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IPT: MS > Block 2 > Flashcards

Block 2 Flashcards

1
Q

Which race and sex has highest fragility fracture rate via osteoporosis?

A

Caucasian/Hispanic women

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2
Q

What is a major predictor factor for osteoporosis?

A

Low bone mineral density

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3
Q

What do osteoclast and osteoblasts do?

A

Clast - resorption, dissolves mineral matrix

Blast - formation, synthesizes new bone in space

Bone loss exceeds formation in osteoporosis

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4
Q

Calcium homeostasis is maintained by what in bone mineral composition?

A

Vitamin D and PTH

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5
Q

Concentration of Vit. D depends on what?

A

Skin conversion

Diet

PTH

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6
Q

What is the most abundant source of Vitamin D?

A

Cholecalciferol (D3)

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7
Q

Conversion of cholecalciferol to calcidiol occurs where? From calcidiol to calcitriol?

A

Calcidiol forms in liver

Calcitriol forms in the kidney

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8
Q

How does estrogen affect BMD loss?

A

Proliferates osteoclasts

Increases calcium excretion and decreases calcium gut absorption

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9
Q

How does testosterone affect BMD loss?

A

Men as they age experience less free testosterone which leads to less estrogen conversion

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10
Q

Which medications are associated with increased bone loss?

A

Glucocorticoids, PPIs, LOOP diuretics (not thiazides)

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11
Q

How is osteoporosis classified?

A

Primary and Secondary

Primary has type I and II

I = Postmenopausal (vertebral and forearms)

II = age-related (>75, vertebral, hip, wrist)

Secondary has type III

III = any age (impaired osteoclast/blast), drug-induced

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12
Q

Lab findings of osteoporosis?

A

DXA = gold standard

T-score of -2.5 or less

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13
Q

Who should get screened for osteoporosis?

A

≥65yo women

Postmenopausal women >50yo

Not for men

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14
Q

What is the FRAX assessment tool? Who is it for?

A

Uses 11 RF and BMD at femoral neck to assess % of major osteoporotic and hip fracture in the next 10 years

Postmenopausal women OR men >50yo

Anyone w/ osteopenia (T score -1 to -2.5

Ppl who have NOT taken osteoporosis Rx

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15
Q

What is the difference between T and Z score?

A

T score is where there is significant difference when compared to young adult reference

Z score is the same except when compared to age matched reference

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16
Q

Bisphosphonates are analogs to what?

A

Pyrophosphate; a bone resorption inhibitor

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17
Q

Bisphosphonates MOA?

A

Stabilizes calcium phosphate

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18
Q

Key structure of bisphosphonates?

A

2 phosphorus groups with 2 alcohols and an oxygen surrounding 1 carbon with 2 R groups

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19
Q

What does R1, R2, and carbon do in bisphosphonates?

A

R1 = enhance binding to hydroxyapatite

R2 = anti-resorptive potency (more N or heterocyclic rings = more potent)

C = enhance stability

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20
Q

Oral bioavailability on bisphosphonates is good/bad?

A

Doodoo

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21
Q

Bisphosphonate AE?

A

GI effects

If inj then injection reactions

Osteonecrosis of jaw

Esophageal erosion

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22
Q

Bisphosphonate CI?

A

Esophageal abnormalities or hypocalcemia

Inability to stand up right for 30 min (60 for ibandronate)

Specific to zoledronic acid = renal impairment

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23
Q

Which RX is an RANKL inhibitor? How does it work?

A

Denosumab

Binds to RANKL which inhibits osteoclastogenesis and increases osteoclast apoptosis

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24
Q

Denosumab AE?

A

Skin infection, hypocalcemia, osteonecrosis of jaw, peripheral edema, HTN

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25
Q

Core structure and side chain of SERMs?

A

2 aromatic rings connected by a few atoms; helps to mimic estrogen and to bind

Flexible side chain which provides anti estrogen effects

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26
Q

What are the SERMs?

A

Raloxifene and Bazedoxifene

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27
Q

Whats the relationship between raloxifene and certain estrogen receptors?

A

Agonists on osteoblast and osteoclast estrogen receptors

Antagonist on breast and uterine estrogen receptors

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28
Q

Indication of use for SERMs?

A

Prevents osteoporosis in postmenopausal women

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29
Q

SERMs AE?

A

Thrombosis of retinal vein

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30
Q

SERMs DDI?

A

Only Raloxifene has them

Warfarin + Cholestyramine

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31
Q

SERMs CI?

A

Both = VTE, nursing mothers, pregnant

Bazedoxifene = h/o uterine bleed, stroke, MI, breast carcinoma, hepatic impairment, thrombophilic disorders

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32
Q

Where is calcitonin metabolized?

A

Kidney

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33
Q

Calcitonin hormone mechanism?

A

Released from thyroid when calcium is elevated

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34
Q

Calcitonin CI?

A

Hypersensitivity to calcitonin-SALMO

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35
Q

Teriparatide MOA?

A

Stimulates Osteoblastic activity

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36
Q

Aspirin (reversibly/irreversibly) inhibits COX1/2

A

Irreversibly

Other NSAIDs reversibly

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37
Q

Which AA does aspirin target?

A

Acetylates Serine 529

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38
Q

APAP and its metabolite info

A

APAP metabolized by CYP450 and its metabolite NAPQI is toxic

Hepatotoxicity is associated with NAPQI

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39
Q

What is produced by COX 1+2 that contributes to CV AE?

A

COX 1 = TXA2; PLTS and vasoconstriction

COX 2 = PGI2; inhibits PLTS and vasodilation

Celebrex inhibits COX 2 and does the opposite^^

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40
Q

COX 1 or 2 inhibitors contribute more to renal AE

A

COX 2

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41
Q

COX 1 or 2 inhibitors contribute more to GI AE

A

COX 1

42
Q

Which calcium products require it to be given w/ meals?

A

All of them except calcium citrate

43
Q

Calcium AE?

A

Constipation

44
Q

Goal of Vit. D levels?

A

30-50ng/mL

45
Q

Indication of use for bisphosphonates?

A

Postmenopausal women (Ibandronate’s only use)

Male and/or glucocorticoid-induced osteoporosis

46
Q

How should bisphosphonates be given?

A

Morning on empty stomach

Dont administer w/ other supplements or medications

47
Q

Alendronate
Ibandronate
Risedronate
Zoledronic Acid

Which one is CI if CrCl <35?

A

Zoledronic Acid

48
Q

Alendronate
Ibandronate
Risedronate
Zoledronic Acid

Which one requires pt to be upright for 60 min after admin?

A

Ibandronate, the others require 30 min only

49
Q

Alendronate
Ibandronate
Risedronate
Zoledronic Acid

Which one is just used for postmenopausal osteoporosis only?

A

Ibandronate

50
Q

Alendronate
Ibandronate
Risedronate
Zoledronic Acid

Which one has IV formulation?

A

Ibandronate (quarterly use)

Zoledronic (yearly)

51
Q

Drug Holidays are used for which drug class?

A

Bisphosphonates; if used for 5+ years

If used for 6-10 years or has h/o of fractures, consider drug holiday at 1-2 years but initiate non-bisphosphonate therapy

52
Q

Can Denosumab be used safely in someone with renal impairment?

A

Yes

53
Q

Denosumab dosing?

A

60mg SQ q6months

54
Q

Denosumab CI?

A

Hypocalcemia

Pregnancy

55
Q

Treatment of duration for teriparatide?

A

2 years

Same for abaloparatide

56
Q

Teriparatide dosing?

A

20mcg SQ QD

57
Q

Teriparatide AE?

A

HYPERcalcemia

Same for abaloparatide

58
Q

Abaloparatide dosing?

A

80mcg SQ QD

59
Q

Indication of use for teriparatide and abaloparatide?

A

Teri - Postmenopausal women

Male and/or glucocorticoid-induced osteoporosis

Abal - postmenopausal women at high risk for fractures

60
Q

Raloxifene vs Bazedoxifene

Which one is used in combo with estrogen?

A

Bazedoxifene

61
Q

Raloxifene vs Bazedoxifene

Which one is used in postmenopausal women with a uterus?

A

Bazedoxifene

62
Q

Romosozumab dosing?

A

2 consecutive inj of 105mg each

63
Q

Romosozumab duration of Tx?

A

12 months

64
Q

Calcitonin dosing?

A

IM/SQ 100u QD

Intranasal 200u in one nostril QD

65
Q

Calcitonin interactions and considerations?

A

Lithium

Linked to malignancies

Not preferred therapy

66
Q

Which rx for osteoporosis is used for prevention?

A

Estrogen

67
Q

Estrogen dosing?

A

0.3mg/day or cyclical

68
Q

What is considered a high risk osteoPENIA pt?

A

T score -1 to -2.5

AND

10yr % of hip fracture ≥3%

OR

10yr% of major osteoporosis related fracture ≥20%

69
Q

When should a pt be considered calcium/vit D supplementation when on steroid therapy?

A

After ≥3 months of use. Highest bone loss is in the first 3-6 months

70
Q

What is osteoarthritis?

A

Progressive destruction of articular cartilage usually in older adults ≥65yo

71
Q

Patho behind osteoarthritis?

A

Damage to articular cartilage leading to increased chondrocyte activity

72
Q

What inflammatory agents have been found in synovial fluid of OA?

A

IL-1, PGE2, TNF-alpha, NO

Crystal or cartilage shards also found in synovial fluid

73
Q

Changes in bone look like what in OA?

A

Denuded bones from eburnation (dense, smooth and glistening)

74
Q

Where does the pain occur from in OA?

A

Due to nociception from mechanical and chemical irritants

75
Q

How is OA classified?

A

Primary (most common and no identifiable cause)

Secondary (inflammation, trauma, disease)

76
Q

OA is (symmetrical/asymmetrical)

A

Asymmetrical

77
Q

NSAIDs are recommended for OA patients that are affected in which region of the body?

A

Knee, hip, hand (strongly recommended

APAP is only conditionally recommended

78
Q

Corticosteroids are recommended for OA patients that are affected in which region of the body?

A

Strongly recommended for knee or hip OA, conditionally for hand

79
Q

Capsaicin is recommended for OA patients that are affected in which region of the body?

A

Conditionally for knee

CI to hypersensitivity to menthol

Dont use the patch for more than 5 consecutive days

80
Q

Duloxetine is recommended for OA patients that are affected in which region of the body?

A

Conditionally for knee, hip, or hand

CI to MAOi within 14 days, zyvox, or methylene blue

81
Q

Tramadol is recommended for OA patients that are affected in which region of the body?

A

Conditionally for knee, hip or hand

82
Q

End of Life, where do most people want to die vs where do they actually die?

A

Prefer at home

But they mostly die in hospitals

83
Q

Key areas highlighted from SUPPORT Study?

A

Pt wishes frequently not followed

Pain was common

53% of physicians did not know if pt preferred to avoid CPR

84
Q

Palliative Care vs Hospice

A

Hospice = specialized type of palliative care, reserved for final 6 months

Palliative = for serious illness, focuses on managing sx, QOL, provided throughout course of illness

85
Q

Treatment of choice for Dyspnea? General strategies?

A

Opioids

Upright position, leaning position, increase air flow to fae, reduce anxiety

Oxygen is NOT helpful in treating sx

86
Q

Dyspnea Opioid Naive pt, MILD pain

A

Hydrocodone 5mg or Codeine 30mg PO q4h

87
Q

Dyspnea Opioid Naive pt, SEVERE pain

A

Morphine or Oxycodone 5mg PO q4h or Hydromorphone 1mg PO q4h

88
Q

Dyspnea Opioid Tolerant treatment?

A

Increase baseline dose by 25-50%

89
Q

Dyspnea breakthrough sx treatment?

A

Give equivalent dose q1-2hrs PRN and titrate by 50-100% every 24hrs

If severe pulmonary disease, start at 50% and titrate at 25%

90
Q

What can be used as adjuncts to dyspnea?

A

BZDs such as alprazolam and lorazepam (due to short t1/2)

DO NOT USE as first line Tx

91
Q

Treatment of choice for constipation?

A

Stimulants

92
Q

Anorexia and cachexia info?

A

NOT reversible w/ improved nutrition. It’s usually due to disease process

93
Q

Meds to treat the anorexia/cachexia?

A

Progestins (megestrol, medroxyprogesterone), corticosteroids, cannabinoids

94
Q

Progestin info and AE?

A

Improves appetite quickly (~1wk) and delayed weight gain

Thrombotic events

95
Q

Corticosteroid info?

A

May improve appetite only, no weight gain

96
Q

Cannabinoid info?

A

Improves mood and appetite, no effect on weight gain

97
Q

Terminal secretion meds and strategies?

A

DOC: glycopyrrolate, hyoscyamine

Only use suctioning IF absolutely necessary, d/c IV hydration and tube feedings, avoid increasing oral intake

98
Q

Weakness and fatigue Tx?

A

Corticosteroids, methylphenidate

d/c unnecessary rx that worsen fatigue.

99
Q

Which route is used for MAID? Which med are given?

A

Oral or feeding tube ONLY

Barbiturates*Gold standard* (Secobarbital; 9g)
BZDs
BB
Opioids
Digoxin
100
Q

What are the 2 regimens used in MAID?

A

DDMP 1 or 2

Diazepam 500 or 1g
Digoxin 25 or 50mg
Morphine 10 or 15g
Propranolol 2g

101
Q

What are the adjunct agents for MAID?

A

Metoclopramide 20mg; start 1 day prior and again 1hrs prior

Zofran or haldol

IPT: MS (3 decks)

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