Osteoporosis Lecture

Question 1

Take 30 mins before AM meal

Take with 8 oz cup of water

Remain upright for 30 mins

**can cause esophagitis

Answer 1

Alendronate (Fosamax) instructions

Question 2

Cornerstone therapy for osteoporosis

Answer 2

Bisphosphonates

Question 3

MOA for bisphosphonates

Answer 3

Inhibits osteoclastic bone resorption

Question 4

Half life of bisphosphonates once in bone?

Answer 4

~10 years

Question 5

How are bisphosphonates excreted?

Answer 5

In urine!

(must adjust dose if CC <35 mL/min)

Question 6

If a pt has esophagitis but needs Bisphosphonates…what do you do?

Answer 6

Can give IV!

Question 7

Side effects of Bisphosphonates?

Answer 7

Muscle, bone, joint pain

Dental concerns: non healing jaw post tooth extraction
**dental care is important for these pts!!!

Question 8

Which bisphosphonates has less GI side effects..

Alendronate (Fosamax) or Risedronate (Actonel)?

Answer 8

Risedronate (Actonel)

Question 9

Bisphosphonate tx duration should not exceed….

Answer 9

5 years

Question 10

1st line osteoporosis tx?

2nd line?

Answer 10

Start with calcium/vitamin D

Then bisphosphonates (no more than 5 years)

Question 11

Which drug is a nasal spray that inhibits osteoclast action

Answer 11

Calcitonin

Question 12

What happens to intake and GI absorption of Ca with age?

Answer 12

Decreases!

Question 13

should have 400-600 IU daily

Answer 13

Vitamin D2

Question 14

If taken above recomended daily amount, can increase risk of MI and stroke, especially women >70 with CHD

Answer 14

Calcium

Question 15

daily dose= 1200-1500 mg

Answer 15

Calcium

Question 16

Pts taking calcium who are also on thiazide diuretics or glucocorticoids

..beware of?

Answer 16

hypercalcemia

Question 17

a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

Answer 17

Osteoporosis

Question 18

Most common metabolic bone disease

Decreased bone matrix and mineral→ “thin bones”.

Women>Men, often asymptomatic early; later, bones fail structurally→fractures.

Answer 18

Osteoporosis

Question 19

Increases dramatically in puberty in response to gonadal steroids.

Peaks in young adults (early 20’s)

Determinants: age, race, genetics, gonadal steroids, timing of puberty, exercise, calcium intake and diet.

Answer 19

Bone density

Question 20

Begins before menses cease.

Accelerated loss in 1st _____ yrs post menopause.

Trabecular (cancellous)> Cortical (compact) bone loss.

Answer 20

5-10 years

Question 21

Sex hormone deficiency: post menopause; hypogonadism- M&W

Excess glucocorticoids (Cushing’s)

Hyperparathyroidism- ↑PTH

Thyrotoxicosis- ↑bone metabolism

Alcoholism, anorexia nervosa, Vit D deficiency.

Answer 21

Causes of bone loss (increased risk)

Question 22

bone mineral density 1.0 to 2.5 standard deviations (SD) below peak bone density

Answer 22

Osteopenia

Question 23

bone mineral density >2.5 standard deviations below peak bone density.

Answer 23

Osteoporosis

Question 24

Peak bone density = young healthy adult of same _____ and _____

Answer 24

gender and race

Question 25

It has been estimated that 1 out of 5 people with osteoporosis are....

Answer 25

MEN

Question 26

If a man appears to have multiple risk factors for osteoporosis..above which age should you consider getting a DEXA scan?

Answer 26

over 65

Question 27

typically looks at spinal bone, proximal femur and other bones at risk for fracture; includes eval of trabecular and cortical bone.

Answer 27

DEXA

Question 28

Rapid exam time Useful for F/U changes in BD; response to Rx Relatively inexpensive Limited radiation exposure

Answer 28

Advantages of DEXA

Question 29

number of SD by which patient BD differs from peak BD of young healthy adults of same gender/race.

Answer 29

T score

Question 30

Osteoporosis: BMD \> 2.5 SD below peak BD of young adults. Presence of “Fragility” Fracture (spontaneous Fx, no trauma); means “severe osteoporosis” regardless of Dexa score) Severe osteopenia: BMD of \> 2 SD below peak BD of young adults (prophylaxis). Controversies regarding Rx (see below).

Answer 30

Initiate treatment for these!

Question 31

Can you reverse established osteoporosis?

Answer 31

NO ## Footnote **can ↑BD, ↓fractures, halt or slow progression.**

Question 32

Use in patients with hypogonadism or premature menopause for prevention. Inhibits osteoclastic bone resorption. Prevents bone loss, fractures. Problems (dose related): ↑risk breast Ca, ↑risk endometrial cancer (if not coupled with progestins), ↑thromboembolic events, ↑in coronary events (when combined with progesterone).

Answer 32

Estrogen replacement

Question 33

All patients at ↑risk for osteoporosis (fam hx, malnourished, alcoholism, renal failure) including early postmenopause + risk factors, or age \>65.

Answer 33

Should be screened!

Question 34

Inhibit osteoclastic bone resorption; ↑bone density, ↓fractures (vertebral and elsewhere). Very long T½ once in bone (≈ 10 years!) **first line tx!**

Answer 34

Bisphosphonates

Question 35

Prior fractures FH of osteoporosis related fractures Low body weight Cigarette consumption Excessive ETOH use Chronic inflammation: RA Patients at risk for falls or frailty

Answer 35

Risk factors for fractures in women with osteoporosis

Question 36

Alternative to estrogen in post-menopausal woman with ↓risk of adverse effects; decrease bone loss, ↑bone density (less than estrogen), ↓ vertebral fractures.

Answer 36

SERMS

Question 37

blocks estrogen effects on breast and uterus. Does not cause endometrial hyperplasia, cancer or uterine bleeding. ↓↓’s incidence of breast cancer; ↑risk of thromboembolism (like estrogen). Increases hot flashes

Answer 37

Raloxifene (Evista) ## Footnote **drug class: SERMS**

Question 38

New- monoclonal antibody that deceases bone resorption by inhibiting osteoclasts. Increases BD in men and post menopausal women, ↓’s spine and hip fractures. SC injection 2x/yr. MOA: Antibody to receptor activator of the nuclear factor-kappa B ligand, which is a key mediator of the resorptive phase of bone remodeling

Answer 38

Denosumab (Prolia)

Question 39

Indication for patients: With prior osteoporotic fractures Who cannot tolerate other meds Who developed fracture in spite of other Rx With multiple risk factors for fractures With autoimmune or inflammatory disease (ulcerative colitis)– 1st line therapy

Answer 39

Denosumab