Module 8: Unic C OSA

Question 1

Example Bisphosphonates

Answer 1

-NATE
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)

zoledronic acid (Reclast)

Question 2

Indications:
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)
zoledronic acid (Reclast)

Answer 2

Prevention and treatment of osteoporosis in postmenopausal women
Treatment of osteoporosis in men
Prevention and treatment of glucocorticoid-induced osteoporosis (GIOP)

Question 3

MOA:
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)

zoledronic acid (Reclast)

Answer 3

They are absorbed and integrated into the bone, causing suppression of resorption of bone by inhibiting osteoclast activity (and ↓ # of osteoclasts). Recruits osteoblasts which in turn inhibit osteoclast formation.

Question 4

Contraindications for Biophosophonates (-NATEs)

Answer 4

Hypersensitivity; hypocalcemia; abnormalities of the esophagus which slow or obstruct emptying; inability to stand or sit upright for at least 30 minutes; ↑ risk of aspiration

Question 5

Adverse effects:
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)
zoledronic acid (Reclast)

Answer 5

Esophagitis, atypical femoral fractures, small risk of esophageal CA, MSK pain, ↑ increased risk (slight and rare) of ocular problems, osteonecrosis of jaw, afib

Question 6

Pt teaching with:
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)
zoledronic acid (Reclast)

Answer 6

Take oral bisphosphonates in the morning with water and wait at least 30 minutes after dosing to eat (60 m w/ibandronate). Remain upright (seated or standing) at least 30 minutes after taking.
(Atelvia, a delayed-release form of risedronate, is the exception as it SHOULD be taken with food)

Do not take any products with Ca, Fe, or Mg within two hours of oral bisphosphonates (antacids, mineral supplements, MVI)

Question 7

Monitoring with
alendronate (Fosamax)
ibandronate (Boniva)
risedronate (Actonel)
zoledronic acid (Reclast)

Answer 7

Obtain baseline DXA, accurate height (actually measured with a stadiometer), calcium, BMP or CMP (creatinine), and 25(OH)D.
Repeat DXA every 1-2 years. Monitor labs

Question 8

Examples Selective estrogen receptor modulators (SERMs)

Answer 8

raloxifene (Evista)

Question 9

Indication raloxifene (Evista)

Answer 9

Prevention and treatment of osteoporosis in postmenopausal women
Protection against estrogen receptor-positive breast CA

Question 10

MOA raloxifene (Evista)

Answer 10

Exerts agonist/antagonist estrogenic effects, acting as an estrogen agonist in the bone to prevent bone loss and antagonist activity to ↓ estrogen effects in the breast and uterine tissues.
↓ bone resorption, ↑ bone mineral density, and ↓ fracture incidence.

Question 11

Contraindications and SE/AE: raloxifene (Evista

Answer 11

Contraindications: Pregnancy, ↑ risk of fetal harm

↑ risk of thromboembolic events (DVT, PE, stroke)
weight gain
hot flashes

Question 12

BBW raloxifene (Evista

Answer 12

Increased risk of VTE:
Increased risk of DVT and PE have been reported with raloxifene. Women with an active or past history of VTE should not take raloxifene.
​
Cardiovascular disease:
Increased risk of death due to stroke occurred in a trial in postmenopausal women with documented coronary heart disease or increased risk for major coronary events. Consider the risk-benefit balance in women at risk for stroke.

Question 13

Special considerations raloxifene (Evista

Answer 13

D/c for at least 72 h before long periods of immobilization (surgery, bed rest, long-distance traveling)

Question 14

Monoclonal antibody/Rank ligand inhibitors

Question 15

Parathyroid hormone analogs examples

Answer 15

Teriparatide (Forteo)

Question 16

Indication Teriparatide (Forteo)

Answer 16

Treatment of osteoporosis in postmenopausal women
Treatment of osteoporosis in men
Treatment of glucocorticoid-induced osteoporosis (GIOP)

Question 17

MOA Teriparatide (Forteo)

Answer 17

As an analog of PTH, teriparatide simultaneously ↑ bone resorption by osteoclasts while ↑ bone deposition by osteoblasts. When given SQ, the transient elevation of PTH ↑ bone deposition by osteoblasts > osteoclast activity, leading to ↑ bone mass density
↑ GI tract Ca absorption and renal tubular reabsorption of Ca

Question 18

SE/AE Teriparatide (Forteo)

Answer 18

Nausea, HA, arthralgia, back pain, leg cramps, injection site discomfort, dizziness, postural hypotension (usually within 4 hours of dosing and improves after the first few doses)
Hypercalcemia
↑ risk of urolithiasis
↑ risk of cutaneous calcification

Question 19

BBW Teriparatide (Forteo)

Answer 19

Teriparatide has been associated with ↑ osteosarcoma in animal studies. (BBW for osteosarcoma was removed 11/20)

Question 20

Monitoring and supplements to take with Forteo

Answer 20

DXA
Vitamin D and calcium
CMP

take Vit D/Calcium

Question 21

Calcium Salts examples

Answer 21

Calcium acetate (Phoslo)
Calcium carbonate (Tums, Rolaids)
Calcium citrate (Citracal)

Question 22

Indication calcium salts

Answer 22

mild hypocalcemia

Question 23

MOA Calcium salts

Answer 23

Orally ingested calcium is absorbed from the intestineCalcium plays a vital role in our skeletal, nervous, muscular, and cardiovascular systems; however, 98% is stored in bones. Homeostatic mechanisms prioritize serum Ca levels via parathyroid (PTH) and thyroid (calcitonin) regulation.

Question 24

Safety/contraindications calcium salts

Answer 24

Contraindicated in hypercalcemia, renal calculi, and hypophosphatemia
Chronically high doses may cause hypercalcemia: nausea, vomiting, constipation, renal dysfunction, lethargy, and depression.

Question 25

D2D Calcium Salts

Answer 25

glucocorticoids ↓ absorption
Ca can ↓ absorption of levothyroxine, tetracyclines, quinolones, phenytoin, and bisphosphonates.
Thiazide diuretics ↑ Ca
Loop diuretics ↓ Ca
Oxalic acid (beets, spinach, greens, rhubarb) and phytic acid/ insoluble fiber (bran/whole grains) can ↓ absorption

Question 26

What calcium supplement is the most bio-available?

Answer 26

Calcium citrate

Question 27

What is a side effect of calcium carbonate?

Answer 27

Constipation

Question 28

Indication
ergocalciferol (aka vitamin D2)
cholecalciferol (vitamin D3)

Answer 28

In this context, vitamin D is essential for bone health
osteomalacia
vitamin D deficiency
hypoparathyroidism
rickets

Question 29

MOA vitamin D2/D3

Answer 29

Two forms, D2 and D3, which must undergo metabolic activation to active form. D3 is more effective in ↑ 25(OH)D (the metabolically active form of vitamin D) and thus preferred over D2.
Regulates homeostasis of calcium and phosphorus by ↑ serum level via ↑ absorption in the intestine, prompting resorption from bone, and ↓ renal excretion of Ca and phosphate. Note: vitamin D can ↑ bone decalcification when serum Ca concentrations are low.

Question 30

Safety Vitamin D

Answer 30

toxicity-hypervitaminosis
Symptoms of toxicity 2° to hypercalcemia
Large, sustained doses of vitamin D can cause decalcification of bone
Vitamin D poisoning can suppress growth in children