49. Osteoporosis Flashcards
1
Q
Osteoporosis is most common in ___
A
postmenopausal females
2
Q
___ fractures are the most devastating type of fractures, with higher costs, disability, and mortality than all other fractures combined
A
Hip
3
Q
____ fractures can occur without a fall and can initially be pain less (only clue may be gradual loss of height)
A
Vertebral
4
Q
Wrist fractures and other types of fractures appear in younger people and serve as an early indicator of ___
A
poor bone health
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
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
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)
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)
9
Q
____ cells are involved in bone formation.
____ cells are involved in bone resorption; they breakdown tissue in the bone.
A
Osteoblasts
Osteoclasts
10
Q
Bone health is evaluated by measuring ____
A
Bone mineral density (BMD)
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
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
13
Q
Who should have BMD measured?
A
women ≥ 65 yo and men ≥70 yo
Younger pts at hgih risk for fracture
14
Q
Interpret T-score -1 to -2.4
A
Osteopenia (low bone mass)
15
Q
Interpret T-score ≤ -2.5
A
Osteoporosis
16
Q
Interpret T-score ≥ -1
A
Normal
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
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)
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)
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)
21
Q
___ is required for calcium absorption
A
Vit D
22
Q
Vit D deficiency in children causes ___ and in adults it causes ___
A
children = rickets
Adults = osteomalacia (softening of bones)
23
Q
Many endocrinologists suggest intake of ____ vitamin D daily
A
25-50mcg (800-2000IU) daily
24
Q
Calcium absorption is saturable; doses above ___ of elemental calcium should be divided
A
500-600mg
25
Which has more elemental calcium per unit: calcium carbonate or calcium citrate?
Calcium carbonate -- but requires acidic environment for absorption
26
Which has better absorption with an increased gastric pH: calcium carbonate or calcium citrate?
Calcium citrate
27
Vit D deficiency can be treated with high doses of ____ or ___ for 8-12 weeks, followed by maintenance therapy (25-50mcg (1000-2000IU) daily)
Vit D2 (ergocalciferol) 1250 mcg (50,000 IU) weekly
Vit D3 (cholecalciferol) 125-175 mcg (5000-7000 IU) daily
28
Recommended daily intake for most adults is ___ mg elemental calcium
1000-1200mg daily
29
Calcium carbonate (e.g. Tums)
__% elemental calcium
Absorption requirements?: ____
With meals?: ___
40%
acid-dependent
must take with meals, do not use with PPIs
30
Calcium citrate (e.g. Citracal)
__% elemental calcium
Absorption requirements?: ____
With meals?: ___
21%
Not acid-dependent
Take with or without food
31
Vitamin D deficiency is defined as serum vit D [25(OH)D] < ____
30 ng/mL
32
1g of calcium carbonate = ___ elemental calcium
400mg
33
1g clacium citrate = ____ elemental calcium
210mg
34
Side effects of calcium supplements
Constipation
Hypercalcemia, nausea
35
Medications approved for osteoporosis prevention
Bisposphonates (except IV ibandronate)
Estrogen-based therapies, raloxifene, Duavee
36
Medications approved for osteoporosis treatment
Bisphosphonates
Denosumab
Parathyroid hormone analogs (e.g. teriparatide, abaloparatide)
Calcitonin
37
Regardless of drug selection for osteoporosis, treatment must include adequate ___ intake
Adequate calcium and vit D intake
38
Criteria for initiating treatment in osteoporosis
T-score ≤ -2.5 in the spine, femoral neck, total hip or 1/3 radius OR
Presence of a fragility fracture, regardless of BMD
39
Criteria for initiating treatment in osteopenia (if high risk)Bisphosphonates
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%
40
First line treatment or prevention in most patients is ____
Bisphosphonates (alendronate)
41
Administration notes for bisphosphonates
PO administration, must stay up right for 30 min (60 min for ibandronate) and drink 6-8oz of plain water
42
Side effects for bisphosphonates
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
43
Treatment duration for bisphosphates
3-5 yrs in pts with a low risk of fracture (d/t risk of femur fractures and ONJ)
44
Place in therapy Denosumab (Prolia)
Alt to bisphosphonatesD
45
Denosumab administration and frequency
SC every 6 months
46
Denosumb side effect
Hypocalcemia
47
Place in therapy Teriparatide (Forteo), Abaloparatide (Tymlos)
Recommended for very high-risk pts only (e.g. hx of severevertebral fractures)
48
Teriparatide (Forteo), Abaloparatide (Tymlos) administration and frequency
SC administration daily
49
Teriparatide (Forteo), Abaloparatide (Tymlos) side effect
Hypercalcemia
50
Place in therapy raloxifene (Evista), Bazedoxifene/estrogens (Duavee)
Alt to bisphosphonates if high risk of vertebral fractures
51
Concerns with raloxifene (Evista), Bazedoxifene/estrogens (Duavee)
Increased risk for VTE and stroke
52
Raloxifene can be used if low risk of ___ or high risk of ____
Low VTE risk or High breast cancer risk
53
Side effect of raloxifene (Evista)
Vasomotor symptoms
54
_____ can be used in women with an intact uterus for prevention of osteoporosis. Also used as tx for vasomotor symptoms.
Bazedoxifene/estrogens (Duavee)
55
Side effect of Bazedoxifene/estrogens (Duavee)
Increased risk of breast cancer
56
Last line or not recommended options for osteoporosis
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
Bisphosphonates MOA
increase bone density by inhibiting osteoclast activity and bone resorption
58
Bisphosphonates reduce vertebral and hip fracture risk except ____ which only reduces vertebral fractures
ibandronate
59
A drug holiday should be considered for low-risk pts after ___ years of treatment with bisphosphonates
3-5 years
60
Risedronate (Atelvia delayed release) should not be used with ___ (decreases absorption)
H2RAs or PPIs (requires acidic gut for absorption)
61
Separate PO bisphosphonates from calcium, antacids, iron, and magnesium by at least ___
2 hrs
62
Alendronate (Fosamax) dosing frequency
Daily or weekly
63
Risedronate (Actonel, Atelvia) dosing frequency
Daily, weekly, or monthly
64
PO Ibandronate (Boniva) dosing frequency
Monthly
65
IV Ibandronate (Boniva) dosing frequency
every 3 months
66
IV Zolendronic acid (Reclast) dosing frequency
yearly
67
When is IV bisphosphonates preferred over PO?
If esophagitis is present d/t risk for esophageal cancer)
68
Warnings for bisphosphonates
ONJ
Femur fractures
Esophagitis, esophageal ulcers, erosions
Hypocalcemia
Renal impairment (Do not use alendronate if CrCl <35, ibrandonate, risedronate if CrCl <30)
69
Raloxifene MOA
Selective estrogen receptor modulator (SERM) that decreases bone resorption
70
Conjugated estrogen/bazedoxifene (Duavee) is an ___ estrogen /SERM combo indicated for osteoporosis prevention
equine (horse)
71
Boxed warnings Raloxifene (Evista)
Increased risk of VTE, death d/t stroke in women with CHD or at risk for coronary events
72
Contraindications for Raloxifene (Evista)
hx or current VTE
Pregnancy
73
Side effects for Raloxifene (Evista)
Hot flashes, peripheral edema, arthralgia, leg cramps/muscle spasms, flu symptoms, infection
74
Boxed warnings Conjugated estrogen/bazedoxifene (Duavee)
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
Contraindications for Conjugated estrogen/bazedoxifene (Duavee)
Breast cancer (any hx)
Pregnancy
Undiagnosed bleeding
Hx or active VTE, MI or stroke
Protein C, S, or antithrombin deficiency
Hepatic impairment
76
Warnings for Conjugated estrogen/bazedoxifene (Duavee)
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
Calcitonin MOA
Inhibits bone resorption by osteoclasts
78
Calcitonin (Miacalcin) formulations
Nasal spray, injection
79
Calcitonin (Miacalcin) nasal spray administration
1 nostril daily (alternate)
80
Warnings for Calcitonin (Miacalcin)
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
Teriparatide and abaloparatide MAO
Analogs of human parathyroid hormone (stimulates osteoblast activity and increases bone formation
82
D/t safety issues with teriparatide (Forteo) and abaloparatide (Tymlos), the cumulative lifetime treatment duration is restricted to ___
2 yrs or less
83
Warnings teriparatide (Forteo) and abaloparatide (Tymlos)
osteosarcoma (bone cancer) - risk dependent on dose and duration of use
Hypercalcemia
Others: orthostatic hypotension, use caution iwht urolithiasis (urinary stones)
84
Side effects of teriparatide (Forteo) and abaloparatide (Tymlos)
Arthralgias, leg cramps, nausea, orthostasis/dizziness
85
Storage teriparatide (Forteo) and abaloparatide (Tymlos)
Refrigerated
Forteo - protect from light
86
Denosumab (Prolia) MOA
Monoclonal antibody that inhibits RANKL (receptor on osteoclasts)to prevent osteoclast formation >> decreased bone resorption and increased bone mass
87
Denosumab (Prolia) formulation and dosing frequency
Injection SC every 6 months
88
Denosumab (Prolia) Warnings
ONJ
Femur fractures
Hypocalcemia
Infections, derm reactions
89
Denosumab (Prolia) Contraindications
Hypocalcemia (correct prior to using)
Pregnancy
90
Denosumab (Prolia) side effects
HTN, fatigue, edema, dyspnea, headache, N/V/D, decreased PO4
91
Menopause is reached when the last menstrual period was over ___ ago
12 months
92
In menopause, a decrease in estrogen and progesterone causes an increase in ____ resulting in ____
FSH
Vasomotor symptoms (hot flashes, night sweats)
93
D/t decline in estrogen in the vaginal mucosa in menopause, ___ can occur
vaginal dryness, burning and painful intercourse (genitourinary syndrome of menopause)
94
The most effective treatment for vasomotor symptoms from menopause is ___
systemic hromone therapy with estrogen
Estrogen causes decrease in LH and more stable temp control
95
Which estrogen formulations for menopause are a/w lower risk of VTE and stroke?
Transdermal, local (topical) and low-dose oral estrogen products
96
Which estrogen formulations for menopause are preferred for pts who have vaginal symptoms only?
Local estrogen products
97
___ is a lubricant marketed specifically for dyspareunia (painful intercourse)
Astroglide
98
___-based lubricants should not be used with condoms as they can cause the condom to tear
Oil
99
Menopausal women with uterus should take estrogen in combo with ___ d/t increased risk of ___ if estrogen is unopposed
progesterone (e.g. a progestin)
endometrial cancer
100
What types of progestins are considered to be safer: micronized vs synthetic?
Micronized progestins (e.g. Prometrium) are safer than synthetic progestins (medroyprogesterone)
101
Criteria for use of hormone therapy in menopause
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
Progestins (e.g. norethindrone, levonorgestrel, drospirenone) can cause ___ which may be intolerable as menopausal treatment
Mood disturbances
103
17 Beta-Estradiol formulations
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
Conjugated equine estrogens formulations
Local:
Vaginal cream (Premarin)
Systemic:
Oral tablet (Premarin)
Injection (Premarin)
105
Estradiol patch names
Alora, Climara, Vivelle-Dot, Menostar, Minivelle
106
Conjugated equine estrogen and medroxyprogesterone (MPA) formulations
Oral tablet (Prempro)
Oral tablet (Premphase)
107
Medroxyprogesterone formulations
Oral tablets(Provera)
108
Micronized progesterone formulations
Oral tablet (Prometrium)
109
Boxed warnings for hormone therapy products for menopause
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
Contraindications for estrogen-containing products
Breast cancer(any hx)
Undiagnosed uterine bleeding
Active VTE , arterial thromboembolic disease, or known protecin C, S, or antithrombin deficiency
Pregnancy
Hepatic impairment
111
Warnings for hormone therapy products for menopause
increased risk of breast cancer (From use of estrogen alone) and ovarian cancer
112
Compare frequency of application for patches: Vivelle-Dot, Minivelle, Climara, and Menostar
Vivelle-Dot, Minivelle = twice weekly
Climara, Menostar = once weekly
113
Natural products for menopause
Black cohosh, evening primrose oil, red clover, soy, flaxseed, dong quai, St.. John's wort and cahsteberry
114
___ is a non-hormonal treatment for moderate-severe vasomotor symptoms a/w menopause (lower dose than recommended dose for depression)
Paroxetine (Brisdelle)
115
Why should Brisdelle not be used with tamoxifen or warfarin?
Brisdelle (Paroxetine) = SSRI
Paroxetine = CYP2D6 inhibitor, will block effectiveness of tamoxifen (prodrug)
SSRIs can increase risk of bleeding with warfarin use
116
____ have shown effectiveness for treating vasomotor symptoms related to menopause but they are not FDA-approved for this indication
SNRIs (e.g. venlafaxine, desvenlafaxine), clonidine, gabapentin, pregabalin
117
___ 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
Ospemifene (Osphena)
118
what medications can decrease tesosterone?
Opioids (esp methadone when used for opioid dependence)
Chemotherapy for prostate cancer
Cimetidine and spironolactone
119
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
CV risks
Clotting risks - tesosterone increases hematocrit > polycythemia and increase in clotting risk
120
Testosterone can cause noncancerous ____ and use is restricted in men with severe ___
prostate growth
severe BPH
121
Common side effects of testosterone
Baldness, acne, gynecomastia
122
Testosterone and anabolic androgenic steroids (AAS) carry warning for ___ and risk of serious adverse events such as ___
abuse potential
MI, HF, stroke, depression, hostility, aggression, liver tox, and male infertility
123
Tesosterone formulations
parenteral (IM or SC) injections - painful
topical gels (AndorGel) and solutions
124
What is the concern of secondary exposure to testosterone in children with topical gel/solution testosterone products?
early virilization (enlarged genital organs, aggressive behavior, premature pubic hair growth)
125
What new topical formulations of testosterone has reduced accidental exposure risk?
Fortesta, Natesto
126
Side effects of testosterone products
Increased appetite, acne, edema, hepatotoxicity, reduced sperm count
Others: increased SCr, sensitive nipples, sleep apnea
Natresto: nasal irritation
127
Administration notes for testosterone gels
Apply at the same time each morning, flammable until dry
Dry prior to dressing and be careful of secondary exposure (d/t virilization risks)
128
Bisphosphonates formulations
PO - weekly/monthly
IV - given quarterly/yearly (if GI side effects or adherence issues with PO formulation
