Osteoporosis

Question 1

Osteoporosis is a bone disorder of….

Answer 1

low bone density

impaired bone architecture

compromised bone strength

increased fracture risk

Question 2

Describe the progression of osteoporosis?

Answer 2

normal bone >

osteopenia >

osteoporosis >

severe osteoporosis

Question 3

When to men and women start losing bone mass?

Answer 3

3rd or 4th decade because of reduce bone formation

men are at lower risk

Question 4

Prevention of osteoporosis

Answer 4

bone healthy lifestyle

regular exercise, nutritious diet, tobacco avoidance, minimal alcohol use

fall prevention

Question 5

Risk factors for osteoporosis ?

Answer 5

advancing age, previous fx, glucocorticoid therapy, family hx of hip fx, low body weight, smoking, excessive alcohol consumption, RA

Question 6

What tools can you use to determine pts at high risk for fx?

Answer 6

FRAX tool

Garvan calculator

Question 7

Dx standard for osteoporosis?

Answer 7

DXA (dual energy x-ray absorptiometry)

Question 8

Dx of of osteoporosis is based on….

Answer 8

low trauma fx or

DXA using WHO T score thresholds

Question 9

T score for osteopenia?

for osteoporosis?

Answer 9

-1 and -2.5

below -2.5

Question 10

What are some antiresorptive therapies?

Answer 10

• Ca
• Vit D**
• biphosphonates**
• calcitonin
• Estrogen agonists-antagonists
• Estrogen
• Testosterone
• Teriparatide
• Denosumab

Question 11

At what age range do we need to most Ca and Vitamin D?

Answer 11

9-18 y/o

Question 12

What are the 2 forms of calcium?

Answer 12

Calcium carbonate

Calcium citrate

Question 13

ADEs of calcium carbonate?

Answer 13

Gas, upset stomach, bloating, constipation

Rare kidney stones

Question 14

ADEs for both calcium carbonate and calcium citrate?

Answer 14

Hypophosphotemia

Hypercalciumia

Question 15

When should you increase dose of Vit D3?

Answer 15

malabsorption

if also taking anticonvulsants

Question 16

ADEs of Vit D3?

Answer 16

Hypercalcemia: cardiac rhythm disturbance, HA, weakness

Hypercalciuria

Question 17

When is vitamin D2 (ergocalciferol) indicated?

Answer 17

for vitamin D deficiency

Question 18

When is Vitamin D (calcitrol) indicated?

Answer 18

Renal osteodystrophy

Hypoparathyroidism

Refractory rickets

Question 19

Examples of biphosphonates?

Answer 19

Alendronate

Ibandronate

Risedronate

IV Zoledronic Acid

Question 20

IV and oral Ibandronate is indicated only for….

Answer 20

postmenopausal osteoporosis

Question 21

MOA of biphosphonates?

Answer 21

Decreased osteoclast maturation, number, recruitment, bone adhesion and life span

Question 22

What is the half life of biphosphonates?

Answer 22

up to 10 yrs, becomes incorporated in bones

Question 23

What is important about the admin of biphosphonates?

Answer 23

Administered in the morning on an empty stomach with 6–8 ounces of plain water. Do not eat and remain upright for at least 30 minutes following administration

(prevents esophageal damage)

Question 24

Which biphosphonate has a delayed release product that can be taken immediately after breakfast?

Answer 24

Risedronate

Question 25

Which biphosphonate is administered IV yearly?

Answer 25

Zoledronic acid

Question 26

Monitoring for pt taking biphosphonate?

Answer 26

generally 1-2 yrs after initiation then every 2+ yrs

Question 27

ADEs of biphosphonate?

Answer 27

PO: nausea, dyspepsia IV: transient flu like sxs rare: perforation, ulceration, GI bleeding, musculoskeletal pain, fx, ONJ

Question 28

What are some bone turnover markers?

Answer 28

Resorption markers: Type I collage degradation products, enzymes Formation markers: matric proteins, enzymes

Question 29

Contraindications for biphosphonates?

Answer 29

Cr clearance < 30-35 Serous GI conditions: ex. achlasia, barrett's esophagus pregnancy

Question 30

What is ONJ?

Answer 30

osteonecrosis of the jaw Subtrochanteric femoral fracture BB warning: MC in pts with CA, chemo, radiation or high dose glucocorticoid therapy

Question 31

What is a "drug holiday"?

Answer 31

can stop drug therapy in women without evidence of low trauma fx, who have responded well to bisphophonate therapy and those with increasing T BMD

Question 32

What is calcitonin? Use?

Answer 32

Endogenous hormone released from the thyroid gland when serum calcium is elevated 3rd line tx for women who are at least 5 yrs past menopause, may help with bone pain

Question 33

How is calcitonin usually administered?

Answer 33

intranasally

Question 34

Examples of Estrogen Agonist/Antagonist and tissue selective estrogen complex? MOA?

Answer 34

Raloxifene Bazedoxidene decreases bone resorption, increasing bone mineral density and decreasing fracture incidence

Question 35

Bazedoxifene can be used in...

Answer 35

postmenopausal women with a uterus, no progestogen needed

Question 36

When is estrogen therapy used?

Answer 36

Short-term in women who need estrogen therapy for the management of menopausal symptoms as the risks of estrogen therapy outweigh the bone benefits.

Question 37

When is testosterone used?

Answer 37

Replacement of testosterone (male) or methyltestosterone (female) have demonstrated increases in BMD

Question 38

What is Teriparatide? Use?

Answer 38

Anabolic therapy, recombinant produce representing first 34 aa in human PTH increase bone formation, remodeling rate and osteoblast number and activity

Question 39

Teriparatide may be indicated in....

Answer 39

postmenopausal women, men, and patients on glucocorticoids at high risk Very low bone density T score < -3.5

Question 40

How is Teriparatide available?

Answer 40

as a prefilled "pen" delivery device

Question 41

What is Abaloparatide?

Answer 41

Synthetic analog of human parathyroid hormone (PTH) related peptide acting as an anabolic agent to stimulate bone formation used for high risk postmenopausal osteoporosis

Question 42

MOA of Denosumab (RANKL Inhibitor)?

Answer 42

binds to RANKL on the surface of osteoclast precursor cells and mature osteoclasts Inhibits osteoclatogenesis and increases osteoclast apoptosis

Question 43

ADEs of Denosumab?

Answer 43

back, extremity, and musculoskeletal pain | increased cholesterol, cystitis, decreased serum calcium, skin problems

Question 44

What are the 1st line osteoporosis treatments?

Answer 44

Alendronate risedronate zoledronic acid denosumab

Question 45

Alternatives to first line therapy for osteoporosis?

Answer 45

Ibandronate, raloxifene, and teriparatide

Question 46

Last resort for osteoporosis?

Answer 46

Calcitonin

Question 47

What is a vertebroplasty/Kyphoplasty?

Answer 47

bone cement is injected into the fractured vertebral space stablized damaged vertebrae and reduces pain used in pts with debilitating pain after vertebral fracture

Question 48

ADEs of vertebroplasty/Kyphoplasty

Answer 48

cement leakage into the spinal column, which can result in complicating nerve damage, and vertebral fracturing around the cement

Question 49

What is osteomalacia?

Answer 49

"soft bones" a condition seen in adults in which the bone is significantly undermineralized

Question 50

What is the childhood equivalent of osteomalacia?

Answer 50

rickets

Question 51

Causes of osteomalacia?

Answer 51

MCC = prolonged vitamin D deficiency disorders that cause hypophosphatemia, rarely meds such as anticonvulsant therapy

Question 52

Consequences of osteomalacia?

Answer 52

pathologic fx and/or deep bone pain, proximal muscle weakness, low BMD

Question 53

Labs findings in pt with osteomalacia?

Answer 53

extremely low 25 (OH) vit D <10ml +/- elevated bone specific alkaline phosphate and hypocalcemia

Question 54

Tx for osteomalacia?

Answer 54

high dose Vit D replacement therapy -oral ergocalciferol