Bones Flashcards
Osteopersosis
- Fragility of skeleton due to loss of bone architecture
- Most common in post menopausal women [primary or type I osteoporosis]
- Can also be seen from other disease states—hyperthyroidism, use of steroids, anti-seizure or blood thinning agents [secondary osteoporosis]
Type I Osteoperosis
caused by post menopause-cause by bone resorption that is out of proportion to bone formation
Therapy for osteoperosis
• Adequate dietary Calcium and Vitamin D
• Weight bearing exercise [it stimulates bone growth]
• Smoking cessation; avoidance of ETOH [both mute bone formation]
• Avoid [if possible] drugs that increase bone loss—steroids, anti-psychotics, anti-epileptic agents, others
• When these drugs must be used—baseline DEXA should be done and then yearly while on these
medications
Secondary osteoperosis
is defined as bone loss that results from specific, well-defined clinical disorders. Many times reversible, secondary causes of bone loss are not considered in a patient with low bone mineral density (BMD).
Difference between osteopenia and osteoporosis
Bone density of -1.0 to -2.5 is osteopenia
Bone density of -2.5 or below is osteoporosis
Bone Density (DEXA scan)
• Compares thickness of bones to a normal
• In young adults, compared to an aged matched control and Z score is evaluated
• In middle aged and older adults, compared to a 35 y/o adult, same gender, comparable height, weight and
race and T score is evaluated
• Patient’s score [Z or T] is used to decide if
treatment needed—a score of -2.5 or
more standard deviations below normal
is osteoporosis
What do bisphosphonates do?
decrease osteoclast bone resorption
FRAX score (fracture risk assessment tool)
A FRAX score indicates the risk of a fracture in a person with osteoporosis. Doctors can use it to determine the best measures to prevent fractures and treat the condition.
BISPHOSPHONATE:
Drug name: Alendronate
Brand Name: Fosamax and Binosto
Can be given daily or weekly
• Binosto is an effervescent tablet
• Given in AM with 4-8 ounces of water 30-60” AC breakfast [no recumbancy for 30-60”]
• Thought to have worst GI side effect profile
• Approved for prevention and treatment of osteoporosis of hip and spine
• Rapidly cleared from plasma—binds to hydroxyapalite in the bone; once bound they are
cleared over months to years; renally eliminated [cannot be given in severe renal disease—
GFR <35 cc/min]
• ADE—GI distress, esophagitis, osteonecrosis of jaw [associated with high doses over long
periods3 consecutive years]; atypical fractures [seen with long term use]
BISPHOSPHONATE
Drug name: Risedronate
Brand name: Actonel, Atelvia Route: PO Approved use for: hip and spine disease DOSAGE: 35 mg (weekly) PO 150mg (monthly) PO 35 mg pc (weekly)
BISPHOSPHONATE
Drug name: Ibandronate
Brand name: Boniva
Route: PO or IVP
Approved use for: spine disease
BISPHOSOPHONATE
Drug name: Zoledronic acid
Brand name: Reclast, Zometa
Route: IV infusion YEARLY
Approved use for: hip and spine disease
*contraindication: heart issues or high risk for a fib ; can have some flu like symptoms
second line agents for osteoperosis
- estrogens
- younger, healthy women for short amount of time - selective estrogen receptor blockers
- given for people intolerant to bisphosphonates, hx breast cancer, contraindicatated for women with hx of DVT, stroke, etc
SE: hot flashes
Selective Estrogen Receptor Blockers
Drug name: Raloxifene (EVISTA)
Brand name: Evista
- Oral daily agent – used for women intolerant to bisphosphonates
- It has estrogen like effects on bone and estrogen antagonistic effects on breast and endometrium
- This agent also lowers LDL cholesterol
- CONTRAINDICATED in women with prior history of thromboembolic disease [DVT, stroke, etc.]
- Main SE—HOT FLASHES!! MAJOR! 35% IN WOMEN
Selective Estrogen Receptor Blockers
Drug name: DUAVE (Bazedoxifne/conjugated estrogens)
Brand name: Duavee
• 0.45/20 [1] tab daily
• Approved for vasomotor sx of menopause and osteoporosis prevention
• Estrogen + SERM—CANNOT be used in those with INTACT UTERUS; hx of breast, endometrial, ovarian cancers
- ADE—thromboembolism
- Same precautions as for estrogens & Evista
Drug name: Duavee: Bazedoxifne/conjugated estrogens
Brand name: Duavee
• 0.45/20 [1] tab daily
• Approved for vasomotor sx of menopause and osteoporosis prevention
• Estrogen + SERM—cannot be used in those with intact uterus; hx of breast, endometrial, ovarian cancers
• ADE—thromboembolism
• Same precautions as for estrogens & Evista
Drug name: Calcitonin (miacalcin)
Brand name: miacalcin
- ANTIRESPORPTIVE
- MAINLY USE TO HELP WITH PAIN AFTER A FX
- Can be used for acute pain after a fracture
- Approved to treat osteoporosis in women who are at least 5 year postmenopausal
- Can be used in patients with vertebral osteoporosis – NOT effective for HIP disease
- Nasal spray used every day [alternate nostrils]
- ADE—nosebleeds and rhinitis
Drug name: Teriparatide (Forteo)
Brand name: Forteo
-for men and women with severe disease and can not take anything else
-synthetic form of parathyroid hormone which stimulates bone formation
Only agent that will build bone by stimulating osteoblasts
- Approved for men and women with severe disease or those in need of treatment that cannot take the other agents
- SC injection daily for 2 years; then off – best option is to follow this therapy with bisphosphonate or Prolia [so patient will not lose new bone that they have built] *****
- Contraindicated in patients who have had skeletal XRT
ONLY DRUG THAT BUILDS BONE
Drug name: Denosumab (Prolia)
Brand name: Prolia
RANKL (receptor activator of nuclear factor kappa B) ligand inhibitor; prevents bone loss by blocking a certain receptor in the body to decrease bone breakdown
- Indicated for post-menopausal women with osteoporosis at high risk for fracture or patients who have failed/cannot tolerant other available therapies
- In post-menopausal women agent reduces the incidence of vertebral, non-vertebral, and hip fractures
- SQ injection twice per year
- Targeted for women and men with renal insufficiency **
- ADE—dermatological reactions, hypocalcemia (will need to monitor calcium!)
Osteomalacia
• Soft or “mushy” bone
• Bone architecture is intact, but strength is impaired
• Most common cause is Vitamin D deficiency
• In children – known as Rickets
• Recent studies tell us that Vitamin D deficiency is rampant in healthy younger adults +
other groups that have long been known to be high risk—those that are ill, frail and older
• By far, Vitamin D deficiency is the most common cause
• Other causes – primary hyperparathyroidism, secondary hyperthyroidism from renal disease
• Deficiencies of Ca++, PO4
• Tumor induced
• Patients with long standing low levels of Vitamin D can develop a secondary
hyperparathyroid state [that corrects itself with Vitamin D replacement]
Normal range for 25 vitmainD
20-20 mM/L; min. acceptable norm is 40
Treatment for osteomalacia
• Replenish with OTC Vitamin D3 [start with 800 IU daily] + daily sun exposure of 25-
30′′ [morning sun] 5-6 days/week without sunscreen]
What is the inactive form of 25 Vitamin D?
vitamin D2 (from plants)
- 50,000 units per day, week, or monthly until dose is acceptable
- close monitoring of Ca++, PO4, and vit D levels if used
Paget’s Disease
- Disorder of bone remodeling leading to disorganized bone formation—usually limited to one or a few bones—skull, upper extremity involvement common
- Patient’s with Paget’s disease will have bone pain, deformities and/or fractures
- Alkaline phosphatase is elevated, as is urine and serum pyridinoline and hydroxyproline
- Calcium Carbonate 500 mg BID with Vitamin D3 400 units daily
Primary agents used to treat Paget’s-high dose bisphosphonates
• Reclast [Zolendronic acid] 5 mg IV
• Fosomax [Alendronate] 40 mg daily for 6 months
• Aredia [Pamidronate] 30 mg IV daily for 3 days
• Actonel [Risedronate] 30 mg daily for 60 days
• Skelid [Tiludronate] 400 mg daily for 90 days
• Didronel [Etidronate] 5-10 mg/kg daily for 90
days
Second line agents used to treat Paget’s
Calcitonin: 100 units subq or IM daily on day 1, the 50-100 units daily for 3 days
*only use if bisphosphonates cannot be used
When should you take calcium carbonate
with food
What should you teach patients on calcium?
-may interfere with iron preparation, thyroid replacement, and fluoroquinolone and tetracycline antibiotics so take calcium several hours from these
What do you need in order to absorb calcium
vitamin D
Drugs that can contribute to bone loss
aluminum antacids anitconvulsants aromatase inhibitors furosemide glucocorticoids heparin medroxyprogersteron acetate selective serotonin reuptake inhibitors thiazolidinediones thyroid (excessive replacement)
Dosing instructions for ORAL bisphosphonates
- take with 6-8 oz plain water only
- take at least 30 minutes (60 minutes for ibandronate) BEFORE other food, drink, or medications
- remain upright and do not lie down or recline for at least 30 minutes (60 for ibandronate)
Parathyroid agents
Teriparatide - recumbant form of parathyroid hormone
Abaloparatide - analog of parathyroid hormone related peptide
Above act as antagonist at the parathyroid hormone receptor
-reserved for pts at high risk for fractures and those who have failed or cannot tolerate other osteoporosis therapies
What effect does estrogen have on bones
low levels promote proliferation and activation of osteoclasts, and bone mass can decline rapidly
What is SECONDARY osteoporosis?
Osteoporosis due to drugs
What is type 2 osteoperosis
bone loss as we age
FRAX score
- fracture risk assessment tool
- used when bone density is normal, but at risk
- helps decide if we need to treat or monitor them
BISPHOSPHONATES
- AM in with water
- renal excreted (can’t give to kidney patients)
- can’t give with people with GI issues
- for HIP and SPINE
Duavee
conjugated estrogen + bazedoxifene
• 0.45/20 [1] tab daily
• Approved for vasomotor sx of menopause and osteoporosis
prevention
• Estrogen + SERM—cannot be used in those with intact uterus; hx of
breast, endometrial, ovarian cancers
• ADE—thromboembolism
• Same precautions as for estrogens & Evista
BISPHOSPHONATES INFO
MOA: bind to hydroxyapatite crystals in the one and decrease osteoclastic bone resorption, results i a small decrease in bone mass and decreased risk of fractures in patients with osteoporosis
PHARMACOKINETICS: poor absorption after oral intake. Food and other medications can effect absorption. Rapidly cleared from plasma. Once bound to bone, they are cleared over a period of hours to years. Eliminated by kidneys (avoid in renal impaired pts)
AE: diarrhea, abd pain, and musuloskeletal pain. ESOPHAGITIS, ESOPHAGEAL ULCERS, osteonecrosis jaw
TEACHING: Remain upright after taking for 30 minutes , take 30 min before food , drink, or meds, take with water only
**take only for 3 years because it hardens bones and makes them brittle. Take a break, monitor them (DEXA) to decided if and when to restart them
CONTRAINDICATIONS: not for renal pts, those with acid reflux
