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Spring Pharm Block 4 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

How is osteoporosis defined clinically?

A

Low bone mass defined by distance from standard deviation on DEXA score

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2
Q

Differentiate osteoblasts from osteoclasts.

A

Osteoblasts: build bone
Osteoclasts: break down bone

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3
Q

What is the biggest risk factor for osteoporosis?

A

Estrogen deficiency, particularly after menopause

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4
Q

T/F: Women over the age of 65 lose bone mass at a faster rate than males of the same age.

A

False: but women have lower bone mass to start with, so they are at greater risk

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5
Q

List 8 risk factors for developing osteoporosis.

A

Advancing age, poor calcium and vitamin D intake, glucocorticoid therapy, low body weight, smoking, excessive alcohol, sedentary lifestyle, overuse of aluminum containing antacids.

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6
Q

How much of a steroid dose is needed to decrease bone mass?

A

Daily dose of 5mg of prednisone (or equivalent) for 3 or more months

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7
Q

List some non-pharmacologic interventions indicated for osteoporosis patients.

A

Smoke and alcohol cessation, fall prevention, regular weight bearing exercise, adequate intake of calcium and vitamin D

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8
Q

Describe the three salt forms of calcium in terms of the elemental calcium each form delivers.

A

Ca carbonate: delivers 40% elemental calcium
Ca citrate: delivers 24% elemental calcium
Ca gluconate: minimal elemental calcium

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9
Q

What patients should avoid taking calcium carbonate and why?

A

Patients taking PPIs or H2RAs –> calcium carbonate requires acid to be absorbed

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10
Q

What are the AEs of calcium supplementation?

A

GI effects - constipation, nausea, gas, etc.
Hypercalcemia - especially when combined with a thiazide
Hypophosphatemia - calcium binds phosphate
Kidney stones (hypercalciuria)
Chelator (Ca carbonate) - binds quinolones, tetracyclines, bisphosphonates

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11
Q

Describe the mechanism of action of vitamin D supplementation as it relates to osteoporosis.

A

Vitamin D is required for the intestinal absorption of calcium

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12
Q

List and describe the three forms by which vitamin D is available.

A

Ergocalciferol (D2): requires 1-alpha-hydroxylation in kidneys to convert to active form
Cholecalciferol (D3): also requires 1-alpha-hydroxylation and is naturally formed in the skin via sunlight
Calcitriol (1,25(OH)D3): does not require 1-alpha-hydroxylation –> best for CKD patients

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13
Q

T/F: Vitamin D is a fat soluble vitamin that is absorbed in the stomach.

A

False: Fat soluble but it is absorbed in the intestines

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14
Q

T/F: All vitamin D supplement forms are available OTC.

A

False: higher strength vitamin D is available by prescription only and may be available by injection

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15
Q

What is the mainstay of osteoporosis therapy?

A

Bisphosphonates

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16
Q

What are the indications (including off-label uses) for bisphosphonate use?

A

Osteoporosis, Paget’s Disease, bone metastases

Off-label: decreased bone mineral density from IBD, hypercalcemia of malignancy

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17
Q

Describe the mechanism of action of bisphosphonates.

A

Incorporated into bone in areas of active bone remodeling. There they decrease activity of osteoclasts allowing osteoblast activity to prevail

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18
Q

Describe the duration of activity of bisphosphonates.

A

Long duration because they are incorporated in the bone matrix.

19
Q

Name and describe the first bisphosphonate.

A

Alendronate: first and least expensive, many dosing options (qd tablet, qw tablet, liquid)

20
Q

Describe the 30 minute rule of bisphosphonates and describe how Ibandronate is different.

A

Patients must take most bisphosphonates 30 minutes before eating and remain standing for 30 minutes after to allow the drug to travel easily down the esophagus and into the stomach –> risk for esophageal ulcers. Ibandronate requires 60 minutes standing.

21
Q

T/F: Ibandronate is only available as a PO tablet.

A

False: It is also available IV

22
Q

What is unique about the administration of Risedronate?

A

Must be taken with water immediately AFTER breakfast

23
Q

Describe the administration of Zoledronic Acid.

A

It is administered IV once per year.

24
Q

List the disadvantages of Zoledronic Acid.

A

Expensive, may cause nephrotoxicity and infusion reactions.

25
Q

What are 5 precautions associated with all bisphosphonates?

A

GI issues - N/V/D, constipation, abdominal pain
Flu-like symptoms - HA, fever
Arthralgia, myalgia, bone pain
Hypocalcemia
Osteonecrosis of jaw - caution in patients with poor oral hygiene

26
Q

What are the contraindications of bisphosphonate use?

A

GI ulcers and erosions, esophagitis, pharyngitis, esophageal cancer, delayed gastric emptying

27
Q

What is the primary reason people are unable to tolerate bisphosphonates?

A

GI upset

28
Q

Describe the mechanism of action of selective estrogen receptor modulators (SERM).

A

Agonize estrogen receptors on bone but antagonize estrogen receptors on uterine and breast tissue

29
Q

What is the broad-view explanation as to why agonizing estrogen in bone helps osteoporosis?

A

Estrogen decreases osteoclast activity

30
Q

Name and give the indications for the one SERM discussed in class.

A

Raloxifene - postmenopausal osteoporosis, prevention of estrogen receptor positive breast cancer in post menopausal women.

31
Q

What affect do SERM medications have on lipids?

A

Decrease LDL, but no effect on HDL or triglycerides

32
Q

What are the AEs of SERMs?

A

Decrease bone density in premenopausal women
Vasomotor symptoms –> hot flashes
Leg cramping
Use caution in patients with impending prolonged immobilization
Contraindicated in pregnancy
May decrease INR (blood clots faster) in patients taking warfarin

33
Q

What is the black box warning for SERMs?

A

Increased risk of venous thromboembolism

34
Q

What are the two ways by which calcitonin may be administered?

A

Intranasal or injection –> calcitonin is not hot

35
Q

When is estrogen replacement therapy indicated for postmenopausal women and why?

A

Only when they have severe vasomotor symptoms –> not used as much anymore s/p increased risk of clots

36
Q

What are the three black box warnings for estrogen replacement therapy?

A

Increased risk of endometrial and other uterine/ovarian cancers
Increased risk of breast cancer
Increased risk of venous thromboembolism

37
Q

Describe the use of parathyroid hormone (PTH) for osteoporosis.

A

Not hot –> patients on PTH have issues

38
Q

How is PTH administered?

A

Subcutaneous injection

39
Q

Describe the mechanism of action of RANK-L inhibitors.

A

RANK binding to RANK-L receptors activates osteoclasts. Blocking RANK-L decreases bone breakdown.

40
Q

Name the one RANK-L medication and state what kind of drug it is.

A

Denosumab - monoclonal antibody

41
Q

How is denosumab administered?

A

Subcutaneous injection every 6 months.

42
Q

What are the common AEs of denosumab?

A

GI effects, limb/back pain, fatigue, osteonecrosis of the jaw, increased risk of infections in certain cancers

43
Q

What blood lab must be obtained before administering denosumab?

A

Serum calcium - calcium must be normal before administering denosumab

44
Q

Summarize the second-line options to consider in patients unable to tolerate a bisphosphonate?

A

IV zoledronic acid is first line in patients unable to take bisphosphonates
SERMs in postmenopausal women
Denosumab subcutaneous injection

Spring Pharm Block 4 (17 decks)

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