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Flashcards in Osteoporosis & Hormone Therapy Deck (93):
0

What's osteoporosis?

Defined as a T-score < -2.5

1

What's osteopenia?

Defined as a T-score btw -1 & -2.5

2

What's Osteoblasts?

Cells involved in bone formation

OsteoBlast - Build Bones

3

What's Osteoclasts?

Break-down of bone

OsteoClasts - Crack bone

4

What's DEXA or DXA?

Bone scan performed by a dual energy x-ray absorptiometry machine

5

Risk factors for low bone density? Which is most important?

Genetic factors (most imp), Caucasians and Asian American women at highest risk

Advanced age

Low bone mineral density

Previous fracture (other than skull, facial bone, ankle, finger or toe)

More than 2 alcoholic drinks per day

Oral or IM glucocorticoid use > 3 months (daily dose of >= 5mg prednisone or equivalent)

Body wt < 127 pounds
Or low BMI < 21 kg/m^2

A decline in adult estrogen levels

Rheumatoid arthritis & lupus

Low level of physical activity & adequate nutrition - low over life span

Ca + Vit. D intake low over life span

Smoking

6

Drugs that put u at risk of osteoporosis risk?

Steroids (>= 5mg/d of prednisone equivalent for >= 3 months)

Depot medroxyprogesterone acetate

Anticonvulsants (CBZ, Fosphenytoin, phenobarbital, PHT, Primidone)

Warfarin & Heparin

Excess thyroid hormone

Loop diuretics

Aromatase inh

Nafarelin (Synarel) - used in endometriosis

Androgen blockers used for prostate CA

Proton pump inh used chronically (reduced Ca absorption due to reduced gastric PH)

7

Fall prevention measures?

Appropriate lighting

Floors are safe (thrips rugs/clutter/cords have been removed)

Storage (at reasonable heights)

Bathrooms have safety bars

Handrails are present on all stairs

Stairs are well-lit with non-skid treads or carpets

8

What's req for all low bone density rx meds?

Ca + Vit. D

9

What should be accessed first in to presenting with low bone density?

Dietary intake of Ca

10

When's adequate Ca intake most critical?

Children

In pregnancy

During yrs around menopause

11

Results of Vit D deficiency in children? Adults?

Children - Rickets

Adults - Osteomalacia

12

How should Ca be dosed? Why?

Ca doses should be divided

Ca absorption is saturable

13

Which Ca has a better absorption? Issue with this Ca?

Calcium citrate (Citracal, others) - tab has 315mg Ca

Larger tablet to swallow

14

Ca citrate absorption and PPIs?

Ca citrate may be preferred with little or no stomach acid

May use with PPIs

15

Disadvantage of Ca carbonate (Oscal, Tums etc)? How does this affect how it's taken?

Ca carbonate has acid-dependent absorption

Should be taken with meals

16

What's the NIH recommended Vit. D intake for people up to 70 yrs?

600 IU daily

17

What's the NIH recommended Vit. D intake for people 71+ yrs?

800 IU daily

18

What's the preferred source of Vit. D2 in renal dx or short-term in adults with deficiency to replenish stores?

Cholecalciferol or Vit. D3

19

What's the 1st line in most pts with low bone density?

Bisphosphonates

20

Alt to oral Bisphosphonates with those with GI problems?

Injectable Bisphosphonates

21

Alt. in adherence issues?

Annual infusion of Zoledronic acid (Reclast)

22

What's the duration of Bisphosphonates use? Why?

Stop after 3-5 yrs

Due to risk of atypical femur fracture, esophageal CA & osteonecrosis of the jaw

23

Role of Teriparatide inj (Forteo) in therapy?

In pts with osteoporosis with HIGH risk for fracture, or have already had an osteoporotic fracture, or have OP + need to take long-term steroids, or who can't tolerate Bisphosphonates

24

Role of estrogen in therapy?

No longer first line for osteoporosis

May be useful short-term, in younger women w/o CI, esp due to time limit on Bisphosphonates

25

What's used most commonly in women who are at risk or have fear of breast CA?

Raloxifene (Evista)

26

MOA of Bisphosphonates?

Work by inhibiting osteoclast activity

27

Uses of Bisphosphonates?

Prevention (osteopenia)

Tx (osteoporosis)

Paget's dx

Glucocorticoid-induced osteoporosis

Zoledronic acid - used for hypercalcemia of malignancy

28

List Bisphosphonates

Alendronate (Fosamax, Binosto)

Risedronate (Actonel, Atelvia)

Ibandronate (Boniva)

29

Brand name of Alendronate?

Fosamax

Binosto

30

Brand name of Risedronate?

Actonel

Atelvia

31

Brand name of Ibandronate?

Boniva

32

Hows Alendronate (Fosamax, Binosto) dosed for osteoporosis?

70 mg PO weekly

33

SEs of Bisphosphonates?

Hypocalcemia (mild, transient)

Back pain

Arthralgias

Dyspepsia

N/V

Dysphagia

Heartburn

Esophagitis

34

Injectable Bisphosphonates?

Zoledronic acid (Reclast)

35

Brand name of Zoledronic acid (injectable Bisphosphonates)?

Reclast

36

MOA of Raloxifene?

An Estrogen agonist/Antagonist, also called selective estrogen receptor modulator (SERM) and reduced bone resorption

37

Brand name of Raloxifene?

Evista

38

Role of Raloxifene (Evista)?

Used often in women at risk (or have fear of) breast CA

39

Effect of Raloxifene (Evista)?

Favorable lipid effects (reduced CH and LDL; no effect on HDL and TGs)

40

SEs of Raloxifene (Evista)?

Hot flashes

Peripheral edema

Hot flashes

Arthralgias

Leg cramps/muscle spasms

Flu-like syndrome

Infection

Amenorrhea

Vaginal bleeding/discharge

Skin changes

41

MOA of Calcitonin nasal spray and injection?

Inhibits osteoclastic bone resorption

42

SEs of Calcitonin nasal spray and injection?

Rhinitis

Alt nostril daily

43

MOA of Teriparatide injection?

Stimulates new bone formulation and depresses osteoclast activity; recombinant human PTH 1-34

44

Brand name of Teriparatide injection?

Forteo

45

Role of Teriparatide (Forteo) injection in therapy?

For pts who are at very high risk for fracture

46

Daily dose and max duration of use for Teriparatide (Forteo) injection?

20mcg SC inj daily.

Max of 2 yrs

47

SEs of Teriparatide (Forteo) injection?

Orthostasis/dizziness

Increased HR (esp with 1st few doses)

Injection site pain

Hypocalcemia (transient, post-dose)

48

MOA of Monoclonal antibody?

Binds to nuclear factor-kappa ligand (RANKL) & prevents interaction btw RANKL & RANK, preventing osteoclast formation

Leads to decreased bone resorption and increased bone mass

49

Agent under Monoclonal antibody used in low bone density?

Denosumab (Prolia)

50

Brand name of Denosumab?

Prolia

51

Which Denosumab is for hypercalcemia of malignancy

Xgeva

52

Role of Denosumab (Prolia) in therapy?

High risk

53

CI to Denosumab (Prolia) use?

Hypocalcemia - check levels prior to using drug

54

Ses of Denosumab (Prolia)?

Fatigue

Hypocalcemia (correct)

Eczema

Rash

Weakness

Arthralgia/weakness/limb pain

Nausea

Dyspnea

Cough

55

Bisphosphonates use counseling?

Take 1st thing in the morning b4 u eat/ drink anything else except 6-8 ounces (1 cup) of plain water

Sit up or stand up and stay upright for at least 30 mins (60 mins with monthly Boniva)

Swallow tab whole

Bisphosphonates don't work well if u're not taking enough Ca + Vit. D

PPIs may increase fracture risk

Exercise

Common SE include GI upset, joint pain, back pain, dyspepsia or heartburn

Stop taking this medicine if u develop difficult or painful swallowing, chest pain or very bad heartburn

56

When should dental work be done?

B4 starting Bisphosphonates

57

Atelvia (long-acting form of Risedronate) use?

Take medicine AFTER breakfast

Sit/stand upright for 30 mins

Don't use acid suppressing "heart burn" therapy with this medicine

Don't take Ca, Iron, Mg or MVTE supplements till later in the day

58

What's shouldn't be used with Reclast inj?

Zometa ( same drug)

59

SE of Teriparatide (Forteo) injection, esp after the 1st few doses?

U may feel dizzy or have a fast heartbeat

60

Storage of Teriparatide (Forteo) injection? When should it be discarded?

Refrigerator (re-cap after each use)

After 28 days, pen should be discarded

61

Site of injection of Teriparatide (Forteo) injection?

Thigh or abdomen (lower stomach area)

Sites must be rotated

62

Max duration of Teriparatide (Forteo) injection use?

Don't exceed 2 yrs of use

63

Effect of decrease in estrogen?

Hot flashes

Night sweat

64

Most effective therapy for vasomotor sx (hot flashes, night sweats)?

Estrogen, (cause decrease in LH => more stable temp control)

65

Role of Estrogen in therapy?

Most effective therapy for vasomotor sx (hot flashes, night sweats)

To prevent postmenopausal osteoporosis

66

Should estrogen be given alone in women with a uterus?

No

67

How should estrogen be used?

Use lowest possible dose for the shortest possible time

68

Ses Estrogen + Progestin? Max duration?

Increases breast CA risk

3-5 yrs

69

Natural pdts used for vasomotor sx? (Hot flashes and night sweats)

Black cohosh

Red clover

Soy

Flaxseed

70

CI to estrogen (in any form) use

Undiagnosed abnormal genital bleeding

Active or past breast CA

Known or suspected estrogen-dependent CA

Active or past deep vein thrombosis or pulmonary embolism

Active or recent arterial thromboembolic dx (stroke, MI)

Liver dysfxn / dx

Known or suspected pregnancy

71

SEs of estrogen?

Nausea

Dizziness

Bloating

Breast tenderness/fullness

72

What's most useful for pts who have vaginal sx (dryness, painful intercourse)?

Vaginal pdt

73

Effect of Paroxetine (Brisdelle) - used in hot flashes - wrt warfarin and tamoxifen?

Increase the risk of bleeding (warfarin)

Blocks the effectiveness of Tamoxifen

(cuz Brisdelle is a CYP450 2D6 inh)

T4 don't use with either warfarin or tamoxifen

74

Why are forms of Paroxetine preg cat D/X?

Cardiovascular risks in newborn

75

Brand name of Paroxetine used in hormone therapy for Hot flashes?

Brisdelle

76

List most common HRT pdts?

Vivelle, Vivelle-Dot

Provera

Premarin

Premarin vaginal cream

Prempro

77

Do estrogen HRT contain progestin? Why/ why not?

No!

78

Report any unusual vaginal bleeding, right away while on estrogen?

True

79

Risk of which dx states increases with the use of estrogen?

Heart attacks
Strokes
Breast CA
Blood clots

80

What's Estrogen used for primarily? Duration of use?

Primarily in menopausal sx

Should not be continued indefinitely

81

Whats should done on Vivelle-Dot patch application?

Mark the 2-day schedule

82

Site of Vivelle-Dot patch application?

Apply to lower abdomen, below waistline

83

Where shouldn't Vivelle-Dot patch be applied?

Never to the breast

84

Testosterone therapy demand is on the increase becuz?

Improved sexual interest (increased libido) and performance

85

Whys the use of Testosterone replacement controversial?

May increase prostate CA risk

May also increase cholesterol levels

May cause liver damage

86

Role of testosterone therapy?

An accepted used in men with

Low prostate CA risk + low testosterone level + a related condition! such as low muscle mass

87

Men at high risk of prostate CA and use of testosterone therapy? BPH?

Men at high risk of prostate CA should NOT use of testosterone therapy

BPH sx would worsen

88

Agents under Testosterone pdts? Control substance class?

AndroGel 1%, 1.62%

Testim gel 1%

Androderm patch

Striant buccal tabs

Testosterone soln (Axiron)

Testosterone gel (Fortesta)

C III

89

Sites of application that may reduce accidental exposure to others eg women and children?

Thighs, underarms

90

BBW of testosterone pdt

Secondary exposure to testosterone in children and women

91

SE of testosterone pdt

Increased appetite

Increased risk of Hepatoxicity

92

Look at pg 496 - AndroGel Pt Counseling

Ok

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