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Adv Pharm > Chapter 61: Calcium Levels And Bone Mineralization > Flashcards

Chapter 61: Calcium Levels And Bone Mineralization Flashcards

1
Q

Calcium

A

Functions and daily requirements
Critical to function of the skeletal, nervous, muscular, and cardiovascular systems

Body stores
Bones: More than 98% stored in the bones
Blood: Total serum calcium = 10 mg/dL

Absorption
Occurs in the small intestine
Increased by parathyroid hormone and vitamin D
Glucocorticoids decrease absorption

Excretion
Calcitonin augments calcium elimination

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2
Q

Regulation of calcium levels

A

Absorption from the small intestine

Excretion by the kidney

Resorption in bone

Regulated by
Parathyroid hormone
Vitamin D
Calcitonin

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3
Q

PTH

A

Promotes calcium resorption from bone

Promotes tubular reabsorption of calcium that had been filtered by the kidney glomerulus

Promotes activation of vitamin D, and thereby promotes increased absorption of calcium from the intestine

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4
Q

Recommended dietary intake of Ca

A

0-6m 200-1000 mg
6-12m 260-1500 mg
1st 3 yr of life between 700-2500mg
4-8y ~1000mg
9-18y 1300mg
19-50y ~1000mg
51-70y M 1-2000, F 1200-2500 mg
>70 1200-2000 mg

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5
Q

Vit d

A

Increases calcium resorption from bone

Decreases calcium excretion by the kidney

Increases calcium absorption from the intestine

Important regulator of calcium and phosphorus homeostasis

Health benefits
Found helpful in preventing CV disease, DM, some autoimmune disorders

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6
Q

Calcitonin

A

Released from the thyroid gland when calcium levels in the blood rise too high

Lowers calcium levels by inhibiting resorption of calcium from bone and increasing calcium excretion by the kidney

Does not influence calcium absorption

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7
Q

Hypercalcemia

A

Usually asymptomatic

If symptoms are present: Kidney, gastrointestinal (GI) tract, CNS

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8
Q

HyperCa causes

A

Cancer

Hyperparathyroidism

Vitamin D intoxication

Sarcoidosis

Use of thiazide diuretics

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9
Q

HyperCa tx

A

Drugs that promote urinary excretion of calcium

Drugs that decrease mobilization of calcium from bone

Drugs that decrease intestinal absorption of calcium

Drugs that form complexes with free calcium in the blood

IV saline

Then diuresis with a loop diuretic

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10
Q

HyperCa drugs

A

Edetate disodium

Glucocorticoids

Calcitonin

Bisphosphonates

Gallium nitrate

Cinacalcet (Sensipar): Suppresses parathyroid hormone (PTH) secretion; used for hypercalcemia associated with hyperparathyroidism

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11
Q

Hypocalcemia

A

Increases neuromuscular excitability

Clinical presentation
Tetany, convulsions, and spasm of the pharynx

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12
Q

HypotCa cases

A

Deficiency of PTH

Deficiency of vitamin D

Deficiency of calcium

Chronic renal failure

Long-term use of certain medications, such as magnesium-based laxatives, and drugs used to manage osteoporosis (e.g., bisphosphonates and denosumab)

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13
Q

HypoCa tx

A

Intravenous calcium supplementation (calcium gluconate)

Once calcium levels have been restored: Calcium citrate for maintenance

Vitamin D

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14
Q

Rickets

A

Vitamin D deficiency results in reduced calcium absorption

PTH is released

PTH restores serum calcium by promoting calcium resorption from bone, thereby causing bones to soften

Stress on softened bones caused by bearing weight results in deformity

Treatment: Vitamin D replacement therapy

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15
Q

Osteomalacia (adult counterpart of rickets)

A

Absence of vitamin D

Impaired mineralization of bone

Bowing of the legs

Fractures of the long bones

Kyphosis (“hunchback” curvature of the spine)

Diffuse, dull, aching bone pain

Treatment: Vitamin D replacement therapy

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16
Q

Hypoparathyroidism

A

Cause: Inadvertent removal of parathyroid glands during surgery on the thyroid gland

Lack of PTH: Hypocalcemia, paresthesias, tetany, skeletal muscle spasm, laryngospasm, convulsions

Treatment: Calcium supplements and vitamin D

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17
Q

Primary hyperparathyroidism

A

Cause: Usually results from a benign parathyroid adenoma

Increase in PTH secretion: Hypercalcemia and hypophosphatemia

Skeletal muscle weakness, constipation, CNS symptoms, renal calculi, bone abnormalities

Treatment: Surgical resection of parathyroid glands; calcium-lowering drugs—cinacalcet [Sensipar]

18
Q

Secondary hyperparathyroidism

A

Cause: Common complication of chronic kidney disease (CKD)

High levels of PTH and disturbances of calcium and phosphorus homeostasis

Treatment
Vitamin D sterol (e.g., paricalcitol) and calcium-containing phosphate-binding agents
Cinacalcet [Sensipar]: Can reduce PTH and has a positive effect on calcium and phosphorus levels

19
Q

Calcium salts oral

A

Mild hypocalcemia, dietary supplements

PMS

Colorectal adenoma

Adverse effects: Hypercalcemia

Drug interactions: Corticosteroids, tetracycline, fluoroquinolone, thyroid hormone, phenytoin, bisphosphonates, loop diuretics, thiazide diuretics

20
Q

Parental Ca salts

A

Parenteral: Calcium chloride and calcium gluconate

Adverse effects: Highly irritating; do not give IM; can cause IV extravasation

Drug interaction: Digoxin

21
Q

Vit d for deficiency

A

Vit D25 hydroxy 30-60 nanograms per mL

To treat deficiency:
<1y ~2000 iu/day
1-18y ~4000 iu/day
>19 up to 10,000 iu/day

22
Q

Types of vit D

A

Ergocaliferol [Calciferol Drops, Drisdol] -> vit D2. Found in plants. Used in prescriptions drugs and fortifying foods.

Cholecalciferol -> vit D3. This is the vit d that is produced in humans when skin is exposed to sunlight

No differences with biological effects of vit d2 and vit d3
First 2 are dietary supplements. Vit d3 is preferred.

Calcitriol (1,25-Dihydroxy-D3) 

Doxercalciferol [Hectorol]

Paricalcitol [Zemplar]

Calcitonin-salmon

23
Q

Vitamin D toxicity

A

Early symptoms: Weakness, fatigue, nausea, vomiting, anorexia, abdominal cramping, constipation

Later symptoms: Kidney function is affected, resulting in polyuria, nocturia, and proteinuria

Neurologic: Seizures, confusion, ataxia

Cardiac dysrhythmia

Coma

Calcium deposition in soft tissues

Decalcification of bone

Seen in infants with > 1000 iu/day

Seen in adults with > 50,000 iu/day

Tx -> d/c vit d and increase IVF

24
Q

Drugs for Disorders Involving Calcium

A

Calcium salts

Vitamin D

Calcitonin-salmon [Calcimar, Miacalcin, Fortical]

Bisphosphonates
Alendronate, risedronate, ibandronate, tiludronate, etidronate, zoledronate, pamidronate

25
Q

Calcitonin

A

Inhibits the activity of osteoclasts

Decreases bone resorption

Inhibits tubular resorption of calcium

Increases calcium excretion

Therapeutic uses: Osteoporosis, Paget disease, hypercalcemia

Adverse effects: nausea, flushing of face and hands, intranasal dryness

26
Q

Bisphosphonates

A

Structural analogs of pyrophosphate

Incorporate into bone: Inhibit bone resorption by decreasing activity of osteoclasts

Indications: Postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget disease of bone, hypercalcemia of malignancy

May also help prevent and treat bone metastases in patients with cancer

Adverse effects: May include ocular inflammation, osteonecrosis of the jaw (ONJ), atypical femur fractures, atrial fibrillation (A-fib)
-monitor jaw pain

27
Q

Alendronate [Fosamax, Fosamax Plus D]

A

Most widely used oral bisphosphonate

Uses: Postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, Paget disease of bone

Oral bioavailability: Poor

Adverse effects: Generally safe; esophageal ulceration, atypical femoral fracture, esophageal cancer, musculoskeletal pain, ocular problems, ONJ, hyperparathyroidism, A-fib

Don’t want pt to eat or drink until 30 min after med

Wait 2 hr to take any Ca products or any other mineral supplements

28
Q

Risedronate [Actonel]

A

Uses: Postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, Paget disease of bone

Adverse effects: Arthralgia, diarrhea, headache, rash, nausea, flulike syndrome, esophagitis, atypical femoral fractures, ocular problems, musculoskeletal pain

Take in morning

Delayed release form -> they can eat

29
Q

Ibandronate [Boniva]

A

Uses: Prevention and treatment of postmenopausal osteoporosis

Dosing:Once a month or once every 3 months

Adverse effects: GI effects, including esophagitis, dyspepsia, abdominal pain; ocular inflammation; atypical fractures; ONJ; renal damage if IV administered too rapidly

Oral dosing on empty stomach in the morning with full glass of water an stay upright for 60 min after

If given IV, needs to be slow admin

30
Q

Tiludronate [Skelid]

A

Use: Paget disease of bone

Adverse effects: Nausea, diarrhea, dyspepsia, esophagitis, ocular problems, musculoskeletal pain, possibly esophageal cancer, chest pain, edema, paresthesias, hyperparathyroidism, vomiting, flatulence

31
Q

Raloxifene [Evista]

A

Structurally similar to estrogen and binds to estrogen receptors

Comparison to estrogen

Therapeutic uses
Osteoporosis
Breast cancer

Adverse effects
Thromboembolic events, such as deep vein thrombosis (DVT), pulmonary embolism, stroke, and fetal harm, weight gain

Daily tablet

32
Q

Teriparatide [Forteo]

A

Form of PTH

Treat GIOP –glucocorticoid induced OP

Produced by recombinant DNA

Only drug that increases bone formation

Generally well tolerated
Nausea, headache, back pain, leg cramps

33
Q

Denosumab [Prolia, Xgeva] indications

A

First-in-class RANKL (RANKL, receptor activator of nuclear factor kappa-B ligand) inhibitor with three indications:

Osteoporosis in postmenopausal women and in men at high risk for fractures

Bone loss in women and men receiving certain anticancer therapy
Prostate or breast cancer

Prevention of skeletal-related events in patients with bone metastases from solid tumors

Treat GIOP

34
Q

Denosumab ADR

A

Hypocalcemia

Serious infections

Dermatologic reactions
Dermatitis, eczema

Osteonecrosis of the jaw
Wary about dental implants and dental procedures

35
Q

Denosumab admin

A

Prolia store in fridge an warm this ~15-30 min at room temp before admin. Should be clear an colorless or very pale yellow. Any cloudiness –do not Admin

36
Q

Cinacalcet [Sensipar]

A

Calcimimetic drug

Approved for primary hyperparathyroidism and secondary hyperparathyroidism (caused by CKD)

Increases the sensitivity of calcium-sensing receptors to activation by extracellular calcium

Suppresses PTH secretion

Adverse effects: Nausea, vomiting, diarrhea, hypocalcemia

37
Q

Drugs for Hypercalcemia

A

Furosemide
Promote renal excretion of Ca

Glucocorticoids
Decrease intestinal absorption of Ca

Bisphosphonates
Decrease bone reabsorption by osteoclasts

Inorganic phosphates
Decrease plasma levels of Ca

Edetate disodium
Chalating agent
Bind with Ca to ensure renal excretion occurs

38
Q

Osteoporosis

A

Most common disorder of calcium metabolism

Low bone mass and increased bone fragility

OP seen with aging

typically in women –small boned, small frame women. Can also be seen small framed men

Weight bearing exercise offset OP

Primary prevention
Calcium, vitamin D, lifestyle

Diagnosis
Measurement of bone mineral density (BMD)
Dual-energy x-ray absorptiometry (DEXA)

Effects ~ 10 million Americans
~34 million have reduced bone mass

Common fx sites: vertebrae (spinal), distal forearm around the wrist, femoral neck (hip)

39
Q

Treating Osteoporosis in Women

A

Agents that decrease bone resorption: Estrogen, raloxifene, bisphosphonates, calcitonin, denosumab; sufficient calcium and vitamin D are important

Agent that promotes bone formation: Teriparatide (Forteo)

Agents that reduce fractures: Teriparatide, denosumab, zoledronate

Treat anyone with hip or vertebrae fx, OP t score of </= -2.5 at the femoral neck or spine, someone who presents with low bone mass –t score between -1 and -2.5 at the femoral neck or spine, 10-year probability of hip Fx of 3% or more, a 10 year probability of another OP factor
* based on USA adapted Frax calculations

40
Q

Treating Osteoporosis in Men

A

Five drugs have been approved for osteoporosis treatment in men:
Alendronate [Fosamax]
Risedronate [Actonel]
Zoledronate [Reclast]
Teriparatide [Forteo]
Denosumab [Prolia]

2 million men

3 million at risk

Adv Pharm (76 decks)

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