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PATHO/PHARM II > Conditions Affecting the Musculoskeletal System and PharmacotherapyPart Three: Metabolic DX – Osteoporosis and Fractures > Flashcards

Conditions Affecting the Musculoskeletal System and PharmacotherapyPart Three: Metabolic DX – Osteoporosis and Fractures Flashcards

Exam 4 (Final)

1
Q

Normal A&P: Calcium

What are the roles of calcium?

A

Blood coagulation

Integrity

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2
Q

Normal A&P: Calcium

Roles of Calcium: Integrity of what?

A

Bones, nerves, muscle, heart

Bones remodel continuously

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3
Q

Normal A&P: Calcium

Roles of Calcium: Integrity

Bones remodel continuously what is involved?

A

osteoclasts resorb (breakdown) old bone

osteoblasts lay down new bone

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4
Q

Osteoclasts

A

Resorb (breakdown) old bone

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5
Q

Osteoblasts

A

lay down new bone

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6
Q

Normal A&P: Calcium

Where is the majority of calcium stored?

A

Majority stored in bone ~ 98%

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7
Q

Normal A&P: Calcium

Factors affecting regulation of calcium include:

A

PTH

Vitamin D

Calcitonin

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8
Q

Normal A&P: Calcium

When not stored in the bones, where is calcium located?

A

Remainder present in blood

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9
Q

Normal A&P: Calcium

What are normal levels?

A

Normal (Total): 8.9 to 10mg/dL

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10
Q

Normal A&P: Calcium

When in the blood, what is calcium binded to?

A

50% bound to albumin, citrate, & phosphate

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11
Q

Normal A&P: Calcium

When in the blood, calcium is binded to proteins, when not attached to protein how is it?

A

50% free, active, ionized, clinically important & participates in bodily processes

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12
Q

Normal A&P: Calcium

Calcium absorption: Where is calcium absorbed?

A

Small intestines ~ ingested calcium

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13
Q

Normal A&P: Calcium

Calcium absorption: What is calcium absorption increased by?

A

Increased by PTH & vitamin D

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14
Q

Normal A&P: Calcium

Calcium absorption: What is it reduced with?

A

Meds:

Oxalic acid

Phytic acid & insoluble fiber

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15
Q

Normal A&P: Calcium

Calcium absorption: What meds reduce calcium absorption?

A

GCs, Cinacalcet, some chemo, TCNs, Levothyroxine, Phenytoin, Phenobarb, Loops

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16
Q

Normal A&P: Calcium

Calcium absorption: What are examples of oxalic acid that reduce calcium absorption?

A

Oxalic acid ~ spinach, rhubarb, swiss chard, beets

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17
Q

Normal A&P: Calcium

Calcium absorption: What examples of Phytic acid & insoluble fiber
that reduce calcium absorption?

A

bran, grain cereals

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18
Q

Normal A&P: Calcium

Calcium excretion: Where is it primarily excreted?

A

Primarily through kidney

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19
Q

Normal A&P: Calcium

Calcium excretion: Calcium primarily excreted through the kidney is determined by what?

A

Loss determined by GFR & tubular reabsorption

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20
Q

Normal A&P: Calcium

Calcium excretion: Calcium primarily excreted through the kidney-what is excretion reduced by?

A

Excretion reduced by PTH & vitamin D, & thiazides

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21
Q

Normal A&P: Calcium

Calcium excretion: Calcium primarily excreted through the kidney-what is excretion increased by?

A

Increased excretion ~ loops, calcitonin

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22
Q

Normal A&P: Calcium

What happens when there is Low Serum Calcium?

A

PTH (pulls) secretion

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23
Q

Normal A&P: Calcium

When there is Low Serum Calcium, PTH pulls secretion, what does this promote?

A

Ca resorption from bone

Tubular reabsorption of Ca from kidney

Activation of vitamin D promotes increased absorption of calcium from the intestine

Pulls from bones –> demineralized

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24
Q

Normal A&P: Calcium

What does Vitamin D do?

A

Increases calcium resorption from bone

Decreases calcium excretion by the kidney

Increases calcium absorption from the intestine

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25
Q

Normal A&P: Calcium

What does Vitamin D work similar to?

A

Works similar to PTH

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26
Q

Normal A&P: Calcium

What does a high serum calcium do?

A

Ca leaves blood, causing a Suppression of PTH release
and no vitamin D activation

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27
Q

Normal A&P: Calcium

What happens when calcitonin (keeps) is released by thyroid?

A

decrease plasma Ca levels

Inhibits calcium resorption in bone

increase in renal excretion

No effect on calcium absorption

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28
Q

Slide 5

A
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29
Q

Normal A&P: Vitamin D3

Pharmokinetics: Where is Vitamin D3 absorbed from?

A

Absorbed from small intestine

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30
Q

Normal A&P: Vitamin D3

Pharmokinetics: What is needed for Vitamin D3 to be absorbed?

A

Need bile for absorption

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31
Q

Normal A&P: Vitamin D3

Pharmokinetics: Where is Vitamin D3 stored?

A

Stored in liver

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32
Q

Normal A&P: Vitamin D3

Pharmokinetics: Where is Vitamin D3 excreted?

A

Excreted in bile

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33
Q

Normal A&P: Vitamin D3

Pharmokinetics: What converts Vitamin D3 to its active form?

A

Kidney converts it to active form

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34
Q

Normal A&P: Vitamin D3

Pharmokinetics: How is Vitamin D3 excreted in urine?

A

Urinary excretion minimal

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35
Q

Vitamin D:

What are the forms of Vitamin D?

A

Ergocalciferol (vitamin D2)

Cholecalciferol (vitamin D3)

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36
Q

Vitamin D:

What form of Vitamin D occurs in plants?

A

Ergocalciferol (vitamin D2)

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37
Q

Vitamin D:

What is Ergocalciferol (vitamin D2) used for? In what form are they?

A

Used for hypoparathyroidism,

Vit D-resistant rickets,

hypophosphatemia

Capsules & solution

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38
Q

Vitamin D:

How is Cholecalciferol (vitamin D3)
produced?

A

Produced naturally from sunlight

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39
Q

Vitamin D:

What food has Cholecalciferol (vitamin D3)? How else is D3 available?

A

Animal-sourced foods (oily fish, egg yolk, butter)

Available pharmaceutically (multiple doses)

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40
Q

Vitamin D:

What are therapeutic uses of Cholecalciferol (vitamin D3)? How is it available?

A

Therapeutic uses
Deficiency – px & tx
Bone health
Calcium absorption

Capsules, liquid, tablets

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41
Q

Vitamin D: What are Physiologic actions similar to?

A

Similar to PTH

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42
Q

Vitamin D: What are Physiologic actions of Vitamin D?

A

Increases Ca & Phos

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43
Q

Vitamin D:
Physiologic actions of Vitamin D: How does Vitamin D increase Ca and Phos?

A

↑ intestinal Ca absorption

↑ resorption Ca in bone

↓ renal Ca excretion

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44
Q

Vitamin D toxicity:

What are early symptoms?

A

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

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45
Q

Vitamin D toxicity:

What are later symptoms?

A

Later symptoms:

Kidney function is affected:

resulting in polyuria, nocturia, and proteinuria

46
Q

Vitamin D toxicity:

What are neurological symptoms?

A

Neurologic: Seizures, confusion, ataxia

47
Q

Vitamin D toxicity:

What other issues can it lead to?

A

Cardiac dysrhythmia

Coma

Calcium deposition in soft tissues – can damage heart, BVs, lungs, kidneys

Decalcification of bone

48
Q

Vitamin D toxicity:

What is treatment?

A

Stopping vit D intake

IV fluids

GCs suppress calcium absorption

If severe, renal excretion of Ca accelerated by furosemide

49
Q

Normal A&P of bones;
How does continuous remodelling occur?

A

Continuous remodeling ~ marrow

50
Q

Normal A&P of bones;
What happens to bone mass over time?

A

Bone Mass △ across lifespan

51
Q

Normal A&P of bones;
When does bone mass peak?

A

Peaks in third decade

52
Q

Normal A&P of bones;
When does bone mass stay stable until? What then happens?

A

Remains stable to 50yo –> slow decline (less than 1% a year)

53
Q

Normal A&P of bones;
Why does bone mass Remain stable to 50yo –> slow decline (less than 1% a year)?

A

Resorbed bone not replaced with new bone –>fragile

54
Q

Normal A&P of bones:

Postmenopausal females: What happens to bone mass?

A

Accelerated loss (2-3% yearly)

Resorption outpaces > deposition new bone

55
Q

Normal A&P of bones:

Where do both osteoclasts and osteoblasts originate from?

A

Both osteoblasts & clasts originate in bone marrow

56
Q

Normal A&P of bones:

Where do Osteoclasts (“the chewers”) develop?

A

Cells that develop from (spongy) bone marrow

57
Q

Normal A&P of bones:

Where do Osteoblasts (“the builders”) originate?

A

Originate from stem cells

58
Q

Normal A&P of bones:

How do Osteoblasts (“the builders”) create new bone?

A

Create new bone matrix by depositing minerals and collagen

59
Q

Normal A&P of bones:

When do Osteoblasts (“the builders”) create new bone?

A

Lay down/rebuild new bone during remodeling process

60
Q

What are the steps to how old bone is removed and new bone is placed?

A
  1. Bone with lining cells covering the surface.
  2. Resorption of old bone by osteoclasts
  3. Osteoblasts migrate to the absorption site
  4. Osteoblasts deposit osteoid, matrix of collagen and other proteins.
  5. Osteoid undergoes calcification
61
Q

What is the most common disorder of calcium metabolism?

A

Osteoporosis

62
Q

Osteoporosis: What occurs with this disease? What does this do to patients?

A

Low bone mass and increased bone fragility

Renders patients vulnerable to fractures from minor trauma.

63
Q

Osteoporosis: How are fracture risks?

A

Spontaneous

Secondary to minor events
coughing, rolling over in bed, falling from standing position

↑ mortality

64
Q

Osteoporosis:

What are the most common sites of osteoporotic fractures are:

A

Most common sites of osteoporotic fractures are the vertebrae, wrist, hip, ribs, and long bones of the arms and legs.

65
Q

Osteoporosis:

Who does osteoporosis occur in mainly? Why?

A

Mainly in the elderly, because after age 50 men and women experience aging-related bone loss that is slow but relentless.

women experience several years of accelerated bone loss after menopause

66
Q

Osteoporosis:

What is the primary prevention?

A

Calcium, vitamin D, lifestyle

67
Q

Patho of Osteoporosis: What is the main idea?

A

Osteoblast activity < osteoclast activity

68
Q

Patho of Osteoporosis:

Osteoblast activity < osteoclast activity
What does this mean?

A

Old bone resorbed faster than new bone formed

69
Q

Patho of Osteoporosis:

What is a protein used to control bone breakdown?

A

RANKL

70
Q

Patho of Osteoporosis:

How does RANKL work?

A

binds to a receptor on osteoclasts, activating them

71
Q

Patho of Osteoporosis:

What stops RANKL work?

A

OPG (Osteoprotegerin) that acts like a “brake” on RANKL

72
Q

Patho of Osteoporosis:

Why would
Osteoblast activity < osteoclast activity
occur (having to do with proteins)

A

Too much RANKL and not enough OPG

73
Q

Patho of Osteoporosis

What happens to bone?

A

Spongy bone become porous

74
Q

Patho of Osteoporosis:

When spongy bone becomes porous, what happens?

A

Leads to a significant reduction in BMD, bones –> brittle, fragile.

Compact bone becomes thin

75
Q

Patho of Osteoporosis:

How can it occur?

A

Can occur as primary or secondary

76
Q

Patho of Osteoporosis:

Secondary osteoporosis: caused by?

A

Hormonal imbalances, hyperPTH, malabsorption
Tobacco
Meds

77
Q

Patho of Osteoporosis:

Secondary osteoporosis: What kind of meds lead to osteoporosis?

A

Heparin, GCs, seizure meds, PPIs

78
Q

Epidemiology of Osteoporosis

Prevalence in men and women?

A

Can occur in women and men (equal rate of bone mass decline)

79
Q

Epidemiology of Osteoporosis

In men how is acceleration of disease?

A

In men no accelerated phase because no menopause

80
Q

Epidemiology of Osteoporosis

How is osteoporosis in women occur?

A

Women tend to have lower calcium intake than men.

Women have less bone mass because of their generally smaller frames.

Bone resorption begins earlier in women and increases at menopause.

Pregnancy and breastfeeding deplete a woman’s skeletal reserve.

Women live longer, greater likelihood of osteoporosis.

81
Q

Epidemiology of Osteoporosis

Prevalence: Who else can it occur in?

A

People with absorption issues (eg Celiacs)

1:2 women vs. 1:4 men over age 50 will sustain an osteoporosis-related fracture

82
Q

Osteoporosis

Risk Factors: Nonmodifiable?

A

Advancing age (>65 yr)

Female sex (smaller body habitus)

White, Norwegian, or Asian ethnicity

Estrogen deficiency in women (surgical or age-related menopause)

Hereditary predisposition

83
Q

Osteoporosis

Risk Factors: Modifiable?

A

Cigarette smoking

Low body weight

Diet low in calcium, vitamin D deficiency, or decreased intestinal absorption of calcium

Sedentary lifestyle

Excessive use of alcohol (>2 drinks/day)

Low testosterone in men

Glucocorticoid/cortisol use

Hormonal factors such as hyperPTHydism (either 1° or 2° due to renal disease), menopause, Cushing’s syndrome, hyperthyroid, or continuous GCs

Excessive caffeine intake

Geographic location: those living in higher latitudes getting less sun exposure resulting in lower vitamin D production in the skin

84
Q

Clinical Manifestations of Osteoporosis

A

Spontaneous fractures

Loss of height and/or kyphosis

Bone pain

85
Q

Clinical Manifestations of Osteoporosis:

Why does spontaneous fractures occur?

A

The loss of bone mass causes the bone to become mechanically weaker and prone to spontaneous fractures or fractures from minimal trauma.

86
Q

Clinical Manifestations of Osteoporosis

What happens if even 1 vertebral fracture occurs?

A

One vertebral fracture due to osteoporosis increases risk of having a second vertebral fracture within 1 year.

87
Q

Clinical Manifestations of Osteoporosis

Loss of height and/or kyphosis: Why does this occur? What develops?

A

Over time, vertebral fractures and wedging cause gradual loss of height.

Patients develop humped thoracic spine (kyphosis, or “dowager’s hump”).

88
Q

Clinical Manifestations of Osteoporosis

Bone pain: Why does this occur?

A

Patients often complain of achiness in their long bones of the legs and arms due to weakening of the bone and inflammation of the periosteum from mechanical stress.

89
Q

Diagnosis & Assessing Fracture Risk:

How is it diagnosed?

A

Dx’d by measuring bone mineral density (BMD), Dual-energy x-ray absorptiometry (DEXA) scan.

90
Q

Diagnosis & Assessing Fracture Risk:

How does WHO diagnose osteoporosis?

A

The World Health Organization (WHO) diagnostic criterion for osteoporosis is a BMD more than 2.5 standard deviations below the mean BMD for young adults.

91
Q

Diagnosis & Assessing Fracture Risk:

Who is routine testing done for?

A

Routine testing for all women at age 65 & younger for post-menopausal at increased risk

92
Q

Diagnosis & Assessing Fracture Risk:

When are men tested?

A

Testing for men 70 yrs and older

93
Q

Diagnosis & Assessing Fracture Risk:

What does BMD measure?

A

Measures BMD wrist, hip, spine

94
Q

Primary Prevention of Osteoporosis

Calcium: What does it do in early life?

A

Early life ~ maximizes bone growth

95
Q

Primary Prevention of Osteoporosis

Calcium: What does it do in later life?

A

Later ~ maintains bone integrity

96
Q

Primary Prevention of Osteoporosis

Calcium: What diet is it in?

A

Diet: dairy, green veggies, processed foods that are fortified (eg cereals)

97
Q

Primary Prevention of Osteoporosis

Recommendations (RDA)

Teens/young adults/older female adults?

A

Adolescents & teens ~ 1300mg/d
Young adults ~ 1000mg/d
Older female adults ~ 1200mg/d

98
Q

Primary Prevention of Osteoporosis

Vitamin D: What does it do?

A

Ensures Ca absorption

99
Q

Primary Prevention of Osteoporosis

Lifestyle

A

Regular weight-bearing exercise

⍉ excessive EtOH

⍉ smoking

100
Q

Primary Prevention of Osteoporosis

Lifestyle:

Regular weight-bearing exercise includes?

A

Walking, yoga, dancing, racquet sports, weightlifting, stair climbing

101
Q

Agents for Primary Prevention for osteoporosis?

Calcium supplementation (oral): When is it used?

A

Used if diet insufficient to meet the requirement, mild hypocalcemia

102
Q

Agents for Primary Prevention for osteoporosis?

A

Vitamin D supplementation

Calcium supplementation (oral)

Calcium salts

103
Q

Agents for Primary Prevention for osteoporosis?

Calcium supplementation (oral): What are adverse effects?

A

Adverse effects: hypercalcemia, GI disturbances, nephrolithiasis, renal destruction, lethargy

104
Q

Agents for Primary Prevention for osteoporosis:

Calcium salts: How does it differ from calcium supplementation? Are they interachangable?

A

Differ in % of elemental calcium

⍉ interchangeable

105
Q

Agents for Primary Prevention for osteoporosis:

Calcium salts: What is max absorption dose at one time?

A

Max 600mg per dose at one time = adequate absorption

106
Q

Nursing Implications

Calcium salts
What should you advise against? How should they be taken? What should be avoided? What should you inform patient about?

A

Advise pts against switching to a different preparation

Take calcium carbonate with meals for best absorption

Take with large glass of H2O

Avoid taking Ca with foods that can suppress Ca absorption

Inform pt about s/s hypercalcemia

107
Q

Nursing Implications

Calcium salts
Avoid taking Ca with foods that can suppress Ca absorption- like what?

A

Oxalate foods: spinach, Swiss chard, beets

Phytic acid & insoluble fiber: bran, whole-grain cereals

108
Q

Nursing Implications

Minimize drug interactions?

A

GCs – reduce Ca absorption

TCNs – Ca binds to TCNs, reducing TCN absorption. Separate by 1 hr

FQs (eg levofloxacin)

Levothyroxine – reduced TH absorption – separate by several hours

Thiazides decrease renal excretion of Ca in exchange for sodium (hypercal)

Loops – increase Ca excretion (hypocal)

109
Q

Pharmacotherapy for Osteoporosis

Agents that ↓ bone resorption- How?

A

Reduce osteoclast activity

109
Q

Pharmacotherapy for Osteoporosis

What is the purpose of them?

A

Agents that ↓ bone resorption

PATHO/PHARM II (27 decks)

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