 mg once monthly
59
What is the duration of therapy of Romosozumab (Evenity)?
should NOT exceed 12 months
60
What are some common adverse effects of Romosozumab (Evenity)?
Joint pain, headache
61
What is the black box warning of Romosozumab (Evenity)?
Should be avoided in patients with significant cardiovascular history * May increase the risk of myocardial infarction, stroke, and cardiovascular death * Should not be initiated in patients who have had a myocardial infarction or stroke within the preceding year * If a patient experiences a myocardial infarction or stroke during therapy, romosozumab should be discontinued
62
What are the counseling points of Romosozumab (Evenity)?
Patients should report signs of any serious ADE’s and take supplemental calcium + vitamin D
63
Raloxifene (Evista)
* Selective Estrogen Receptor Modulators * Estrogen agonist activity on bone--> prevent bone loss, decreases bone resorption
64
What is the indication for Raloxifene (Evista)?
Postmenopausal: Treat and prevent vertebral fractures Reduce risk of invasive breast cancer in postmenopausal women
65
What is the typical dosing of Raloxifene (Evista)?
60 mg once daily
66
What is the renal impairment cutoff for Raloxifene (Evista)?
CrCl < 50, use with caution
67
What are some common side effects of Raloxifene (Evista)?
* Hot flashes * Leg cramps * Peripheral edema * Flu-like syndrome * Arthralgias * Sweating
68
What are some serious adverse side effects of Raloxifene (Evista)?
Increased risk for venous thromboembolism and stroke
69
What are some contraindications of Raloxifene (Evista)?
History of or current venous thromboembolism
70
What are some drug interactions of Raloxifene (Evista)?
Warfarin, cholestyramine, diazepam, diazoxide, and lidocaine
71
Calcitonin
o Antagonizes PTH which inhibits osteoclast formation + analgesic effect
72
What is the indication for Calcitonin?
Approved in women ≥ 5 years post menopause as LAST-LINE short-term treatment + pain relief for vertebral fractures
73
What is the typical dosage of Calcitonin?
Intranasally 1 nasal puff (200 units) once daily
74
What is the duration of therapy of Calcitonin?
4 weeks
75
When should you repeat imaging?
* Repeat DXA screen scan in healthy postmenopausal women every 10 years, unless risk factors change * Repeat DXA scan every 2 years while on therapy
76
Bisphosphonate Drug Holiday
* Why? To reduce drug related adverse effects from accumulation over time * The skeletal binding sites for bisphosphonates are virtually unsaturable leading to a reservoir that continues to be released for months or years after treatment is stopped

Adv. Immunology (3 decks)

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