Exam 2

Question 1

s/sx of osteoporosis

Answer 1

Pain
Immobility
Depression, Fear, Low Self Esteem
Shortened Stature
Kyphosis
Lordosis
Vertebral, Hip, Wrist, or Forearm fx
Low BMD on radiology

Question 2

Markers of Bone Resorprtion

Answer 2

Serum C-telopeptide (CTX)

Urinary N-telopeptide (NTX)

Question 3

Markers of Bone Formation

Answer 3

Serum Bone Specific Alkaline Phosphatase (BSAP)
Osteocalcin (OC)
Aminoterminal Propeptide of Type 1 Procollagen (P1NP)

Question 4

Diagnosing Osteoporosis through BMD

Answer 4

Central DXA

*QCT

Question 5

Screening Tool for BMD

Answer 5

Quantitative Ultrasound Densitometry (QUS) or pDEXA

Question 6

Score Used For Diagnosis

Answer 6

Lowest T-Score

Question 7

T-Score Interpretation

Answer 7

Normal: >-1.0
Osteopenia: -1.0 to -2.5
Osteoporosis:

Question 8

Osteoporosis Pharmacotherapy is Indicated in…

Answer 8

1) T-Score 3%/major osteoporotic fx >20% (FRAX)

Question 9

FRAX Risk Factors

Answer 9

Current Age
Gender
Prior OP Fracture
Femoral Neck BMD
Low BMI
Oral Glucocorticoids (>5 mg Prednisone for >3 mo)
RA
Secondary OP
Parental hx of Hip Fracture
Current Smoking
Alcohol Intake (>3 drinks/day)
*T-Score

Question 10

Factors that increase the risk of falling

Answer 10

Neurologic Disorders
Impaired vision
Impaired Hearing
Fraility and Deconditioning
Proximal Myopathy
Sarcopenia
Sedatives and Hypnotics
Antihypertensive Agents
Narcotic Analgesics
Environmental Factors

Question 11

Secondary Causes of Osteoporosis

Answer 11

Glucocorticosteroids (not inhaled/nasal)
Antiepileptic Drugs
Depot Medroxyprogesterone
Heparin (UF)
Aromatase Inhibitors
PPI
TZD, SGLT-2i
Co-morbid Conditions (on slide)

Question 12

Calcium Supplementation

Answer 12

Carbonate: Acid Dependent; twf, avoid H2RAs/PPIs
Citrate: Acid Independent; twOw/oF, better GI toleration
*1,200-500 mg/day (4 servings)

Question 13

Vitamin D Supplementation Dosing

Answer 13

For Adults >50:
5,000 IU D3 da x8-12w, then 1-2,000 IU da
50,000 IU D3 wkly, then 1-2,000 IU D3 da

Question 14

Bisphosphonates

Answer 14

Only Class that can do a drug Holiday
Have to stay upright/t bb for certain amount of time
1st line therapy
GI SE
Risk of ONJ/Atyp fx
Can't use w. CrCl < 30-35
Avoid Oral: esophageal stricture, achalasia, inability to remain upright, inc risk of aspiration
d/c if atyp fx occurs

Question 15

Denosumab

Answer 15

60 mg SQ qmo

risk of hypocalcemia

Question 16

Estrogen/Hormone Therapy

Answer 16

inc risk of MI, stroke, breast cancer, pulmonary embolism, DVT
Use for shortest duration possible

Question 17

Raloxifene

Answer 17

60 mg po da
Only for post-menopausal F
Don’t use w/ systemic estrogens, if have vasomotor sx of menopause
BBW: VTE, Stroke

Question 18

Duavee (Bazedoxifene, Conjugated Equine Estrogen)

Answer 18

1t po qd

BBW: Endometrial Cancer, CVD, Dementia

Question 19

Salmon Calcitonin

Answer 19

1s in 1 nostril da; SQ inj
for WOMEN 5y post-menopausal
last line therapy
don’t use in those w/ a salmon allergy

Question 20

PTH analogs

Answer 20

BBW: osteosarcoma
Don’t use: Paget’s disease, prior radiation of skeleton, bone metastases, hypercalemia, hx of skeletal malignancy
SQ qd

Question 21

Romosozumab

Answer 21

210 mcg SQ qmo
therapy limited to 12 mo
BBW: risk of MI, stroke, CV death
risk of ONJ, atyp fx

Question 22

Agents that have improvements in hip fractures

Answer 22

BISPHOSPHONATES
DENOSUMAB
Estrogen +/- Progesterone
Romosozumab

Question 23

Monitoring for Efficacy and Toxicity (Osteoporosis)

Answer 23

DXA: Baseline; q2y
BTMs: should see red. 3-6 mo after for ANTRES; inc 1-3 mo after for ANABOL

Question 24

Osteoporosis Treatment Success

Answer 24

Stable/Increased BMD w/ no new fx/fx progression

Appropriate changes in BTMs

Question 25

Osteoporosis Treatment Failure

Answer 25

Progression of BMD/fx

Question 26

Drug Holidays

Answer 26

Biphosphonates only
after 3y (IV)/5y (PO)
Lasts no longer than 5y
End holiday if fx or signif BMD loss, rise in bone resorption markers

Question 27

Osteoporosis Combination Therapy

Answer 27

Only in women using HRT for menopausal sx or raloxifene for breast cancer prevention
*may add BP, denosumab, PTH analog

Question 28

SERM (Clomiphene Citrate)

Answer 28

Requires adequate FSH/LH/estradiol
Blocks Estrogen Receptor @ Hypothal (inhib - feedback loop), body perceives as hypoestrogenic state and inc GnRH prod., acts on pituitary to produce LH/FSH, results in subsequent ovulation

Question 29

Aromatase Inhibitor (Letrazole)

Answer 29

Inhibits enzyme resulting in less androgens converted into estrogen, less estrogen around, triggers hypoestrogenic state, inc in GnRH and subsequent inc in LH and FSH
also causes thinning of cervical mucus
Superior in PCOS and unexplained infertility

Question 30

Gonadotropins

Answer 30

Supplemented for patient depending on what type of disease state they have
If patients fail orals/for certain disease states
Can also be given to males as they can stimulate spermatogenesis

Question 31

GnRH agonist (Leuprolide)

Answer 31

Stimulating GnRH to point where it shuts off

Question 32

GnRH antagonist (certrorelix, ganirelix)

Answer 32

Inhibit production of GnRH to give time for gonadotropins to work, Given in tandem w/ gonadotropins

Question 33

HCG

Answer 33

Known as trigger injection

Protocol: give GnRH ant/agonist, and then gonadotropin or HCG

Question 34

Estrogen

Answer 34

can be given before infertility protocol is initiated to regulate the cycle

Question 35

Progesterone

Answer 35

Supplementation (improve pregnancy rates?)

Question 36

PCOS

Answer 36

Inc GnRH release inappropriately stim. pituitary, LH surge happens more frequently/earlier, follicles don’t mature (fertility issues)

Question 37

CHC’s in PCOS

Answer 37

First line treatment if patient doesn’t desire fertility – treats majority of symptoms
Norgestimate, Desogestrel, Drosperinone

Question 38

Antiandrogens in PCOS

Answer 38

Not for patients desiring fertility

sometimes used with CHCs for synergistic effect