Block 5: Osteoporosis Flashcards
Differentiate BMD classifications?
How do you diagnose osteoporosis?
What are the risk factors for osteoporosis?
- Alcohol use(3+/day)
- Smoking
- Hypogonadism
- Prior fracture as adult/ Parental fx.
- Early menopause(b4 age 45)
- SSRI, PPI, TZD, glucocorticoids
- Chemo drugs
- Corticosteroids(>5mg pred x >3 months)
- Depo-Provera
What is FRAX?
10-year risk model for calculating fracture risk, often used to determine if treatment is warranted
What is Garvan calculator?
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
What are the clinical presentation of osteoporosis?
- Asymptomatic
- Pain
- Immobility-physical limitations
- Fragility
How is osteoporosis assessed based on height?
Loss from maximum height: >1.5 inches loss
Since a previously documented measurement:>0.8 inch loss
Kyphosis or lordosis
Who qualify for Central DXA screening?
Women
- All women 65 years and older
- Postmenopausal
- fragility fracture
- Discontinuing estrogen
- Risk of fractures
Who qualify for Central DXA screening?
Men
- All men older than 70 years of age
- Men ages 50-70 with risk factors or previous fractures
What is the gold standard that measures hip or lumbar spine BMD?
Dual-energy x-ray absorptiometry (DXA)
What measures volumetric BMD of lumbar spine?
Quantitative computed tomography (QCT)
What tools are not appropriate for monitoring?
Peripheral DXA (pDXA) and peripheral QCT (pQCT)
What tool is used to identify vertebral fractures becuase they are asymptomatic?
Vertebral imaging
What is DXA?
Bone density testuses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone
What does DXA assess?
T-score: Compared to young normal adults of same sex
Z-score: Compared to expected norms of patients age and sex
How do you diagnos osteoporosis?
- Low trauma fracture
- femoral neck, total hip and/or spine DXA using WHO T-score thresholds
- Low BMD, osteopenia: -1 and -2.5, osteoporosis <2.5
How do you prevent osteoporosis?
- Healthy lifestyle habits
- Weight bearing exercises
- Vit D 800-1000 Units daily
- Calcium 1000 to 1200mg daily
What are the non-pharm tx for osteoporosis?
- weight bearing exercise: 30-40min/day
- Prevent falls
- Avoid alcohol and smoking
- Limit caffeine (1-2servings/day)
- Calcium (at least 1000 mg/day)
- Vitamin D (600 - 800 IU/day)
Foods high in calcium?
- Dairy products
- Soymilk
- Fortified cereals
- Eggs
- Fortified orange juice
- Sardines with bones
- Salmon with bones
- Halibut
- Collard greens (frozen)
Vitamin D goals?
30-60 ng/mL
What are examples of calcium supplements?
Carbonate: least expensive, most potent, take with food (40%)
Citrate/Gluconate: More expensive, less potent, GI tolerability (21%)
Patient counseling when taking calcium?
- Do not exceed 500-600 mg/dose
- Take most with food
- Start small then titrate
- Gas, bloating, flatulence, constipation
Dosing of Vitamin D?
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)
What are the types of vitamin D supplements?
- Replesta®: 50,000IU wafer
- Ergocalciferol (D2)/Cholecalciferol 50,000 capsule
- Calcitriol
- Vitamin cholecalciferol (D3)
How should recieve pharm tx for osteoporosis?
- With hip or vertebral fracture
- T-score ≤- 2.5 at femoral neck or spine if secondary causes aren’t identified
- Osteopenia and FRAX score of ≥ 3% risk of hip fracture or ≥ 20% risk of major OP fracture
- THose who experienced fragility fractures
What are the pharmacological tx?
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
Bisphosphonates
MOA, ADR, Counseling, CI
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
How long should someone be on BP?
- Suggest a 1-2 year drug holiday after 5 years
- The initial 3- to 5-year treatment period
- BP may have residual effects even after tx d/c
How do assess fracture while on tx?
- Check adherence
- Check administration: inadvertently taking with food/drink/other medications or taking calcium supplements too close to BP can reduce absorption leading to treatment failure
- Check ADR
What is the counseling point for BP?
- Check adherence
- Check admin
- Fall prevention
- Separate Ca, antacids, iron and magnesium from all bisphosphonates by at least 2 hours
- Dental work must be done prior to tx. Due to risk of jaw decay and necrosis
- PPI decrease the amount of Ca that can be absorbed so recommend patient use the Ca Citrate salt
Counseling points for IV BP preps?
Kept in fridge
Denosumab
Brand, MOA, INdication
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
Romosozumab
Brand, MOA, Indication, BBW
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
Raloxxifene
Brand, MOA, ADR
Evista
MOA: Estrogen Receptor Agonist/Antagonist approved for prevention and treatment of PM OP
ADR: VTE, stroke, hot flashes, leg cramps, arthralgia
Teriparatide
Brand, MOA, Dosing, ADR
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
Abaloparatide
Brand, MOA, Indication
Tymlos
MOA: synthetic PTH that stimulates bone formation
Indication: Ppostmenopausal women with osteoporosis at high risk for fracture
Is Estrogen/MHT indicated for osteoporosis?
Prevention:
1. Inhibits osteoclastic activity, stimulates osteoblastic activity
2. Increase BMD
3. PE, fluid retention, HA, abdominal pain
What are most common causes of medication-induced osteoporosis?
Long term GCC and chemo drugs
