Exam 2 Flashcards by Kathryn Krchniak

s/sx of osteoporosis

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

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Markers of Bone Resorprtion

Serum C-telopeptide (CTX)

Urinary N-telopeptide (NTX)

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Markers of Bone Formation

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

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Diagnosing Osteoporosis through BMD

Central DXA

*QCT

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Screening Tool for BMD

Quantitative Ultrasound Densitometry (QUS) or pDEXA

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Score Used For Diagnosis

Lowest T-Score

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T-Score Interpretation

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

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Osteoporosis Pharmacotherapy is Indicated in…

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

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FRAX Risk Factors

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

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Factors that increase the risk of falling

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

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Secondary Causes of Osteoporosis

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

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Calcium Supplementation

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

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Vitamin D Supplementation Dosing

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

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Bisphosphonates

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

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Denosumab

60 mg SQ qmo

risk of hypocalcemia

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Estrogen/Hormone Therapy

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

Raloxifene

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

Duavee (Bazedoxifene, Conjugated Equine Estrogen)

1t po qd

BBW: Endometrial Cancer, CVD, Dementia

Salmon Calcitonin

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

PTH analogs

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

Romosozumab

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

Agents that have improvements in hip fractures

BISPHOSPHONATES
DENOSUMAB
Estrogen +/- Progesterone
Romosozumab

Monitoring for Efficacy and Toxicity (Osteoporosis)

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

Osteoporosis Treatment Success

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

Appropriate changes in BTMs

Osteoporosis Treatment Failure

Progression of BMD/fx

Drug Holidays

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

Osteoporosis Combination Therapy

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

SERM (Clomiphene Citrate)

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

Aromatase Inhibitor (Letrazole)

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

Gonadotropins

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

GnRH agonist (Leuprolide)

Stimulating GnRH to point where it shuts off

GnRH antagonist (certrorelix, ganirelix)

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

HCG

Known as trigger injection | Protocol: give GnRH ant/agonist, and then gonadotropin or HCG

Estrogen

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

Progesterone

Supplementation (improve pregnancy rates?)

PCOS

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

CHC's in PCOS

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

Antiandrogens in PCOS

Not for patients desiring fertility | sometimes used with CHCs for synergistic effect