Lecture 8 - Osteoporosis Flashcards
Endocrine or Metabolic risk factors for Osteoporosis
Diabets
Hyperthyroidism
Hyperparathyroidism
Nutrition/GI conditions risk factors for Osteoporosis
Alcholism
Malabsorption syndromes
Vit D/Ca deficiences
Anorexia/bulimia
Disease related risk factors for Osteoporosis
Leukemia, lymphoma, myeloma
Rheumatoid Arthritis
Meds that are risk factors for osteoporosis
Corticosteroids >5mg/day prednisone
Anticonvulsants = phenobarbital, phenytoin, valproate, carbamazepine
SSRIs
TZDs
PPIs
Meds that inc risk for falls
Risk assessment for falls/osteoporosis?
FRAX
10yr probability of fractures
ages 40-90
FRAX risk factors
age
Gender
Low BMI
Personal/parental history of fractures
Modifiable = smoking or > 3 drinks per day
Heel ultrasound
predicts fracture risk
T score doesn’t correlate with DXA, not used for diagnosis
DXA scan
Used for diagnosis and monitoring therapy
Results = g/cm2
T scores, shows how mane SD you are from where you should be
When should men > 50 get DXA scan?
Clinical risk factor
Fragility factor
DXA scan age cut offs
Women > 50 and men > 70 usually
Who should be screened earlier with DXA?
Rheumatoid Arthritis
Glucocorticoids = > 5mg prednisone for > 3 months
clinical Risks factors for DXA screening
BMI < 20
Smoking
Family history of spine or hip fracture
menopause < 40
Secondary osteoporosis
how to diagnose osteoporosis?
T-sore = less than -2.5
3 ways to get osteoporosis diagnosis
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 **
Lab tests we want
CBC
TSH
Intact PTH
Serum Vit D
CMP = cal + renal function
Phosphate
Mag
Iron/Ferritin if anemia risk
Universal recommendations for > 50yrs old
Muscle strengthening exercises
Weight bearing exercises
Review meds for fall risks
Specific recs if you have Osteoporosis
overall = Stop smoking and reduce drinking
Calcium recommendations
Men 51-70 = 1000mg, Max 2000mg
Women > 51 - 70 + Adults > 70 = 1200mg, Max 2000mg
Calcium limits
> 1200-1500mg per day have limited benefit and inc risk of side effects such as kidney stones, etc
Diet = best source
When to divide calcium doses?
If greater than 600mg, saturated around 500-600mg
Acid dependent and independent calcium?
Carbonate = dependent
citrate = independent
Vitamin D recommendations
Adults 9-70 = 600IU/15mcg, Max 4000IU or 100mcg
Adults > 70 = 800IU/20mcg, Max 4000IU or 100mcg
Vitamin D lvls
Deficient < 12
Insufficient = 12-20
Goal > 30
Vit D treatment to get lvls up
1250mcg/week for 6-8 weeks
Vit D maintenance dosing
1000-2000IU daily to keep lvls
Higher doses maybe necessary Obesity, bariatric surgery, malabsorption, older age, darker skin
Post-menopausal women (High risk/no prior fractures) treatment
Alendronate, risdronate, zoledronate, denosumab
Post-menopausal women, high risk, if inc or stable BMD & no fractures then….
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
Post menopausal women, high risk, dec BMD or fractures then……
Assess compliance
switch to injectable if on oral therapy
Switch to abaloparatide, teriparatide or romosozumab if on inject bisphosphonate
Post menopausal women, high risk, dec BMD or fractures then……
Assess compliance
switch to injectable if on oral therapy
Switch to abaloparatide, teriparatide or romosozumab if on inject bisphosphonateis
Bisphosphonate MOA
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
preferred oral bisphosphonates
alendronate (Fosamax) = 70mg weekly
Risedronate (Actonel) 35mg QW, 150mg QMonthly
Zoledronate info
Recast = bone = 5mg IV Q yearly…15min infusion and premedicate
Zometa = cancers = 4mg IV Q3-4wk
Most SE associated with higher cancer dose
SE Bisphosphonates
Irritating to GI tract, high risk ulceration
Rare: Atypical fractures, Iritis, Esophageal perforation/cancer, Osteonecrosis of Jaw = box warning
Bisphosphonate counseling
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
Bisphosphates CI
GERD
H/o GI bleed
CrCL < 30-35
Denosumab (Prolia) MOA
Binds to and inhibits RANKL, inhibiting osteoclasts
Doesnt have longer term effects like bisphosphanates
Denosumab SE
Back, extremity and muscle pain
Mild inv in cholesterol
Rare: atypical femur fracture, infections, worsen eczema and rash
Denosumab Dosing
60mg SC every 6 months
Must be admin by medical professional
$$$
Denosumab CI
Hypocalcemia
Denosumab considerations
Medicare Part D/B depending who admin
Bone lass can be rapid when stopped
What is Estrogen indicated for?
Has FDA indication for prevention but not really used
not used for treatment of osteoporosis
Raloxifene Agonist/Antagonist
Agonist = Bone
Antagonist = breast/uterus
Raloxifene Adverse effects
inc risk of DVT
Hot flashes
Leg cramps
** Dont use pts with risk factors for DVT/Stroke **
raloxifene Dosing
60mg PO QD
What makes post-menopausal women Very High Risk?
Fracture also 12 months while on therapy or drug causing skeletal harm
High risk for falls
injurious falls
very high FRAX > 30% osteoporosis fracture, > 4.5% hip
Post menopausal women, very high risk, treatments inc
Denosumab
Zoledronate
Teriparatide or Abaloparatide (bone building)
Romosozumab (bone building)
Parathyroid Hormone Receptor Agonists
Teriparatide (Fortet)
Abaloparatide (Tymlos)
both indicated in men and women
Both subQ but different dosages in each pen
Tymlos < $$ than Fortet
How long can use use Parathyroid Hormone Receptor Agonists
> 2yrs for Forteo, expanded
Tymlos = < 2yrs, no studies beyond that
CI of Parathyroid Hormone Receptor Agonists
Hypercalcemia
Hyperparathyroidism
H/o bone cancer or metastases
** Warning = avoid use in pts with inc risk of osteosarcoma **
Adverse effects of Parathyroid Hormone Receptor Agonists
Generally well tolerated
Muscle cramps (legs)
Dizziness
Arthralgias
Headache
Inc Uric Acid
Hypotension/Tachycardia w/ 1st few doses ** = sit when given and dont stand
What happens if use Bisphosphonate 1st before Parathyroid Hormone Receptor Agonists?
Might have a blunted effect and not as good of an response
Loss of Hip BMD if use after Denosumab
Sclerostin inhibitor
Romosozumab aqqg (event)
indicated women only who are at high risk and failed other therapies
Evenity Dosing
Req 2 injections once a month
Evenity CI
Stroke/MI in past year
Hypocalcemia
SE of Evenity
** Inc risk of MACE, MI/stroke/death **
Atypical femur fracture
Hypersensitivity reactions
Osteonecrosis of the jaw
Calcitonin info
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
