Therapeutics of Osteoporosis Exam 1

Question 1

What are the goals and desired outcome for prevention of osteoporosis?

Answer 1

• achieve highest peak bone mass up to age 30
• for pts >30 years, maintain BMD and minimize bone loss
• pts w/ low bone mass, prevent progression to osteoporosis

Question 2

What are the goals and desired outcome for treatment of osteoporosis?

Answer 2

• Patients with osteoporosis, at high-risk for osteoporosis, or with osteoporosis-related fractures: Increase BMD, prevent further bone loss, and prevent falls and fractures
• Patients with osteoporosis-related fractures: Adequate pain control, maximize rehabilitation to restore independence and quality of life, and prevent subsequent fracture and death

Question 3

Relative efficacy of Calcium and Vitamin D Supplementation in prevention / treatment of osteoporosis

Answer 3

• can increase BMD and reduces fractures
• Vitamin D additionally decreases risk of falls
• Optimal calcium absorption is achieved when it is taken with adequate vitamin D

Question 4

Calcium and Vitamin D Supplementation drug interactions

Answer 4

• Fiber decreases calcium absorption
• Calcium can decrease absorption of iron, tetracyclines, quinolones, bisphosphonates, and thyroid supplements
• Cholestryramine, colestipol, orlistat can decrease vitamin D absorption
• Vitamin D can enhance absorption of aluminum

Question 5

Patient counseling points for optimal intake and selection of calcium and vitamin D supplementation

Answer 5

• Select a product with USP verified on label to guarantee the identity, strength, purity, and quality.
• Take with meals.
• Constipation is common adverse effect and can be managed by increased water intake, dietary fiber, and exercise.
• Divide calcium in dose of < 600 mg of calcium per dose
• Patients need recommended vitamin D to ensure optimal absorption of calcium.

Question 6

calcium and vitamin D supplementation place in therapy

Answer 6

standard of care for prevention and treatment of osteoporosis in all patients not getting recommended amount through diet and/or sun exposure

Question 7

Calcitonin salmon relative efficacy

Answer 7

• moderately effective
• can increase BMD and reduction in new vertebral fractures
• not shown to reduce risk of hip and other fractures

Question 8

Calcitonin salmon place in therapy

Answer 8

Because efficacy is less robust and potential risk of cancer compared to the other osteoporosis therapies, calcitonin is reserved for last-line.

Question 9

Bisphosphonates relative efficacy

Answer 9

• high efficacy

- can improve BMD and reduce risk of fracture

Question 10

bisphosphonates precautions

Answer 10

• GI perforation, ulceration, and GI bleeding
• d/c drug if CP occurs, new or worsened heartburn, pain with or difficulty swallowing
• bone / joint / muscle pain
• Osteonecrosis of the jaw (ONJ)
• Atypical, low-trauma fractures of the femoral diaphysis

Question 11

bisphosphonates contraindications

Answer 11

• Renal dysfunction: Not for use in patients with renal insufficiency (CrCl < 35 ml/min)
• Upper GI disorders: Avoid in patients with serious esophageal abnormalities (i.e. strictures).

Question 12

How do you take oral bisphosphonates in order to obtain optimal administration?

Answer 12

• Take with full 6 to 8 oz. glass of plain water immediately after getting up in the morning and do not take other medications, eat, or drink for at least 30 minutes after taking alendronate or risedronate (at least 60 minutes for ibandronate). Exception: delayedrelease risedronate should be taken after breakfast.
  ▫ Do not lie down at least 30 minutes after alendronate or risedronate (at least 60 min for ibandronate) to minimize esophageal irritation.

Question 13

bisphosphonates place in therapy

Answer 13

• Therapy option for prevention of osteoporosis.
• First line option for the treatment of osteoporosis in postmenopausal women, in men, and patients with glucocorticoid-induced disease.
• IV may be preferred over oral in patients unable to stay upright for 30 to 60 minutes, those with significant GI disorders, or those with significant adherence issues.

Question 14

Which circumstances make a patient a good candidate for discontinuation or a drug holiday from bisphosphonate therapy?

Answer 14

if pt has been on it for 3-5 years and has low risk, hasn’t had a fracture, BMD within goal; test BMD every 2 years

Question 15

Which circumstances warrants patient to continue bisphosphonate therapy long term?

Answer 15

• high fracture risk
• pt’s w/ Tscore -2.5 and worst
• previous fracture
• taking high risk meds ex. chronic glucocorticoids

Question 16

Hormone Therapy (HT) relative efficacy

Answer 16

moderate efficacy

Question 17

Hormone Therapy (HT) place in therapy

Answer 17

• Long-term HT is no longer recommended due to risks (i.e. stroke, VTE).
• Should only be used short-term in women who need HT for menopausal symptoms and not solely for osteoporosis prevention.

Question 18

Selective Estrogen Receptor Modulator - SERM (RX) relative efficacy

Answer 18

• moderately effective
• increases BMD similar to calcitonin and hormone therapy, but less than bisphosphonates, denosumab, and PTH analogs
• Does not stimulate the endometrium, thus does not cause endometrial cancer.
• Lowers total and LDL cholesterol
• reduction in invasive breast cancer

Question 19

Selective Estrogen Receptor Modulator - SERM (RX) place in therapy

Answer 19

• Therapy option for prevention of osteoporosis in postmenopausal women.
• Second-line option for treatment of osteoporosis in postmenopausal women due to lesser benefit of fracture risk reduction than other

Question 20

Estrogen/SERM relative efficacy

Answer 20

• moderately effective
• does not work any better that estrogen alone to increase BMD
• alternative to estrogen plus progesterone

Question 21

Estrogen/SERM place in therapy

Answer 21

• Long-term estrogen is no longer recommended due to risks.
• Should only be used short-term in women who need estrogen for menopausal symptoms and not solely for osteoporosis prevention.

Question 22

Parathyroid Hormone Analogs relative efficacy

Answer 22

highly effective

Question 23

Parathyroid Hormone Analogs precautions

Answer 23

• Transient orthostatic hypotension
• Hypercalcemia
• Potential for serious adverse event (included as Black Box Warning for osteosarcoma)

Question 24

Parathyroid Hormone Analogs place in therapy

Answer 24

• Reserve for treatment of osteoporosis in male and female patients who are high-risk for fractures OR do not tolerate or get enough benefit from other osteoporosis medications.
• Not recommended for prevention of osteoporosis due to potential adverse effects.

Question 25

Denosumab relative efficacy

Answer 25

highly effective

Question 26

Denosumab contraindications

Answer 26

Hypocalcemia

Question 27

Denosumab precautions

Answer 27

• Higher risk of serious infections leading to hospitalization. Patients should monitor for fever, cellulitis, severe abdominal pain, or urinary frequency.
• Denosumab has rarely been associated with osteonecrosis of the jaw and atypical fractures.

Question 28

Denosumab place in therapy

Answer 28

Recommended to reserve for treatment of osteoporosis in postmenopausal women and men who are at high risk for fractures OR do not tolerate or get enough benefit from other osteoporosis medications.