Med classes Bones- Quiz 1 Flashcards by Britney Hanley

Osteoporosis vs. Osteomalacia vs. Paget’s Disease

Osteoporosis: progressive loss of bone mass and skeletal fragility
(Loss of architecture)
-Most common postmenopausal women, older men and as a medication side effect like glucocorticoids, anti-seizure & blood thinners. Diseases: hyperthyroidism

Osteomalacia: Soft bone, architecture intact but strength impaired. Most common cause Vit D deficiency. RIKETS in kids.

Paget’s Disease: Disorganized bone formation. Usually limited to one or a few bones (skull & upper extremities common).

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Type 1 Osteoporosis

-Bone resorption exceeds formation, formation is NORMAL

-Post Menopausal women (most common)

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Type II Osteoporosis

Mechanism
Population
Associated factors
Treatment

-Bone FORMATION is SLOWED

-Older men & women starting at 80

-WHo gets: Hyperthyroid, CKD, Steroids Antiseizure meds, blood thinners, PPI

-Treated the same as primary.

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Drugs that cause bone loss?

-Aluminum Antacids
-Anticonvulsants (less formation)
-Antipsychotics (less formation)
-Aromatase Inhibitors
-Lasix (high dose)
-Glucocorticoids (>30 days of 20mg or more will cause osteoporosis for everyone)
-Heparin (decreased growth)
-Provera (increased resorption)
-SSRI (decreased growth)
-Actos (decreased growth)
-Levothyroxine (excess doses)

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Primary Osteoporosis therapies

-Ca & Vit D
-Weight bearing exercise
-No smoking or ETOH
-Avoid drugs that increase bone loss

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What test do you need to order if your patient has to be on bone decreasing medications?

DEXA scan

Baseline & Yearly while still taking the medication

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What does a DEXA scan do?

Compares bone thickness to a 35 yo adult of the same gender, with similar height and weight for adults.

Kids compared to same age control

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How is a DEXA scan scored? At what score do you treat?

Adults T score

Kids Z score

Score -2.5 (=2.5 standard deviations away from normal which defines osteoporosis)

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What is another assessment for fracture risk?
Who is a good candidate for this tool?

FRAX

Older adult, especially one who’s been identified as having osteopenia

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All medications to treat osteoporosis are anti-resorptive except one, which one? How does it work?

Teriparatide (Forteo)- stimulates osteoblasts to create more bone… Is synthetic parathyroid hormone

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What is the biggest problem with the use of anti-resorptive meds?

Make the bone VERY hard causing them to be brittle and fracture.

Should only be used for <3 years!

Problematic if the patient needs tooth extractions, dental implants, or bone grafts.

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Bisphosphonates
MOA & Indication

-Anti-resorptive (slows bone breakdown) slows the osteoclast resorption of bone IF the patient has normal bone growth (less than 80 and not taking any drugs) they will get a net gain in bone.

-Rapidly cleared from plasma bound to hydroxyapalite in bone. Cleared over months to years renally.

-Prevention or treatment of osteoporosis of hip and spine

Suffix -dronate

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Bisphosphonates
Labs/Diagnostics

Creatinine (needs CrCl >30mL/min)

Blood calcium

DEXA baseline

Suffix -dronate

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Bisphosphonates
Follow up labs/diagnostics

CrCl
Ca
Vit D
DEXA Q 1-2yrs

Suffix -dronate

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Bisphosphonates

Blackbox warnings & Contraindications

Black box:
Atypical femur fracture, Osteonecrosis of jaw (high doses over long periods)

DRUG HOLIDAY around 3 yrs-5 yrs depending on the route of administration

-CrCl <30mL/min
-Hypocalcemia
-Esophageal disorders (if oral)
-Patients who can’t sit or stand for at least 30-60 minutes
-Low Vit D

-Caution with pregnancy

Suffix -dronate

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Bisphosphonates

Adverse drug effects & Common side effects

ADE: Diarrhea abdominal and musculoskeletal pain, atypical femur fracture, osteonecrosis of the jaw

Common: Diarrhea, abdominal pain, musculoskeletal pain

Suffix -dronate

Bisphosphonates

Specific education, counseling & follow up

-Oral version
–Take with a full glass of WATER only for 30 minutes.
-Sit or stand for at least 30-60 minutes after taking in AM BEFORE breakfast and at least 2 hrs before vitamins. Absorption can be significantly effected with food or other meds.
-Increased risk of ADE with dental extractions/implants, ETOH, smoking, glucocorticoid use and diabetes
-Should have regular dental check ups (esp if at risk for osteonecrosis of jaw)

Follow Up:
-Initiation 4-6 wks after
-Maintenance: 6-12 months

Bisphosphonates

Drug-drug & drug-food interactions

Decreased absorption of bisphosphonates with:
-PPI
-Ca/Mg/Fe/Al

Risk of ADE:
-NSAIDS
-Aminoglycosides
-Corticosteroids
-Any nephrotoxic medication

Should be taken on empty stomach with water only. NPO or water only for at least 30 min. 2hrs better for food, vitamins or other meds to prevent decreased absorption.

Suffix -dronate

Bisphosphonates

Lifespan considerations

Children: rarely used, corticosteroids

Adults: endocrine disorders, corticosteroids, cancer

Older Adults: Target demographic

Suffix -dronate

Alendronate (Fosamax or Binosto)

Bisphosphonate PROTOTYPE DRUG

-PO
-Daily or weekly
-Worst GI profile
-Binosto- effervescent tablet

Suffix -dronate

Risedronate (Actonel or Atelvia)

Bisphosphonate

-PO
-Weekly or monthly

Ibandronate (Boniva)

Class
Population

Bisphosphonate

-PO or IVP
-Monthly or quarterly
-Only approved for spinal osteoporosis

Way to remember
I band ronate
I band the spine

Zoledronic acid (Reclast or Zometa)

Bisphosphonate

-IV infusion only
-Yearly

Selective Estrogen Receptor Modulator (SERM)

MOA & Indication

Group suffix

MOA: estrogen like effects on bone and estrogen antagonistic effects on breast and endometrium, also lowers LDL cholesterol

Indication: Post menopausal, can’t take bisphosphonates, <75 with uterus

Suffix -ifene

Selective Estrogen Receptor Modulator (SERM) Labs/diagnostics & Follow up labs/diagnostics

-Liver & kidney function -DEXA baseline & follow up -Protein C, S, or antithrombin (can't have deficiency or Hx of DVT/PE) -Ca & Vit D -Pregnancy (can't take if pregnant) Suffix -ifene

Selective Estrogen Receptor Modulator (SERM) Black Box & Contraindications

Black Box: Raloxifene: Risk of VTE and stroke-related death. Contraindications: -Coagulopathy -Decreased liver or kidney function -Hx DVT/PE/Stroke -Low Ca or Vit D -Pregnancy Suffix -ifene

Selective Estrogen Receptor Modulator (SERM) Specific Education

What the symptoms of Stroke and DVT Suffix -ifene

What are the SERMS?

Raloxifene (Evista) Duavee (estrogen + bazedoxifene) Suffix -ifene

Selective Estrogen Receptor Modulator (SERM) Adverse /Common effects

Thromboembolism

Raloxifene (Evista)

SERM Conjugated estrogen + bazedoxifene PO * It has estrogen like effects on bone and estrogen antagonistic effects on breast and endometrium * This agent also lowers LDL cholesterol *Contraindicated in women with prior history of thromboembolic disease [DVT, stroke, etc.] *Main SIDE EFFECT—hot flashes (estrogen antagonist)

Duavee (estrogen bazedoxifene) Route Target population Specific contraindications Side effects Precautions

[conjugated estrogen + bazedoxifene] *PO daily *Approved for vasomotor sx of menopause and osteoporosis prevention *Estrogen + SERM—CAN'T be used in those with intact uterus; hx of breast, endometrial, ovarian cancers *ADE—thromboembolism *Same precautions as for estrogens & Evista

Miacalcin (Calcitonin) MOA Population Route ADE

*Another anti-resorptive agent *Can be used for acute pain after a fracture *Approved to treat osteoporosis in women who are at least 5 year postmenopausal *Can be used in patients with vertebral osteoporosis – not effective for hip disease *Nasal spray used every day [alternate nostrils] *ADE—nosebleeds and rhinitis

Teriparatide (Forteo) MOA Population Use note Contraindication

Only agent that will build bone by stimulating OSTEOBLASTS *Approved for men and women with severe disease or those in need of treatment that cannot take the other agents * SC injection daily for 2 years; then off – best option is to follow this therapy with bisphosphonate or Prolia [so patient will not lose new bone that they have built] *Contraindicated in patients who have had skeletal radiation Triceratops

Denosumab (Prolia) MOA Population ADE

-Receptor activator of nuclear factor kappa B [RANK] ligand inhibitor * Indicated for post-menopausal women with osteoporosis at high risk for fracture or patients who have failed/cannot tolerant other available therapies * In post-menopausal women agent reduces the incidence of vertebral, non-vertebral, and hip fractures * SQ injection twice per year * Targeted for women and men with RENAL INSUFFICIENCY *ADE—dermatological reactions, hypocalcemia

Osteomalacia Causes Labs Treatment

Causes: -Vit D deficiency (most common) -Deficiency of Ca, PO4 -Tumor induced -Long term Vit D deficiency can develop secondary hyperparathyroid that reverses with Vit D replacement Labs: -Vit D in ALL patients with renal disease, Hypercalcemia and osteoporosis. -Normal 25 Vit D 20-80 though accepted minimum is actually 40 to ensure normal parathyroid function Treatment: -OTC Vit D3 start with 800IU/day + 25-30 minutes of AM sun exposure without sunscreen 5-6 days/week

If patient's serum 25 vit D level is <10mm/L how do you treat? Follow up?

Rx vit D-> Calcitriol 0.5mcg (aka Vit D3) weekly, biweekly or daily until within acceptable range -Plant based Inactive form- VitD2 50,000 units per day/week/month until dose is acceptable -May be able to decrease to OTC replacement after goal labs achieved, but keep monitoring REMEMBER: -Also be checking Ca, PO4 and Vit D levels frequently

What is Paget's Disease pathology? Symptoms?

Disorder of bone remodeling leading to disorganized bone formation—usually limited to one or a few bones—SKULL, upper extremity involvement common *Patient’s with Paget’s disease will have bone pain, deformities and/or fractures *Alkaline phosphatase is elevated, as is urine and serum pyridinoline and hydroxyproline

What is the primary treatment for Paget's Disease? 2nd Line?

High Dose Bisphosphonates 2nd: Calcitonin (only if bisphosphonates are contraindicated)