Osteoporosis

Question 1

When do men and women begin to lose bone mass?

Answer 1

30s-40s (reduced bone formation)

Question 2

What effect does Estrogen deficiency have during menopause

Answer 2

less estrogen increases osteoclast activity increasing bone resorption more than formation

Question 3

Osteoblast function

Answer 3

osteoblasts “b”uild bone!

Question 4

Name some drugs that cause osteoporosis

Answer 4

1. Systemic corticosteroids
2. Thyroid replacement
3. Antiepileptic drugs (ex. phenytoin and phenobarbital)

Question 5

Risk factors for fracture

Answer 5

• age
• history of fracture
• rheumatoid arthritis
• excessive alcohol
• smoking
• inflammatory bowel disease, hypogonadism

Question 6

FRAX tool

Answer 6

• created by WHO

- uses risk factors to predict probability of fracture in next 10 years

Question 7

Garvan calculator

Answer 7

• uses 4 risk factors (age, sex, low-trauma fracture, falls)
• Calculates 5 and 10 year risk of hip fracture and major bone fx

[corrects some disadvantages of FRAX)

Question 8

What is osteoporosis diagnosis based on?

Answer 8

1. Low trauma fracture

or

2. Central hip and/or spine DXA using WHO T-score thresholds

Question 9

Osteopenia T score

Answer 9

T-score between -1 and -2.5

low bone mass

Question 10

Osteoporosis T score

Answer 10

T-score -2.5 or less

Question 11

Who does the T score apply to?

Answer 11

• postmenopausal women
• perimenopausal women
• men 50+

Question 12

Who does the Z score apply to?

Answer 12

diagnosis of osteoporosis in

• children
• premenopausal women
• men under 50

Question 13

What does the Z-score have to be to diagnose osteoporosis in children, premenopausal women, and men under 50?

Answer 13

Z score of less than 2 (in combination with other risk factors or fracture)

Question 14

What is the antiresorptive therapy of choice along with calcium and vitamin D?

Answer 14

Bisphosphonates

Question 15

What does Vitamin D increase intestinal absorption of?

Answer 15

calcium and phosphorous

Question 16

What is the recommended dietary allowances of calcium for adults 19-50 years old?

Answer 16

1000-2,500mg

Question 17

What is the recommended dietary allowance of vitamin D for ages 9 to 70?

Answer 17

600- 4,000mg

Question 18

Which form of calcium is better tolerated

Answer 18

Calcium citrate (but, more expensive)

calcium carbonate (gas, bloating, constipation)

Question 19

Adverse effects of calcium supplementation

Answer 19

1. Hypophosphotemia

2. Hypercalcemia

Question 20

How do you treat Vitamin D deficiency

Answer 20

50,000iu weekly for 8-12 weeks

Question 21

Who are bisphosphonates indicated for

Answer 21

• postmenopausal female
• men
• glucocorticoid-induced osteoporosis

Question 22

Intravenous and oral ibandronate is indicated only for _______

Answer 22

postmenopausal women

Question 23

Bisphosphonate: MOA

Answer 23

inhibit bone resorption:

-decreased osteoclast maturation, number, recruitment, and life span

Question 24

Bisphosphonate 1/2 life

Answer 24

up to 10 years

Question 25

What is important to remember about taking oral Alendronate (Fosamax)

Answer 25

Take in the morning on an empty stomach and don't eat or lie down for at least 30 minutes. Avoid taking with calcium and vitamin D

Question 26

What is important to remember about oral Ibandronate (Boniva)?

Answer 26

Take in the morning on an empty stomach and don't eat for at least 60 minutes

Question 27

What is important to remember about Risedronate (Atelvia)?

Answer 27

Immediate release like Alendronate (take on empty stomach and wait 30 min) Delayed release- take immediately following breakfast

Question 28

How is zoledronic acid given?

Answer 28

IV once a year

Question 29

What can be given before infusion with zoledronic acid to decrease infusion reactions?

Answer 29

acetaminophen

Question 30

When is zoledronic acid contraindicated?

Answer 30

if CrCl is <35 mL/min

Question 31

ADEs of oral bisphosphonates

Answer 31

nausea | dyspepsia

Question 32

ADEs of IV bisphosphonates

Answer 32

transient flu-like illness

Question 33

What are 2 rare and adverse effect of bisphosphonates?

Answer 33

1. osteonecrosis of the jaw | 2. Subtrochanteric femoral fracture

Question 34

Bisphosphonate contraindications

Answer 34

1. Creatinine clearance of <30-35mL/min 2. Esophageal abnormalities 3. Pregnancy

Question 35

Who can be considered eligible for a "drug holiday" on bisphosphonates?

Answer 35

1. Women without evidence of a low-trauma fracture 2. If good response to treatment 3. If BMD increasing to >-2 (getting into osteopenic range)

Question 36

When can a drug holiday be considered?

Answer 36

If low risk can consider stopping after 5 years of treatment If high risk for fracture (T-score below -3.5, consider alendronate for up to 10 years

Question 37

At what age can calcitonin be used?

Answer 37

at least 5 years past menopause

Question 38

What form does calcitonin come in?

Answer 38

nasal spray | refrigerate until opening, then use at room temp

Question 39

Raloxifene (Evista) and bazedoxifene (Duavee) drug class

Answer 39

Estrogen Agonist/Antagonist

Question 40

What is Teriparatide

Answer 40

recombinant pieces of PTH

Question 41

Who is Teriparatide indicated for?

Answer 41

Very low bone density with T score

Question 42

What is important for the first dose of teriparatide?

Answer 42

patient needs to be sitting or lying down as first dose can cause orthostatic hypotension

Question 43

Teriparatide dosing?

Answer 43

daily subcutaneous injection

Question 44

Abaloparatide

Answer 44

synthetic analog of human PTH | acts as an anabolic agent to stimuate bone formation

Question 45

Who is abaloparatide used for?

Answer 45

high-risk postmenopausal osteoporosis

Question 46

Denosumab: MOA

Answer 46

RANKL inhibitor that inhibits osteoclatogenesis and increases osteoclast apoptosis

Question 47

Denosumab: ADEs

Answer 47

- back, extremity, and musculoskeletal pain - increased cholesterol - cystitis

Question 48

When is calcitonin used?

Answer 48

LAST RESORT

Question 49

First line therapy for osteoporosis

Answer 49

1. Alendronate 2. Risedronate 3. Zoledronic acid 4. Denosumab

Question 50

What causes Osteomalacia?

Answer 50

Undermineralized bone from prolonged vitamin D deficiency

Question 51

Osteomalacia treatment?

Answer 51

Vitamin D

Question 52

What labs may be seen in osteomalacia

Answer 52

elevated alkaline phosphatase hypocalcemia