5. Osteoporosis MT1 Flashcards
this is a fracture found at the front of a vertebrae; if a patient has one of these types of fractures, they may be seen as hunched forward
crush fracture
true/false: osteoporosis can be primary or secondary
true
osteoporosis can affect people at almost any age, it is most common among Canadians __ years of age or older
50
a pathological fracture that results from minimal trauma (e.g. a fall from a standing height) or no identifiable trauma at all. The fracture is both a sign and a symptom of osteoporosis.
fragility fracture
this comes from osteoclasts; when activated, it triggers bone remodeling. it is the target of denosumab
RANKL
what are the two reasons that explain why osteoporosis is more common in females than males
- males have a higher peak bone mass at around 30 y/o
- females have a bone loss due to menopause (estrogen has a bone protective effect which is lost during menopause)
is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of broken bones (fractures).
osteoporosis
what are some indications for measuring bone mineral density
- age of 65 or older
- had fragility fracture after age 40 yrs
- prolonged used of prednisone
- use of other high risk medications (e.g. aromatase inhibitors or androgen deprivation therapy)
- history of parental hip fractures
- smoker
- high alcohol intake
- low body weight or major weight loss
- rheumatoid arthritis
if a patient is younger than 50, what are some indications for measuring bone mineral density
- fragility fracture
- prolonged use of prednisone
- use of other high risk medications
- hypogonadism or premature menopause
- malabsorption syndrome (b/c can’t absorb vitamin D or calcium)
- primary hyperparathyroidism (b/c parathyroid hormone helps control bone reabsorption and turnover and therefore here there might be too much bone turnover)
a bone mineral density test is done by DEXA which reports a t-score. the T score at _________ is used to estimate fracture risk
femoral neck
osteoporosis is characterized by a T score less than or equal to ___ standard deviations below the mean for a young adult reference mean
2.5
true/false: the risk of a vertebral fracture can be measured by height loss
true
what are some aspects than can contribute to a fall risk assessment
- medications (drowsiness and dizziness)
- stairs/rugs at home
- live alone/what kind of supports they have
- poor vision
basic bone health should be encouraged for all individuals over the age of 50. what may this basic bone health consist of?
- regular active weight bearing exercise
- calcium (diet and supplementation) 1200mg daily
- vitamin D 800-2000 IU
these two tools provide an estimate of 10 year risk of major osteoporotic fracture; both use the T-score at femoral neck
CAROC (what we will use for exam) and FRAX
what are some non pharmacological options for osteoporosis treatment
- regular exercise
- minimizing hazards for falling in home, assess drugs implicated in falls such as benzodiazepines and other psychotropics, improve strength and balance
- smoking cessation
- dietary measures: encourage adequate protein, calcium and vitamin D intake, avoid excessive alcohol intake (> 2 drinks/day) and caffeine (> 4 cups of coffee per day or equivalent)
true/false: vitamin D2 (ergocalciferol) is preferred over vitamin D3 (cholecalciferol)
false - other way around! cholecalciferol seen more commonly in pharmacy
what are some situations where 25-hydroxy vitamin D deficiency is suspected or where levels would affect response to therapy
- individuals with impaired intestinal absorption
- patients with osteoporosis requiring pharmacotherapy
after a patient is started on vitamin D supplementation, when should the serum 25-hydroxy vitamin D levels be checked again
no sooner than 3 months after commencing an adequate supplementation dose
true/false: monitoring routine supplement use of Vitamin D and routine screening of otherwise healthy individuals is unnecessary
true
what are some side effects of vitamin D
- usually well tolerated
- possible side effects include hypercalcemia, hypercalcuria, renal calcification and renal stones (usually at high doses b/c fat soluble vitamin therefore we don’t pee out the extra if we get too much)
true/false: supplementation doses of calcium > 500 mg/day should be in divided doses
true
this type of calcium salt is preferred as it has the most elemental calcium; it requires an acidic media (stomach) thus may be more constipating
carbonate (e.g. tums, rolaids, caltrate)
this type of calcium salt may be used if a patient has low stomach acid or is on a PPI as the preferred calcium salt requires an acidic media
calcium citrate (e.g. Citrical)
what are some side effects of calcium supplementation
- constipation and nausea are the most common side effects
- hypercalcemia, hypercalcuria, renal calcification and renal stones
- may decrease absorption of bisphosphonates, ciprofloxacin, iron, levothyroxine, tetracycline (separate administration by 2h)
if a patient is at a low risk of 10 year fracture, what should be the course of action for management
unlikely to benefit from pharmacotherapy therefore reassess in 5y
if a patient is at a moderate risk of 10 year fracture, what should be the course of action for management
an x-ray of the spine may aid in the choice of pharmacological tx vs being reassessed in a few yrs. if old fractures are seen: they need pahrmacological tx
if a patient is at a high risk of 10 year fracture or has had a prior fragility fracture of the hip or spine or >1 fragility fracture, what should be the course of action for management
good evidence that patient would benefit from pharmacotherapy
what is the dose and duration of prednisone that would warrant a patient to high risk of 10 year fracture risk
at least 3 months cumulative therapy in the previous year at a prednisone equivalent dose of 7.5mg daily
this treatment option only covers vertebral fractures and not hip or non-vertebral fractures
raloxifene
this treatment option only covers vertebral and non-vertebral fractures and does not cover hip fractures
teriparatide
this class of medication are the mainstay of osteoporosis treatment. they absorb to bone and form a coating over the bone therefore the osteoclasts are unable to adhere to bone surfaces
oral bisphosphonates
in what situations would IV bisphosphonates be preferred over oral bisphosphonates
- those who cannot tolerate the GI side effects of oral agents
- when they cannot adhere to dosing instructions
- when it appears a patient is not responding to an oral agent
true/false: adherence with oral bisphosphonates is a major problem
true
should oral bisphosphonates be taken on an empty stomach or with food
poorly absorbed therefore should;d be taken on empty stomach (no juice, coffee, milk or mineral water)
what are three main counselling points regarding Alendronate and Risedronate
- take on an empty stomach
- take with a full glass of water
- stay upright for 30 mins after taking
what are the contraindications for oral bisphosphonates
- pts with hypocalcemia
- CrCl < 35ml/min
this bisphosphonate is administered IV. vitamin D must be administered in appropriate doses for >2 weeks prior to the infusion. patients should be told that they may experience flu like symptoms and acetaminophen can be given prior to the infusion and up to 48 hrs after to minimize the severity of the reaction. elderly pts, those who are on diuretics and those who have impaired renal function should be encouraged to drink 500ml of water prior to or during the infusion
zoledronic acid
what are some common side effects of bisphosphonates.
- GI symptoms
- altered taste
- nighttime leg cramps
what are some rare but more serious more side effects of bisphosphonates
- reflux, esophagitis, esophageal ulcers
- osteonecrosis of the jaw (ONJ)
- “atypical” femoral shot fractures (reported an increase incidence with long term use of bisphosphonates)
this medication my be used in postmenopausal women with a history of osteoporotic fracture, multiple risk factors for fracture or in those who have failed or are intolerant to other therapies.
this is a human monoclonal antibody that binds to the receptor activator of nuclear factor kappa-B ligand (RANKL) to habit binding with its receptor on the surface of osteoclast precursors and osteoclasts
it is an injection into the upper arm, thigh or abdomen q 6 months
denosumab (Prolia)
true/false: Denosumab needs to be dose-adjusted in renal impairment
false
what are some common side effects of denosumab
- flatulence, nausea, decreased Ca, injection site run, limb pain
what are some rare side effects of denosumab
ONJ, atypical femur fracture
what are contraindications for denosumab
- CrCl < 15ml/min
- pre-existing hypocalcemia
this is a first line agent for menopausal females for prevention of vertebral fractures; usually used in breast cancer patients; it is a selective estrogen receptor modulator (SERM). it acts as an estrogen antagonist in breast and uterine tissue, but has estrogen-like activity in bone and lipid metabolism (bone-protective effect)
raloxifene
what are some common, less serious side effects of Raloxifene
vasodilation (hot flashes), leg cramps, peripheral edema, flu-like symptoms
what are some drug interactions with Raloxifene
- cholestyramine (decrease raloxifene)
- levothyroxine (space 12hr)
-warfarin (decrease INR)
what are some contraindications for Raloxifene
- pregnancy
- previous/active VTE (venous thromboembolism) disorder
- more than 65 y/o due to stroke and VTE risk
this medication is first line for post menopausal osteoporosis for secondary prevention of vertebral and non-vertebral fractures with severe OP (decreased bone mineral density) & high fracture risk; is also an alternative if contraindication, failure or intolerance to oral bisphosphonate
- stimulates osteoblast function, increasing GI calcium absorption and increasing renal tubular reabsorption of calcium.
teriparatide
what are some contraindications for teriparatide
- pregnancy/nursing
- pre existing increased Ca2+ or CrCl < 30ml/min
- metabolic bone disease (E.g. Pagets disease, hyperparathyroidism, bone metastases)
these types of medications are no longer considered first choice for tx of osteoporosis. an increased risk for CVA and VTE significantly outweigh the benefits
hormone therapy (estrogen and progesterone)
monitoring: once a pt starts tx for osteoporosis, how often should a repeat measurement of BMD be performed
initially performed after 1-3 years (closer to 1 year for severe pts)
