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NAPLEX 2024 > 49. Osteoporosis > Flashcards

49. Osteoporosis Flashcards

1
Q

Osteoporosis is most common in ___

A

postmenopausal females

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2
Q

___ fractures are the most devastating type of fractures, with higher costs, disability, and mortality than all other fractures combined

A

Hip

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3
Q

____ fractures can occur without a fall and can initially be pain less (only clue may be gradual loss of height)

A

Vertebral

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4
Q

Wrist fractures and other types of fractures appear in younger people and serve as an early indicator of ___

A

poor bone health

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5
Q

Patient characteristics that increase osteoporosis risk

A

Advanced age
Ethnicity (Caucasian and Asian are higher risk)
Family Hx
Sex (Female > male)
Low body weight

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6
Q

Lifestyle factors that increase osteoporosis risk

A

Smoking
Excessive alcohol intake (≥3 drinks/day)
Low aclcium intake
Low vit D intake
Physical inactivity

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7
Q

Medical Diseases/Conditions that increase osteoporosis risk

A

DM
Eating disorders (e.g. anorexia)
GI diseases (e.g. IBD, celiac disease, gastric bypass, malabsorption syndromes)
Hyperthyroidism
Hypogonadism in men
Menopause
Rheumatoid arthritis, autoimmune diseases
Others (e.g. epilepsy, HIV/AIDS, Parkinson disease)

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8
Q

Medications that increase osteoporosis risk

A

Anticonvulsants (e.g. carbamazepine, phenytoin, phenobarbital)
Aromatase inhibitors
Depo-medroxyprogesterone
GnRH (gonadotropin-releasing hormone) agonist
Lithium
PPIs (increase gastric pH, decreases Ca absorption)
Steroids (≥5mg daily of prednisone or equivalent for ≥ 3 months)
Thyroid hormones (in excess)
Others (e.g. loop diuretics, SSRIs, TZDs)

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9
Q

____ cells are involved in bone formation.
____ cells are involved in bone resorption; they breakdown tissue in the bone.

A

Osteoblasts
Osteoclasts

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10
Q

Bone health is evaluated by measuring ____

A

Bone mineral density (BMD)

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11
Q

The gold standard to measure BMD and dx osteoporosis is ____. This measures BMD of the spine and hip and calculates a T-score or a Z-score.

A

Dual-energy X-ray absorptiometry (DEXA or DXA) scan

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12
Q

What is a T-score?

A

It compares the pt’s measured BMD to the average peak BMD of a healthy, young, white, adult of the same sex
T-scores are negative: a score ≥ -1 correlates with stronger (Denser bones), which are less likely to fracture

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13
Q

Who should have BMD measured?

A

women ≥ 65 yo and men ≥70 yo
Younger pts at hgih risk for fracture

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14
Q

Interpret T-score -1 to -2.4

A

Osteopenia (low bone mass)

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15
Q

Interpret T-score ≤ -2.5

A

Osteoporosis

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16
Q

Interpret T-score ≥ -1

A

Normal

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17
Q

____ tool is a computer-based algorithm developed by the WHO thats estimates the risk of osteoporotic fracture in the next ___ years

A

FRAX tool
10 years

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18
Q

Factors that put at increased fall risk

A

Hx of recent falls
Medications that cause sedation or orthostasis (e.g. Anti HTN, sedatives, hypnotics, narcotic analgesics, psychotropics)

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19
Q

What kind of exercises should pts with low bone density do?

A

Weight-bearing exercise (e.g. walking, jogging, Tai-Chi) and muscle-strengthening exercise (e.g. weight training, yoga)

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20
Q

Adequate calcium intake (dietary preferred) is required throughout life. When is it critically important?

A

Children (who can build bone stores)
Pregnancy (when the fetus can deplete mother’s stores)
Years around menopause (when bone loss is rapid)

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21
Q

___ is required for calcium absorption

A

Vit D

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22
Q

Vit D deficiency in children causes ___ and in adults it causes ___

A

children = rickets
Adults = osteomalacia (softening of bones)

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23
Q

Many endocrinologists suggest intake of ____ vitamin D daily

A

25-50mcg (800-2000IU) daily

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24
Q

Calcium absorption is saturable; doses above ___ of elemental calcium should be divided

A

500-600mg

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25
Q

Which has more elemental calcium per unit: calcium carbonate or calcium citrate?

A

Calcium carbonate – but requires acidic environment for absorption

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26
Q

Which has better absorption with an increased gastric pH: calcium carbonate or calcium citrate?

A

Calcium citrate

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27
Q

Vit D deficiency can be treated with high doses of ____ or ___ for 8-12 weeks, followed by maintenance therapy (25-50mcg (1000-2000IU) daily)

A

Vit D2 (ergocalciferol) 1250 mcg (50,000 IU) weekly
Vit D3 (cholecalciferol) 125-175 mcg (5000-7000 IU) daily

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28
Q

Recommended daily intake for most adults is ___ mg elemental calcium

A

1000-1200mg daily

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29
Q

Calcium carbonate (e.g. Tums)
__% elemental calcium
Absorption requirements?: ____
With meals?: ___

A

40%
acid-dependent
must take with meals, do not use with PPIs

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30
Q

Calcium citrate (e.g. Citracal)
__% elemental calcium
Absorption requirements?: ____
With meals?: ___

A

21%
Not acid-dependent
Take with or without food

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31
Q

Vitamin D deficiency is defined as serum vit D [25(OH)D] < ____

A

30 ng/mL

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32
Q

1g of calcium carbonate = ___ elemental calcium

A

400mg

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33
Q

1g clacium citrate = ____ elemental calcium

A

210mg

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34
Q

Side effects of calcium supplements

A

Constipation
Hypercalcemia, nausea

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35
Q

Medications approved for osteoporosis prevention

A

Bisposphonates (except IV ibandronate)
Estrogen-based therapies, raloxifene, Duavee

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36
Q

Medications approved for osteoporosis treatment

A

Bisphosphonates
Denosumab
Parathyroid hormone analogs (e.g. teriparatide, abaloparatide)
Calcitonin

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37
Q

Regardless of drug selection for osteoporosis, treatment must include adequate ___ intake

A

Adequate calcium and vit D intake

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38
Q

Criteria for initiating treatment in osteoporosis

A

T-score ≤ -2.5 in the spine, femoral neck, total hip or 1/3 radius OR
Presence of a fragility fracture, regardless of BMD

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39
Q

Criteria for initiating treatment in osteopenia (if high risk)Bisphosphonates

A

Low bone density (T-score between -1 and -2.5) AND
FRAX score indicates 10-yr probability of major osteoporosis-related fracture ≥ 20% or a 10-yr hip fracture probability ≥ 3%

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40
Q

First line treatment or prevention in most patients is ____

A

Bisphosphonates (alendronate)

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41
Q

Administration notes for bisphosphonates

A

PO administration, must stay up right for 30 min (60 min for ibandronate) and drink 6-8oz of plain water

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42
Q

Side effects for bisphosphonates

A

Esophagitis, hypocalcemia, GI effects (N/V, heartburn, dyspepsia, dysphagia)
Rare(but serious): atypical femur fractures, osteonecrosis of the jaw (ONJ) - jaw bone becomes exposed and cannot heal d/t decrease blood supply

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43
Q

Bisphosphonates formulations

A

PO - weekly/monthly
IV - given quarterly/yearly (if GI side effects or adherence issues with PO formulation

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43
Q

Treatment duration for bisphosphates

A

3-5 yrs in pts with a low risk of fracture (d/t risk of femur fractures and ONJ)

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44
Q

Place in therapy Denosumab (Prolia)

A

Alt to bisphosphonatesD

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45
Q

Denosumab administration and frequency

A

SC every 6 months

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46
Q

Denosumb side effect

A

Hypocalcemia

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47
Q

Place in therapy Teriparatide (Forteo), Abaloparatide (Tymlos)

A

Recommended for very high-risk pts only (e.g. hx of severevertebral fractures)

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48
Q

Teriparatide (Forteo), Abaloparatide (Tymlos) administration and frequency

A

SC administration daily

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49
Q

Teriparatide (Forteo), Abaloparatide (Tymlos) side effect

A

Hypercalcemia

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50
Q

Place in therapy raloxifene (Evista), Bazedoxifene/estrogens (Duavee)

A

Alt to bisphosphonates if high risk of vertebral fractures

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51
Q

Concerns with raloxifene (Evista), Bazedoxifene/estrogens (Duavee)

A

Increased risk for VTE and stroke

52
Q

Raloxifene can be used if low risk of ___ or high risk of ____

A

Low VTE risk or High breast cancer risk

53
Q

Side effect of raloxifene (Evista)

A

Vasomotor symptoms

54
Q

_____ can be used in women with an intact uterus for prevention of osteoporosis. Also used as tx for vasomotor symptoms.

A

Bazedoxifene/estrogens (Duavee)

55
Q

Side effect of Bazedoxifene/estrogens (Duavee)

A

Increased risk of breast cancer

56
Q

Last line or not recommended options for osteoporosis

A

Estrogen (with or without progestin) - for prevention only in postmenopausal women with vasomotor symptoms; use lowest dose for shortest duration
Calcitonin - for treatment only if other options not suitable (less effective and risk of cancer with long-term use)

57
Q

Bisphosphonates MOA

A

increase bone density by inhibiting osteoclast activity and bone resorption

58
Q

Bisphosphonates reduce vertebral and hip fracture risk except ____ which only reduces vertebral fractures

A

ibandronate

59
Q

A drug holiday should be considered for low-risk pts after ___ years of treatment with bisphosphonates

60
Q

Risedronate (Atelvia delayed release) should not be used with ___ (decreases absorption)

A

H2RAs or PPIs (requires acidic gut for absorption)

61
Q

Separate PO bisphosphonates from calcium, antacids, iron, and magnesium by at least ___

62
Q

Alendronate (Fosamax) dosing frequency

A

Daily or weekly

63
Q

Risedronate (Actonel, Atelvia) dosing frequency

A

Daily, weekly, or monthly

64
Q

PO Ibandronate (Boniva) dosing frequency

65
Q

IV Ibandronate (Boniva) dosing frequency

A

every 3 months

66
Q

IV Zolendronic acid (Reclast) dosing frequency

67
Q

When is IV bisphosphonates preferred over PO?

A

If esophagitis is present d/t risk for esophageal cancer)

68
Q

Warnings for bisphosphonates

A

ONJ
Femur fractures
Esophagitis, esophageal ulcers, erosions
Hypocalcemia
Renal impairment (Do not use alendronate if CrCl <35, ibrandonate, risedronate if CrCl <30)

69
Q

Raloxifene MOA

A

Selective estrogen receptor modulator (SERM) that decreases bone resorption

70
Q

Conjugated estrogen/bazedoxifene (Duavee) is an ___ estrogen /SERM combo indicated for osteoporosis prevention

A

equine (horse)

71
Q

Boxed warnings Raloxifene (Evista)

A

Increased risk of VTE, death d/t stroke in women with CHD or at risk for coronary events

72
Q

Contraindications for Raloxifene (Evista)

A

hx or current VTE
Pregnancy

73
Q

Side effects for Raloxifene (Evista)

A

Hot flashes, peripheral edema, arthralgia, leg cramps/muscle spasms, flu symptoms, infection

74
Q

Boxed warnings Conjugated estrogen/bazedoxifene (Duavee)

A

Endometrial cancer (d/t unoopposed estrogen)
Increased risk of DVT and stroke in postmenopausal women 50-79yo (do not use to prevent CVD)
Dementia (women ≥65yo)
Use lowest effective dose for shortest duration

75
Q

Contraindications for Conjugated estrogen/bazedoxifene (Duavee)

A

Breast cancer (any hx)
Pregnancy
Undiagnosed bleeding
Hx or active VTE, MI or stroke
Protein C, S, or antithrombin deficiency
Hepatic impairment

76
Q

Warnings for Conjugated estrogen/bazedoxifene (Duavee)

A

increased risk of breast cancer d/t unopposed estrogen) and ovarian cancer
Increased risk of retinal vascular thrombosis
Lipid effects (increased HDL + TG, lower LDL )

77
Q

Calcitonin MOA

A

Inhibits bone resorption by osteoclasts

78
Q

Calcitonin (Miacalcin) formulations

A

Nasal spray, injection

79
Q

Calcitonin (Miacalcin) nasal spray administration

A

1 nostril daily (alternate)

80
Q

Warnings for Calcitonin (Miacalcin)

A

Hypocalcemia (a/w tetany and seizures)
Incrased risk of malignancy with long-term use
Hypersensitivity reactions to salmon-derived products (e.g. bronchospasm, anaphylaxis, welling of the tongue or throat); antibody formation

81
Q

Teriparatide and abaloparatide MAO

A

Analogs of human parathyroid hormone (stimulates osteoblast activity and increases bone formation

82
Q

D/t safety issues with teriparatide (Forteo) and abaloparatide (Tymlos), the cumulative lifetime treatment duration is restricted to ___

A

2 yrs or less

83
Q

Warnings teriparatide (Forteo) and abaloparatide (Tymlos)

A

osteosarcoma (bone cancer) - risk dependent on dose and duration of use
Hypercalcemia
Others: orthostatic hypotension, use caution iwht urolithiasis (urinary stones)

84
Q

Side effects of teriparatide (Forteo) and abaloparatide (Tymlos)

A

Arthralgias, leg cramps, nausea, orthostasis/dizziness

85
Q

Storage teriparatide (Forteo) and abaloparatide (Tymlos)

A

Refrigerated
Forteo - protect from light

86
Q

Denosumab (Prolia) MOA

A

Monoclonal antibody that inhibits RANKL (receptor on osteoclasts)to prevent osteoclast formation &raquo_space; decreased bone resorption and increased bone mass

87
Q

Denosumab (Prolia) formulation and dosing frequency

A

Injection SC every 6 months

88
Q

Denosumab (Prolia) Warnings

A

ONJ
Femur fractures
Hypocalcemia
Infections, derm reactions

89
Q

Denosumab (Prolia) Contraindications

A

Hypocalcemia (correct prior to using)
Pregnancy

90
Q

Denosumab (Prolia) side effects

A

HTN, fatigue, edema, dyspnea, headache, N/V/D, decreased PO4

91
Q

Menopause is reached when the last menstrual period was over ___ ago

92
Q

In menopause, a decrease in estrogen and progesterone causes an increase in ____ resulting in ____

A

FSH
Vasomotor symptoms (hot flashes, night sweats)

93
Q

D/t decline in estrogen in the vaginal mucosa in menopause, ___ can occur

A

vaginal dryness, burning and painful intercourse (genitourinary syndrome of menopause)

94
Q

The most effective treatment for vasomotor symptoms from menopause is ___

A

systemic hromone therapy with estrogen
Estrogen causes decrease in LH and more stable temp control

95
Q

Which estrogen formulations for menopause are a/w lower risk of VTE and stroke?

A

Transdermal, local (topical) and low-dose oral estrogen products

96
Q

Which estrogen formulations for menopause are preferred for pts who have vaginal symptoms only?

A

Local estrogen products

97
Q

___ is a lubricant marketed specifically for dyspareunia (painful intercourse)

A

Astroglide

98
Q

___-based lubricants should not be used with condoms as they can cause the condom to tear

99
Q

Menopausal women with uterus should take estrogen in combo with ___ d/t increased risk of ___ if estrogen is unopposed

A

progesterone (e.g. a progestin)
endometrial cancer

100
Q

What types of progestins are considered to be safer: micronized vs synthetic?

A

Micronized progestins (e.g. Prometrium) are safer than synthetic progestins (medroyprogesterone)

101
Q

Criteria for use of hormone therapy in menopause

A

Healthy, symptomatic women who are within 10 yrs of menopause, ≤60yo, and no contraindications to use
Extending treatment beyond 60yo is acceptable (e.g. pt has osteoporosis) if lowest possible dose is used and women is advised of safety risks
Consider QOL and personal risk factors (e.g. age, time since menopause, risk of blood clots, heart disease, stroke, breast cancer) before use
Pts with risk factors should use non-hormonal treatments (e.g. SSRIs, SNRIs, gabapentin, or pregabalin)

102
Q

Progestins (e.g. norethindrone, levonorgestrel, drospirenone) can cause ___ which may be intolerable as menopausal treatment

A

Mood disturbances

103
Q

17 Beta-Estradiol formulations

A

Local:
Vaginal cream (Estrace)
Vaginal ring (Estring)
Vaginal tablet (Vagifem)
Vaginal insert (Imvexxy)

Systemic:
Oral table, micronized (Estrace)
Topical gel (Divigel, Estrogel)
Topical spray (Evamist)

104
Q

Conjugated equine estrogens formulations

A

Local:
Vaginal cream (Premarin)

Systemic:
Oral tablet (Premarin)
Injection (Premarin)

105
Q

Estradiol patch names

A

Alora, Climara, Vivelle-Dot, Menostar, Minivelle

106
Q

Conjugated equine estrogen and medroxyprogesterone (MPA) formulations

A

Oral tablet (Prempro)
Oral tablet (Premphase)

107
Q

Medroxyprogesterone formulations

A

Oral tablets(Provera)

108
Q

Micronized progesterone formulations

A

Oral tablet (Prometrium)

109
Q

Boxed warnings for hormone therapy products for menopause

A

Endometrial cancer (if estrogen used without progestin in women with uterus)
Dementia (women≥65yo)
Increased risk of VTE and stroke in postmenopausal women 50-79yo (do not use to prevent CVD)
Breast cancer

110
Q

Contraindications for estrogen-containing products

A

Breast cancer(any hx)
Undiagnosed uterine bleeding
Active VTE , arterial thromboembolic disease, or known protecin C, S, or antithrombin deficiency
Pregnancy
Hepatic impairment

111
Q

Warnings for hormone therapy products for menopause

A

increased risk of breast cancer (From use of estrogen alone) and ovarian cancer

112
Q

Compare frequency of application for patches: Vivelle-Dot, Minivelle, Climara, and Menostar

A

Vivelle-Dot, Minivelle = twice weekly
Climara, Menostar = once weekly

113
Q

Natural products for menopause

A

Black cohosh, evening primrose oil, red clover, soy, flaxseed, dong quai, St.. John’s wort and cahsteberry

114
Q

___ is a non-hormonal treatment for moderate-severe vasomotor symptoms a/w menopause (lower dose than recommended dose for depression)

A

Paroxetine (Brisdelle)

115
Q

Why should Brisdelle not be used with tamoxifen or warfarin?

A

Brisdelle (Paroxetine) = SSRI
Paroxetine = CYP2D6 inhibitor, will block effectiveness of tamoxifen (prodrug)
SSRIs can increase risk of bleeding with warfarin use

116
Q

____ have shown effectiveness for treating vasomotor symptoms related to menopause but they are not FDA-approved for this indication

A

SNRIs (e.g. venlafaxine, desvenlafaxine), clonidine, gabapentin, pregabalin

117
Q

___ is an oral estrogen agonist/antagonist indicated for dyspareunia (painful intercourse) and moderate-severe vaginal dryness,w hich are symptoms of vulvar and vaginal atrophy d/t menopause

A

Ospemifene (Osphena)

118
Q

what medications can decrease tesosterone?

A

Opioids (esp methadone when used for opioid dependence)
Chemotherapy for prostate cancer
Cimetidine and spironolactone

119
Q

The FDA released a warning about the __ risks a/w testosterone use and they recommend treatment only in men with low testosterone levels caused by certain medical conditions and confirmed by lab tests.
There have bee reports of increased ___ risk in men using testosterone therapy

A

CV risks
Clotting risks - tesosterone increases hematocrit > polycythemia and increase in clotting risk

120
Q

Testosterone can cause noncancerous ____ and use is restricted in men with severe ___

A

prostate growth
severe BPH

121
Q

Common side effects of testosterone

A

Baldness, acne, gynecomastia

122
Q

Testosterone and anabolic androgenic steroids (AAS) carry warning for ___ and risk of serious adverse events such as ___

A

abuse potential
MI, HF, stroke, depression, hostility, aggression, liver tox, and male infertility

123
Q

Tesosterone formulations

A

parenteral (IM or SC) injections - painful
topical gels (AndorGel) and solutions

124
Q

What is the concern of secondary exposure to testosterone in children with topical gel/solution testosterone products?

A

early virilization (enlarged genital organs, aggressive behavior, premature pubic hair growth)

125
Q

What new topical formulations of testosterone has reduced accidental exposure risk?

A

Fortesta, Natesto

126
Q

Side effects of testosterone products

A

Increased appetite, acne, edema, hepatotoxicity, reduced sperm count
Others: increased SCr, sensitive nipples, sleep apnea

Natresto: nasal irritation

127
Q

Administration notes for testosterone gels

A

Apply at the same time each morning, flammable until dry

Dry prior to dressing and be careful of secondary exposure (d/t virilization risks)

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