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CDM 4 Exam 1 > Lecture 8 - Osteoporosis > Flashcards

Lecture 8 - Osteoporosis Flashcards

1
Q

Endocrine or Metabolic risk factors for Osteoporosis

A

Diabets
Hyperthyroidism
Hyperparathyroidism

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2
Q

Nutrition/GI conditions risk factors for Osteoporosis

A

Alcholism
Malabsorption syndromes
Vit D/Ca deficiences
Anorexia/bulimia

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3
Q

Disease related risk factors for Osteoporosis

A

Leukemia, lymphoma, myeloma
Rheumatoid Arthritis

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4
Q

Meds that are risk factors for osteoporosis

A

Corticosteroids >5mg/day prednisone

Anticonvulsants = phenobarbital, phenytoin, valproate, carbamazepine
SSRIs
TZDs
PPIs

Meds that inc risk for falls

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5
Q

Risk assessment for falls/osteoporosis?

A

FRAX

10yr probability of fractures

ages 40-90

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6
Q

FRAX risk factors

A

age
Gender
Low BMI
Personal/parental history of fractures

Modifiable = smoking or > 3 drinks per day

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7
Q

Heel ultrasound

A

predicts fracture risk

T score doesn’t correlate with DXA, not used for diagnosis

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8
Q

DXA scan

A

Used for diagnosis and monitoring therapy

Results = g/cm2
T scores, shows how mane SD you are from where you should be

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9
Q

When should men > 50 get DXA scan?

A

Clinical risk factor
Fragility factor

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10
Q

DXA scan age cut offs

A

Women > 50 and men > 70 usually

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11
Q

Who should be screened earlier with DXA?

A

Rheumatoid Arthritis
Glucocorticoids = > 5mg prednisone for > 3 months

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12
Q

clinical Risks factors for DXA screening

A

BMI < 20
Smoking
Family history of spine or hip fracture
menopause < 40
Secondary osteoporosis

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13
Q

how to diagnose osteoporosis?

A

T-sore = less than -2.5

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14
Q

3 ways to get osteoporosis diagnosis

A

T-score < 2.5
Hip or vertebral fracture
Low bone mass and one of the following…. > 3% hip fracture 10yr prob, > 20% osteoporosis related fracture prob, fragility fracture of humerus, pelvis or distal forearm

**Post menopausal women or men >50 **

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15
Q

Lab tests we want

A

CBC
TSH
Intact PTH
Serum Vit D
CMP = cal + renal function
Phosphate
Mag
Iron/Ferritin if anemia risk

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16
Q

Universal recommendations for > 50yrs old

A

Muscle strengthening exercises
Weight bearing exercises
Review meds for fall risks

Specific recs if you have Osteoporosis

overall = Stop smoking and reduce drinking

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17
Q

Calcium recommendations

A

Men 51-70 = 1000mg, Max 2000mg

Women > 51 - 70 + Adults > 70 = 1200mg, Max 2000mg

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18
Q

Calcium limits

A

> 1200-1500mg per day have limited benefit and inc risk of side effects such as kidney stones, etc

Diet = best source

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19
Q

When to divide calcium doses?

A

If greater than 600mg, saturated around 500-600mg

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20
Q

Acid dependent and independent calcium?

A

Carbonate = dependent
citrate = independent

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21
Q

Vitamin D recommendations

A

Adults 9-70 = 600IU/15mcg, Max 4000IU or 100mcg

Adults > 70 = 800IU/20mcg, Max 4000IU or 100mcg

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22
Q

Vitamin D lvls

A

Deficient < 12
Insufficient = 12-20
Goal > 30

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23
Q

Vit D treatment to get lvls up

A

1250mcg/week for 6-8 weeks

24
Q

Vit D maintenance dosing

A

1000-2000IU daily to keep lvls

Higher doses maybe necessary Obesity, bariatric surgery, malabsorption, older age, darker skin

25
Q

Post-menopausal women (High risk/no prior fractures) treatment

A

Alendronate, risdronate, zoledronate, denosumab

26
Q

Post-menopausal women, high risk, if inc or stable BMD & no fractures then….

A

consider drug holiday after 5yrs oral or 3 yrs of IV bisphosphonates

Resume therapy if fractures occur, BMD declines, or pt meets initial treatment criteria

27
Q

Post menopausal women, high risk, dec BMD or fractures then……

A

Assess compliance

switch to injectable if on oral therapy

Switch to abaloparatide, teriparatide or romosozumab if on inject bisphosphonate

28
Q

Post menopausal women, high risk, dec BMD or fractures then……

A

Assess compliance

switch to injectable if on oral therapy

Switch to abaloparatide, teriparatide or romosozumab if on inject bisphosphonateis

29
Q

Bisphosphonate MOA

A

Binds to hydroxyapatite in bone (1/2 life 7-10yrs) and inhibits osteoclasts

effects outer layer and becomes incorporated into bone itself and continues to work

30
Q

preferred oral bisphosphonates

A

alendronate (Fosamax) = 70mg weekly

Risedronate (Actonel) 35mg QW, 150mg QMonthly

31
Q

Zoledronate info

A

Recast = bone = 5mg IV Q yearly…15min infusion and premedicate

Zometa = cancers = 4mg IV Q3-4wk

Most SE associated with higher cancer dose

32
Q

SE Bisphosphonates

A

Irritating to GI tract, high risk ulceration

Rare: Atypical fractures, Iritis, Esophageal perforation/cancer, Osteonecrosis of Jaw = box warning

33
Q

Bisphosphonate counseling

A

Take on empty stomach, no other food or meds due to low bioavailability

Take with 8oz plain water

Dont lie down, eat or drink for 30min

If need serious dental work then do before starting meds

34
Q

Bisphosphates CI

A

GERD
H/o GI bleed
CrCL < 30-35

35
Q

Denosumab (Prolia) MOA

A

Binds to and inhibits RANKL, inhibiting osteoclasts

Doesnt have longer term effects like bisphosphanates

36
Q

Denosumab SE

A

Back, extremity and muscle pain
Mild inv in cholesterol

Rare: atypical femur fracture, infections, worsen eczema and rash

37
Q

Denosumab Dosing

A

60mg SC every 6 months
Must be admin by medical professional

$$$

38
Q

Denosumab CI

A

Hypocalcemia

39
Q

Denosumab considerations

A

Medicare Part D/B depending who admin

Bone lass can be rapid when stopped

40
Q

What is Estrogen indicated for?

A

Has FDA indication for prevention but not really used

not used for treatment of osteoporosis

41
Q

Raloxifene Agonist/Antagonist

A

Agonist = Bone
Antagonist = breast/uterus

42
Q

Raloxifene Adverse effects

A

inc risk of DVT
Hot flashes
Leg cramps

** Dont use pts with risk factors for DVT/Stroke **

43
Q

raloxifene Dosing

A

60mg PO QD

44
Q

What makes post-menopausal women Very High Risk?

A

Fracture also 12 months while on therapy or drug causing skeletal harm

High risk for falls

injurious falls

very high FRAX > 30% osteoporosis fracture, > 4.5% hip

45
Q

Post menopausal women, very high risk, treatments inc

A

Denosumab
Zoledronate

Teriparatide or Abaloparatide (bone building)
Romosozumab (bone building)

46
Q

Parathyroid Hormone Receptor Agonists

A

Teriparatide (Fortet)
Abaloparatide (Tymlos)

both indicated in men and women

Both subQ but different dosages in each pen

Tymlos < $$ than Fortet

47
Q

How long can use use Parathyroid Hormone Receptor Agonists

A

> 2yrs for Forteo, expanded
Tymlos = < 2yrs, no studies beyond that

48
Q

CI of Parathyroid Hormone Receptor Agonists

A

Hypercalcemia
Hyperparathyroidism
H/o bone cancer or metastases

** Warning = avoid use in pts with inc risk of osteosarcoma **

49
Q

Adverse effects of Parathyroid Hormone Receptor Agonists

A

Generally well tolerated

Muscle cramps (legs)
Dizziness
Arthralgias
Headache
Inc Uric Acid
Hypotension/Tachycardia w/ 1st few doses ** = sit when given and dont stand

50
Q

What happens if use Bisphosphonate 1st before Parathyroid Hormone Receptor Agonists?

A

Might have a blunted effect and not as good of an response

Loss of Hip BMD if use after Denosumab

51
Q

Sclerostin inhibitor

A

Romosozumab aqqg (event)

indicated women only who are at high risk and failed other therapies

52
Q

Evenity Dosing

A

Req 2 injections once a month

53
Q

Evenity CI

A

Stroke/MI in past year
Hypocalcemia

54
Q

SE of Evenity

A

** Inc risk of MACE, MI/stroke/death **

Atypical femur fracture
Hypersensitivity reactions
Osteonecrosis of the jaw

55
Q

Calcitonin info

A

Not rec any guidelines

potential use, slight pain relief after vertebral fractures

losses effectiveness over time

found inc Malignancies, removed from guidelines

sometimes used short periods of time

CDM 4 Exam 1 (12 decks)

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