Block 5: Osteoporosis

Question 1

Differentiate BMD classifications?

Answer 1

Question 2

How do you diagnose osteoporosis?

Answer 2

Question 3

What are the risk factors for osteoporosis?

Answer 3

1. Alcohol use(3+/day)
2. Smoking
3. Hypogonadism
4. Prior fracture as adult/ Parental fx.
5. Early menopause(b4 age 45)
6. SSRI, PPI, TZD, glucocorticoids
7. Chemo drugs
8. Corticosteroids(>5mg pred x >3 months)
9. Depo-Provera

Question 4

What is FRAX?

Answer 4

10-year risk model for calculating fracture risk, often used to determine if treatment is warranted

Question 5

What is Garvan calculator?

Answer 5

Uses age, sex, low trauma fracture, and falls to calculate 5-10 year risk for osteoporotic and hip fractures

Disadvantages: doesnt include falls and number of previous fractures

Question 6

What are the clinical presentation of osteoporosis?

Answer 6

1. Asymptomatic
2. Pain
3. Immobility-physical limitations
4. Fragility

Question 7

How is osteoporosis assessed based on height?

Answer 7

Loss from maximum height: >1.5 inches loss

Since a previously documented measurement:>0.8 inch loss

Kyphosis or lordosis

Question 8

Who qualify for Central DXA screening?

Women

Answer 8

1. All women 65 years and older
2. Postmenopausal
3. fragility fracture
4. Discontinuing estrogen
5. Risk of fractures

Question 9

Who qualify for Central DXA screening?

Men

Answer 9

1. All men older than 70 years of age
2. Men ages 50-70 with risk factors or previous fractures

Question 10

What is the gold standard that measures hip or lumbar spine BMD?

Answer 10

Dual-energy x-ray absorptiometry (DXA)

Question 11

What measures volumetric BMD of lumbar spine?

Answer 11

Quantitative computed tomography (QCT)

Question 12

What tools are not appropriate for monitoring?

Answer 12

Peripheral DXA (pDXA) and peripheral QCT (pQCT)

Question 13

What tool is used to identify vertebral fractures becuase they are asymptomatic?

Answer 13

Vertebral imaging

Question 14

What is DXA?

Answer 14

Bone density testuses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone

Question 15

What does DXA assess?

Answer 15

T-score: Compared to young normal adults of same sex
Z-score: Compared to expected norms of patients age and sex

Question 16

How do you diagnos osteoporosis?

Answer 16

1. Low trauma fracture
2. femoral neck, total hip and/or spine DXA using WHO T-score thresholds
3. Low BMD, osteopenia: -1 and -2.5, osteoporosis <2.5

Question 17

How do you prevent osteoporosis?

Answer 17

1. Healthy lifestyle habits
2. Weight bearing exercises
3. Vit D 800-1000 Units daily
4. Calcium 1000 to 1200mg daily

Question 18

What are the non-pharm tx for osteoporosis?

Answer 18

1. weight bearing exercise: 30-40min/day
2. Prevent falls
3. Avoid alcohol and smoking
4. Limit caffeine (1-2servings/day)
5. Calcium (at least 1000 mg/day)
6. Vitamin D (600 - 800 IU/day)

Question 19

Foods high in calcium?

Answer 19

1. Dairy products
2. Soymilk
3. Fortified cereals
4. Eggs
5. Fortified orange juice
6. Sardines with bones
7. Salmon with bones
8. Halibut
9. Collard greens (frozen)

Question 20

Vitamin D goals?

Answer 20

30-60 ng/mL

Question 21

What are examples of calcium supplements?

Answer 21

Carbonate: least expensive, most potent, take with food (40%)
Citrate/Gluconate: More expensive, less potent, GI tolerability (21%)

Question 22

Patient counseling when taking calcium?

Answer 22

1. Do not exceed 500-600 mg/dose
2. Take most with food
3. Start small then titrate
4. Gas, bloating, flatulence, constipation

Question 23

Dosing of Vitamin D?

Answer 23

Concentration: 20-30ng/mL

↑ 100 units/day → ↑ ~ 1 ng/mL 25(OH) vitamin D

Treatment: Vitamin D2 orD3 50,000 units/week for 8–12 weeks or monthly
Monitor: 3 -4 months of replenishment for maintenance therapy changes
ADR: Hypercalcemia, hypercalciuria, weakness, headache, somnolence, nausea (cardiac rhythm disturbances)

Question 24

What are the types of vitamin D supplements?

Answer 24

1. Replesta®: 50,000IU wafer
2. Ergocalciferol (D2)/Cholecalciferol 50,000 capsule
3. Calcitriol
4. Vitamin cholecalciferol (D3)

Question 25

How should recieve pharm tx for osteoporosis?

Answer 25

1. With hip or vertebral fracture 2. T-score ≤- 2.5 at femoral neck or spine if secondary causes aren’t identified 3. Osteopenia and FRAX score of ≥ 3% risk of hip fracture or ≥ 20% risk of major OP fracture 4. THose who experienced fragility fractures

Question 26

What are the pharmacological tx?

Answer 26

**First:** Alendronate, risedronate, zoledronic acid for women & men * Denosumab for women  **Second:** Ibandronate, raloxifene **Thrid:** Raloxifene **Forth:** Calcitonin **Reserved for very high fracture risk or failed BP:** Teriparatide

Question 27

Bisphosphonates | MOA, ADR, Counseling, CI

Answer 27

**MOA:** Inhibit bone resorption and osteoclastic activity and have been reported to increase BMD **ADR:** Esophageal/gastric irritation, BRONJ **Counseling:** Must be taken on an empty stomach with a full glass of water and remain upright for at least 30 min * 60 min for ibandronate * Risedronate sodium (delayed release) should be taken after breakfast **CI:** * CrCl <30mL/min or < 35 mL/ min for Zol and alendronate * Hypocalcemia-must be corrected before initiating therapy 

Question 28

How long should someone be on BP?

Answer 28

1. Suggest a 1-2 year drug holiday after 5 years 2. The initial 3- to 5-year treatment period 3. BP may have residual effects even after tx d/c

Question 29

How do assess fracture while on tx?

Answer 29

1. Check adherence 2. Check administration: inadvertently taking with food/drink/other medications or taking calcium supplements too close to BP can reduce absorption leading to treatment failure  3. Check ADR

Question 30

What is the counseling point for BP?

Answer 30

1. Check adherence 2. Check admin 3. Fall prevention 4. Separate Ca, antacids, iron and magnesium from all bisphosphonates by at least 2 hours  5. Dental work must be done prior to tx. Due to risk of jaw decay and necrosis  6. PPI decrease the amount of Ca that can be absorbed so recommend patient use the Ca Citrate salt 

Question 31

Counseling points for IV BP preps?

Answer 31

Kept in fridge

Question 32

Denosumab | Brand, MOA, INdication

Answer 32

Prolia **MOA:** inhibits osteoclast-mediated bone resorption by binding to RANKL **Indication:** high risk of fracture or failed other therapy  and for men and women with bone loss associated with prostate and breast cancer

Question 33

Romosozumab | Brand, MOA, Indication, BBW

Answer 33

Evenity **MOA:** blocks the effects of the protein sclerostin and primarily stimulates new bone formation, it also has antiresorptive activity **Indication:** Osteoporosis in postmenopausal women **BBW:** MI, Stroke, CV death

Question 34

Raloxxifene | Brand, MOA, ADR

Answer 34

Evista **MOA:** Estrogen Receptor Agonist/Antagonist approved for prevention and treatment of PM OP **ADR:** VTE, stroke, hot flashes, leg cramps, arthralgia

Question 35

Teriparatide | Brand, MOA, Dosing, ADR

Answer 35

Forteo **MOA:** PTH analog that builds new bone up to 2 years **Dosing:** First dose at night. Refrigerate before and after each use. Use new needle with each dose. Inject thigh or stomach. Discard after 28 days or if cloudy **ADR:** Increased osteosarcoma if had prior exposure to radiation therapy

Question 36

Abaloparatide | Brand, MOA, Indication

Answer 36

Tymlos **MOA:** synthetic PTH that stimulates bone formation **Indication:** Ppostmenopausal women with osteoporosis at high risk for fracture

Question 37

Is Estrogen/MHT indicated for osteoporosis?

Answer 37

Prevention: 1. Inhibits osteoclastic activity, stimulates osteoblastic activity 2. Increase BMD 3. PE, fluid retention, HA, abdominal pain

Question 38

What are most common causes of medication-induced osteoporosis?

Answer 38

Long term GCC and chemo drugs