Osteoporosis Therapeutics Flashcards
(24 cards)
When can you get a bone mineral density BMD test?
- Age 70+
- Age 65-69 with 1 risk factor
- Age 50-64 with 2+ risk factors or previous OP fracture
What are risk factors for low BMD
- Previous fracture in 40+
- Glucocorticoids (3 months/yr at 5mg)
- 2+ falls in the past year
- BMI less than 20
- Smoking
- Alcohol 3+ drinks/day
- Secondary osteoporosis
When to use CAROC? What does it use to calculate risk?
What is a low, moderate, high risk %? For how long?
CAROC 50+
- uses sex, age, femoral neck T-score
Risk in the next 10 years
Low: less than 10%
Moderate: 10-20%
High: greater than 20%
What is considered a major OP fracture?
- Vertebra
- Hip
- Wrist
- Upper humerus
When should you go up a risk category in the CAROC? When are patients considered high risk?
- Prior fragility fracture after age 40
- Prednisone over 7.5mg/dose for 3 mos
Are considered high risk if they have both
When to use FRAX? What does it use to calculate risk?
FRAX (40+)
- Age, sex, BMI
- Parental hip fracture, prolonged glucocorticoid use, RA
- Smoking, 3+ drinks/day
- Secondary osteoporosis risk factors
**OPTIONAL femoral neck T-score
In the physical assessment of body weight, what is associated with higher risk? (2)
In men 50+ and post-menopausal women
- Low body weight <60kg
- Major weight loss (10%+ of weight at age 25)
In the physical assessment of height, what is associated with higher risk? (2)
Inc risk of vertebral fracture if:
- Historical height loss over 6 cm
- Measured height loss over 2 cm
- use a lateral thoracic and lumbar spine x-ray
Explain the reasoning and interpretation of the following tests for a high risk
Rib-pelvis distance
Occiput-to-wall distance
Rib-pelvis distance
- identify lumbar fractures
- 2+ fingerbreadths line is a risk
Occiput-to-wall distance
- identify thoracic spine fractures
- 5+ cm is a risk
Explain the indications of VIt D tests. Normal value? When to test again?
25-hydroxyvitamin D good for measuring Vit D stores
Normal: 75+ nmol/L
Indications
- planning to give OP drug therapy
- Recurrent fractions or bone loss despite therapy
- Vit D malabsorption
Test 3-4 months again after
What other lab work can be used to see if there are secondary causes of patients osteoporosis?
- Creatinine
- Calcium (corrected)
- Alkaline phosphate
- TSH
- CBC
- Vit D
What intake of calcium and vitamin D should be given to osteoporosis patients
Calcium
51-70 years: 1000mg/day
70+: 1200mg/day
Women 50+: 1200mg/day
**Always try to take calcium from diet
Vitamin D
- less than 70: 600IU/day
- 70+: 800 IU
**Patients over 50 should supplement with 400IU/day
What are the bisphosophonate drugs?
MOA?
How long is it used?
Oral: Alendronate, Risedronate
IV: Zoledronic acid
MOA: increase bone mass throughout skeleton, reduce risk fracture
Used for 3-6 years then take a drug holiday
for 3 years
- use 6 years if they have more risk factors
- going from 5-10 years of treatment has minimal positive effects
How to take oral bisphosphonates, exceptions?
Administration
- take on empty stomach 30 min before food, sit upright for 30 min
- EXCEPT risedronate DR, take with food
Mostly well tolerated
What are the contraindications for oral bisphosphonates?
- Esophageal abnormalities
- Inability to be upright for 30 min
- Hypocalcemia
How to take zoledronic acid? What needs to be checked before each infusion? Why?
Once a year IV infusion
- do not give if patient has renal impairment
Monitor
- serum calcium, vit D, creatinine to be checked before each infusion
- bc of higher risk of IV hypercalcemia
What are serious side effects of bisphosphonates
- Esophogeal ulceration (PO only)
- Ocular effects, hypocalcemia
- Osteonecrosis of the jaw
- Atypical femur fractures
What drug class is Denosumab (Prolia)?
MOA?
How long is it used for?
Who can take?
RANK ligand inhibitors
MOA:
- Monoclonal antibody that neutralizes RANKL
- Not retained in the skeleton.. rapid loss of BMD after stopped
- Used for 10 years
Who can take
- can’t tolerate/ineffective bisphosphonates
What drug class is Raloxifene (Evista)?
Indication?
Side effects?
MOA
Selective estrogen receptor modulators (SERMS)
Indication:
- prevention of vertebral fractures in postmenopausal women
Side effects:
- increase risk of blood clotting, VTE, stroke, hot flashes
MOA
- Agonist on bone density
- Antagonist for breast cancer
Drug class of teriparatide (Forteo)?
MOA?
Treatment regimen?
When to consider as first line?
Synthetic parathyroid hormone –> stimulates osteoblast –> direct anabolic effect
- Not retained in the skeleton, rapid loss after stopped
Treatment: 20mcg SC daily for 2 years then any antiresorptive med after
Consider as first line:
- Patients with history of vertebral fracture and T-score less than 2.5
What drug class is Romosozumab (Evenity)
MOA?
Indication?
Treatment?
Efficacy?
When to consider as first line?
Sclerostin inhibitor –> increases bone growth AND decreases bone breakdown
Indication
- Treatment for OP in Post-menopausal women
Treatment
- 210mcg SC for 1 year then antiresorptive med
- not retained in the skeleton
Efficacy
- more effective than forteo at improving density
- more effective than alendronate at reducing fractures with PRIOR fracture
Consider as first line:
- Patients with history of vertebral fracture and T-score less than 2.5
What medication to give if CrCl is less than 30
Do not give bisphosponate
- consider denosumab (prolia)
When to:
Not recommend therapy
suggest therapy
Recommend therapy
Do not recommend therapy
- Fracture risk <15% OR
- t-score -2.5+
Suggest therapy
- Fracture risk 15-19.9% OR
- T score below -2.5 AND age less than 70
Recommend therapy
- Fracture risk 20%+ OR
- T- score below 2.5 and age 70+
- Previous hip or spine fracture OR
- 2+ fracture events
When do you follow up for treatment OP?
When do you follow up for no treatment with risk factor of
less than 10%
10-15%
15%+
Treatment: BMD in 3 years
No treatment:
less than 10%: 5-10 years
10-15%: 5 yrs
15%+: 3 years
