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competency 10/11 > endo: osteo > Flashcards

endo: osteo Flashcards

1
Q

fragility fractures

A

spine, hip, wrist, humerus, rib, pelvis
- occurs spontaneously or from minor trauma (fall from a standing height or less)

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2
Q

BMD =< 2.5 SD

A

osteoporosis, provided that other causes of low BMD have been ruled out (such as osteomalacia)

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3
Q

BMD: -1 to -2.5 SD

A

low bone mass (osteopenia)

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4
Q

BMD >= -1 SD

A

normal bone density

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5
Q

Z-score =< -2

A

expected range for age

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6
Q

Z-score > 2 SD

A

prompt careful scrutiny for coexisting problems eg. glucocorticoid therapy or alcoholism

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7
Q

site of BMD measurement with DXA

A

spine and hip

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8
Q

does measurement of spine/hip BMD detect responses to therapy earlier?

A

spine

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9
Q

decr bone mass can occur because

A
  • peak bone mass is low
  • bone resorption is excessive
  • bone formation during remodelling is decr
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10
Q

most post-menopausal women with osteoporosis have

A

age- or estrogen deficiency-related bone loss due primarily to excessive bone resportion

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11
Q

adequate calcium intake

A

1200mg daily

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12
Q

adequate vitD intake

A

800IU

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13
Q

higher/lower dose of vitD required if patient is taking concomitant antiseizure medications

A

higher

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14
Q

1250mg of calcium carbonate

A

500mg of elemental Ca (40%)

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15
Q

calcium citrate

A

21% of elemental Ca

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16
Q

alendronate vs risedronate

A

limited studies comparing the two agents, but risedronate has fewer GI side effects

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17
Q

alendronate dosing

A

10mg once daily or 70mg once weekly

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18
Q

risedronate immediate release dosing

A

5mg once daily or 35mg once weekly or 150mg once monthly

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19
Q

risedronate, delayed release (enteric coated)

A

35mg once weekly

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20
Q

zoledronic acid dosign

A

5mg every 12 months, IV

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21
Q

ibandronate dosing

A

(oral) 150mg once monthly
(iv) 3mg every 3 months
- no evidence for hip fracture reduction
- no direct evidence for nonvertebral fracture reduction

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22
Q

discontinuation of therapy after

A

all except zoledronic acid: 5 yrs
z: 3 yrs

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23
Q

before initiation of oral biphosphonates, assess for:

A
  • normal Ca
  • vit D>= 20ng/mL
  • eGFR >= 30ml/min
  • comorbidities that may preclude use or alter adm of meds: abnormalities of esophagus (stricture, etc.) or inability to remain upright for at least 30-60mins
  • plans for invasive dental procedures: discuss risk factors for developing osteonecrosis of the jaw
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24
Q

take biphosphonates before or after food?

A

before, poorly absorbed orally (<1% of the dose) hence taken before food for maximal absorption

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25
Q

biphosphonates should be taken

A
  • alone, on an empty stomach
  • first thing in the morning
  • with 240ml of water
  • aft adm, do not take any food, drinks, supplements, meds for at least half an hr
  • remain upright (sitting or standing) for at least 30 minutes after adm to minimise the risk of reflux
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26
Q

why must we take biphosphonates with water?

A

minimise risk of tablet getting stuck in the esophagus

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27
Q

why must we take biphosphonates while fasting and waiting half an hour until eating or drinking?

A

bioavail may be srsly impaired by:
- ingestion with liquids other than plain water - such as mineral water, coffee, or juice
- retained gastric contents with insufficient fasting time
- gastroparesis
- eating or drinking too soon afterwards

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28
Q

when shud we take enteric-coated, delayed-release risdronate?

A

immediately after breakfast, with 120ml of water

29
Q

adr of IV biphosphonates? and how to min?

A

flu-like sx: w/ longer infusion time eg. 45-60mins
hypoCa: correct vitD deficiency before infusion

30
Q

clinically significant BMD decr - what should we evaluate for?

A
  • poor adherance to therapy
  • inadequate GI absorption
  • inadequate intake of Ca and vitD
  • development of a disease or disorder with adverse skeletal effects
  • adequate Ca and vit D supplementation?
  • secondary causes of bone loss
31
Q

low risk for fracture in near future: definition and duration of therapy

A
  • stable BMD
  • no pervious verterbral or hip fractures

3yrs for zolendronic acid
5yrs for alendronate or risedronate

32
Q

high risk for fracture in near future: definition and duration of therapy

A
  • history of osteoporotic fracture before or during therapy
  • Tscore =< -3 in the absence of fractures

A: 10yrs
R: 7yrs
Z: 6yrs

33
Q

typical length of drug holiday`

A

3-5 yrs

34
Q

typically restart biphosphonates within the first 5 yrs of the drug holiday when one of the following occurs:

A

-Reproducible bone loss (approximately 5 percent) on at least two dual-energy x-ray absorptiometry (DXA) measurements taken at least two years apart, using the same make and model DXA scanner.

-Evidence of bone loss on one DXA measurement at the spine and the hip.

-Evidence of bone loss on one DXA measurement at either site and accompanied by a fasting C-terminal telopeptide of type I collagen (CTX) >600 pg/mL (ie, above the upper limit of the premenopausal reference range).

35
Q

biphosphonates moa

A

inhibit bone resorption by suppressing osteoclast activity

36
Q

we typically initiate biphosphonates ___ weeks postfracture

A

2 weeks
- fracture healing req callus remodeling and the coupled activity of osteoclasts and osteoblasts: biphosphonates may imapir fracture healing

37
Q

denosumab moa

A

fully human monoclonal antibody
- specifically binds RANKL, blocks binding of RANKL to RANK
- thereby reducing the formation, function, and survival of osteoclasts
- decr boen resorption and incr bone density

38
Q

when is denosumab used as initial therapy

A
  • certain patients at high risk of fracture eg, older patients who have difficulty with the dosing req of oral biphosphonates
  • intolerant or unresponsive to other therapies, incl iv biphosphonates
  • markedly impaired kidney function
39
Q

duration of denosumab therapy

A

indefinite
- incr risk of veterbral fracture with discontinuation
- transitioning to other drug is complicated

40
Q

denosumab dosing

A

60mg every 6 months, SC
- upper arm, thigh or abdomen
- 27gauge needle w syringe to withdraw and inject 1ml dose
- stored in refrigerator and brought to room temp by removing from refrigerator 15-30mins before adm

41
Q

renal dose adj for denosumab

A

not req! not renally excreted

42
Q

effects of desonumab on bone density and bone remodelling are

A

reversible with discontinuation of therapy
- results in bone loss within a relatively short time

43
Q

discontinuation or delayed denosumab treatment beyond 2-3 months

A

administer a biphosphonate to prevent rapid bone loss and an incr in veterbral fracture as early as 7 months after the prior dose
- incr risk as delays in adm grow longer

44
Q

how long after last dose of denosumab, should alendronate or zoledronic acid be administered?

A

6 months

45
Q

should anabolic therapy be sequentiated after denosumab?

A

no, usually precedes

46
Q

adr of denosumab

A

flatulence, hypercholesterolemia, back/extremity/musculoskeletal pain, severe bone or joint pain, infections (cystitis, cellulitis), skin reactions

47
Q

denosumab: rates of oversuppression complications

A

did not seem to rise after 10 years of treatmetn

48
Q

denosumab on fracture healing

A

few data

49
Q

other indications for denosumab

A
  • prevent osteoporosis and veterbral fracture in men with nonmetastatic prostate cancer receiving androgen deprivation therapy
  • incr bone density in postmenopausal osteopenic women receiving adjuvant aromatase inhibitor therapy
  • bone metastases
  • treatment of hyperCa
50
Q

when are anabolic agents used as initial therapy?

A

postmenopausal women with severe osteoporosis (T=<-3.0 even in the absence of fractures, or T=<-2.5 plus a fragility fracture)
- or in patients who were treated initially with biphosphonates but unable to tolerate them

51
Q

rank anabolic agents according to preference of sue

A

based on efficacy and LT safety data:
teriparatide>abaloparatide>romosozumab (but has better BMD response)

52
Q

dosing regimen of anabolic agents

A

teriparatide, abaloparatide: SC daily
romosuzumab: SC, monthly by HCP

53
Q

following anabolic agent therapy

A

T,A: limited to 18-24months
R: limited to 12 monthly doses
-> to preserve BMD gains: use anti-resorptive agents

54
Q

when decline in BMD >= 5%

A

switch from oral biphosphonate to an IV biphosphonate
- if lack of response is related to poor absorption

55
Q

for postmenopausal women with severe osteoporosis who continue to frature after 1 yr of biphosponate therapy

A

discontinue the biphosphonate and switch to teriparatide
- effective in incr BMD in women previously treated with biphosphonates

56
Q

bone turnover markers

A

NTX: N-teolpeptide
CTX: serum carboxy-terminal collagen crosslinks

57
Q

monitoring of bone turnover markers

A

in pt who have conditions that might interfere with drug absorption or efficacy - small bowel resections, other types of malabsorption, or pt reluctant to take anti-resportive meds refularly
- measure fasting NTX and CTX: before and 3-6months after initiation

58
Q

decr of >50% NTX or 30% CTX

A

compliance and drug efficac

59
Q

approach with bone resorption markers only useful with

A

anti-resorptive therapy, not with recombinant PTD or romosozumab

60
Q

BMD that is stable or improving is evidence for

A

treatment response

61
Q

raloxifene moa

A

selective estrogen receptor modulator - inhibit bone resoprtion

62
Q

when is raloxifene considered for osteoporosis?

A

when there is an independent need for breast cancer prophylaxis - has beneficial breast cancer risk reduction

63
Q

moa of anabolic agents

A

stimulate bone formation and activate bone remodelling

64
Q

why is estrogen-progestin therapy no longer a first-line approach for treatment of osteoporosis in postmenopausal women

A

incr risk of breast cancer, stroke, vte, cad
- possible indiations include women with persistent menopausal sx and cannot tolerate other drugs

65
Q

romosozumab moa

A

monoclonal anti-sclerostin antibody
- sclerostin produced by osteocytes and inhibit bone formation

66
Q

is combi therapy reco?

A

no

67
Q

calcitriol

A

effective in perventing glucocorticoid-induced and post-transplant-related bone loss
- must be given w low calcium diet
- monitor for hyperCa, hypercalciuria, renal insufficiency

68
Q

folic acid or vit b12

A

not reco

69
Q
A

competency 10/11 (31 decks)

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