Bone/Joint and Rheumatology Flashcards
Which medications may cause decrease BMD/osteoporosis?
-Antiepileptic agents
-Cyclosporine
-Lithium
-PPIs
-Systemic corticosteroids
-SSRIs
-TCAs
-TZDs
What is the recommended calcium intake to prevent fractures?
1000 mg (elemental)/day
What is the recommended vitamin D intake to prevent fractures?
400 units/day
Who qualifies for osteoporosis screening per AACE recommendations?
All post-menopausal women 50 years or older
Who qualifies for osteoporosis screening per BHOF recommendations?
-Women 65 years or older
-Men 70 years or older
-Post-menopausal women and men age 50-69 years with a history of adult-age fractures
What T-score is diagnostic for osteopenia?
1-2.5 SDs below the mean
What T-score is diagnostic for osteoporosis?
> 2.5 SDs below the mean
When would treatment be warranted in a patient with osteopenia?
When FRAX score reveals one of the following:
-Hip fracture risk > 3%
-Major fracture risk > 20%
What is first-line treatment for osteoporosis?
Bisphosphonates
-Alendronate
-Ibandronate
-Risedronate
-Zoledronic acid
What are rare but serious concerns of bisphosphonates?
-ONJ
-Atypical femur fracture/subtrochanteric fracture
What are counseling points on the administration of bisphosphonates?
Should be taken with 6-8 oz of water at least 30-60 min before eating or drinking
Should remain upright for at least 30 min after being administered an oral dose
In general, when should you consider a drug holiday with bisphosphonates?
After 5 years of oral therapy or 3 years of IV therapy
What are second-line treatments for osteoporosis?
-RANKL Antagonist (Denosumab)
-Estrogen
-Parathyroid Hormone (Teriparatide/Abaloparatide)
-SERM
What is third-line treatment for osteoporosis?
Sclerostin Inhibitor (Romosozumab)
What are safety concerns related to denosumab?
-Increasing renal dysfunction
-Cellulitis
-ONJ
-Infections
What is a benefit of denosumab over bisphosphonate therapy?
Every 6 month dosing
When should denosumab not be recommended?
If ongoing or long-term continuation is not feasible
Drug holiday is not recommended
What are contraindications to teriparatide/abaloparatide?
-Alkaline phosphatase elevation
-Open epiphyses
-Paget disease
-Prior skeletal radiation
What is a con of administration of teriparatide/abaloparatide?
Daily subcutaneous injections
What is the black box warning associated with romosozumab?
Increased risk of MI, stroke, and CV death - should not be initiated in patients who had a MI or stroke within previous year
Who would be a candidate for romosozumab therapy?
One of the following:
-Multiple fragility fractures
-High risk of fracture who cannot tolerate any other therapies
-Other therapies have failed (fracture with loss of BMD despite adherence to therapy)
Which agents require antiresorptive therapy after treatment discontinuation?
-Romosozumab
-Teriparatide/abaloparatide
How often should DEXA be repeated after osteoporosis diagnosis?
Yearly (some insurances will only cover every 2 years if not on therapy)
What is the only intervention shown to reduce progression of OA?
Nonpharmacologic interventions (weight loss, low-impact exercise, PT, support braces)
What is the first-line therapy for mild OA?
Acetaminophen (as needed or scheduled)
-Not recommended for hand OA
How long should topical NSAIDs be used for OA?
< 12 weeks
Which patients may topical NSAIDs be preferred over oral NSAIDs?
-> 75 years old
-History of CV disease
-Contraindications to oral NSAIDs
What is the second-line therapy for mild OA and first-line therapy for moderate OA?
NSAIDs
-Consider COX-2 inhibitor (celecoxib) for less GI side effects
What therapy is reserviced for refractory, severe OA?
Opioids (although not routinely recommended)
What therapy can be considered for OA after inadequate pain relief w/ APAP and NSAIDs?
Tramadol
What is the first-line therapy for pain/symptoms associated with fibromyalgia?
TCAs
-Amitriptyline
-Cyclobenzaprine
-Nortriptyline
What are second-line therapies for pain/symptoms associated with fibromyalgia?
-Gabapentin/pregabalin
-Dopamine D3 receptor agonists (pramipexole)
-SSRIs (fluoxetine, paroxetine)
-SNRI (duloxetine)
-Nonopioid mu-receptor antagonist (tramadol)
How should SSRIs be taken when being used for fibromyalgia?
In combination w/ TCAS (if possible)
What are medications that can increase uric acid and can precipitate gout?
-Thiazide diuretics
-Aspirin
-Nicotinic acid
-Vitamin B12
-Cyclosporine
-Levodopa
-Pyrazinamide
When is monotherapy indicated for an acute gouty attack?
Mild-to-moderate pain, particularly for an attack affecting only 1 or a few small joints, or 1-2 large joints
When is initial combination therapy indicated for an acute gouty attack?
Severe pain, particularly for a polyarticular attack or an attack affecting multiple large joints
What medications are available for first-line management of an acute gouty attack?
-NSAID or COX-2 inhibitor
-Systemic corticosteroids
-Colchicine
What is a risk of colchicine therapy?
Adverse hematologic events (myelosuppression, leukopenia, thrombocytopenia, and pancytopenia)
Which treatment for an acute gouty flare is recommended for patients with renal insufficiency?
Corticosteroids
When should uric acid lowering therapy be considered?
-2 or more acute gouty attacks per year
-Presence of tophi
-Stage II CKD or worse
-History of urolithiasis
What is the goal uric acid level for patients with gout?
-< 5 mg/dL (with tophi)
-< 6 mg/dL (without tophi)
What are safety concerns with allopurinol?
-Severe cutaneous adverse reactions (SCARs)
-Drug reaction with eosinophilia and systemic symptoms (DRESS)
-Mucositis
-Hepatotoxicity
When would it be appropriate to use fuboxostat?
-Absolute contraindication to allopurinol
-Allopurinol therapy has failed
