Osteoporosis

Question 1

BMD alone is___

Answer 1

considered a risk factor

Clinical indication alone is limied

Question 2

Which anti resorptive agent is weak?

Answer 2

Etidronate, not considered first line

Question 3

Reassess fracture risk after____

Answer 3

3 (IV) or 5 years (PO) of bisphosphonate therapy

Consider extending if still high risk, longest duration of therapy studied is 10 years

Question 4

When is bisphosphonate therapy best started?

Answer 4

Based on limited data, 2-12 weeks after fracture repair

Question 5

Vertebral fractures risk _____ within the first year of tx, and non vertebral fracture risk _______ 3 years

Answer 5

1: decreases
2: decrease may take up to

Question 6

Non pharm for osteoporosis

Answer 6

For prevention: diet (ca, vitamin D, protein), body weight (>20 bmi), limit caffeine and alcohol, smoking cessation, oral hygeine, fall prevention, exercise

Question 7

Osteoporosis screening

Answer 7

Screen all those >65(F), >70(M), with 1 risk factor using a BMD test

Question 8

Risk factors for Osteoporosis

Answer 8

Medical/family history: fragility fracture after age 40, osteopenia on xray, T1DM, malabsorption (IBD, DM, HIV, etc), early menopause, parental hip fracture
Medication history: corticosteroid use (prolonged), SSRIs, warfarin, PPIs, cyclosporine, antiepileptics
Lifestyle: smoker, alcohol, LBW, poor diet, fallen >2 times in past year, etc.

Question 9

Risk factor tools

Answer 9

FRAX and CAROC

Initiate therapy at mod-high risk

Question 10

When D/C denosumab,

Answer 10

initiate alternative within 6 months of last dose

Question 11

Bisphosphonate drugs

Answer 11

Alendronate, risedronate, Zoledronic acid (IV)

Question 12

Bisphosphonate MOA

Answer 12

binds to hydroxyapatite, increases osteoclast apoptosis, which decreases bone resorption and increases BMD
1st line

Question 13

Bisphosphonate counselling tip

Answer 13

Must take on empty stomach (>30 min prior to breakfast with a full glass of water and stay upright for 30 minutes)
F is decreased by >60% when taken with coffee of juice
Failure to do so can cause erosive esophagitis

Question 14

Bisphosphonate A/E

Answer 14

upper GI sx (ab pain, N/V, dyspepsia, flatulence), MSK pain (cramps, myalgia), headache
Rare: eosophagitis, GI ulcers, atypical femur fracture

Question 15

Bisphosphonate CI

Answer 15

CrCl <30 (Risedronate), <35 (alendronate), inability to sit/stand for >30 minutes, esophageal abnormalities, uncorrected Ca

Question 16

Bisphosphonate DI

Answer 16

Wait >30 min before other drugs
Decreases Bisphos absorption: Ca, mg, fe, al, PPIs, multivitamin (makes sense), bile acid sequestrants, orlistat, mineral oil, H2RAs, antacids

Question 17

RANKL inhibitor MOA

Answer 17

Anti resorptive too, (denosumab)
binds to RANKL which prevents osteoclast formation = decrease in bone resorption and increases BMD
1st line, intital or alternative esp if intolerant or CI to bisphos

Question 18

Denosumab A/E

Answer 18

Flatulence, nausea, decrease Ca, injection site rxn, limb pain, eczema, rash, cellulitis
Rare: ONJ, atypical femur fracture

Question 19

Denosumab CI

Answer 19

CrCl <15mL/min, uncorrected Ca

Question 20

Denosumab DI

Answer 20

immunosuppressants (increased risk of infections)

Question 21

Bisphosphonates vs Denosumab

Answer 21

No difference in hip, non vertebral, and vertebral fractures

Question 22

SERM MOA

Answer 22

binds to estrogen receptors which prevents osteoclast formation = decrease in bone resorption and increased BMD
anti-resorptive
1st line in females for prevention of vertebral fractures

Question 23

SERM A/E

Answer 23

Raloxifene A/E: vasodilation (hot flashes), leg cramps, peripheral edema, flu like sx
Rare: VTE/PE, DVT risk similar to estrogen, fatal stroke

Question 24

Serm CI

Answer 24

pregnancy, active or past VTE, >65 yr due to stroke/VTE risk

Question 25

SERM DI

Answer 25

cholestyramine (decreases raloxifene), levothyroxine (space 12 hr), warfarin (decreases INR

Question 26

PTH analogue MOA

Answer 26

Binds to RANKL which prevents osteoclast formation = decrease bone resorption and increases osteoblast activity
Anabolic
1st line for secondary prevention with severe OP, or alternative if CI for bisphos

Question 27

Teriparatide (PTH) A/E

Answer 27

Upper GI, HA, dizziness, palpitations, leg cramps, arthalgia, injection site erythema, hypotension, increased Ca
Rare: hypotension, ?osteosarcoma

Question 28

Teriparatide CI

Answer 28

Pre-existing Ca increase, CrCl <30mL/min, metabolic bone dx (pagets, hyperthyroidism), increased alk phos, pregnancy, nursing

Question 29

Teriparatide DI

Answer 29

Digoxin (increases digoxin level from increased Ca)

Max 500mg Ca a day

Question 30

Estrogen therapy

Answer 30

use for the dual management of menopausal symptoms and increased fracture risk in early menopausal women to prevent bone loss in those at high risk of fracture when alternate therapies are not appropriate

Question 31

Calcium and Vitamin D

Answer 31

As adjunctive therapy with antiresorptive or anabolic therapy to prevent bone loss Ca
Ca and Vit D supplementation alone is sufficient as the effectiveness on fracture prevention is uncertain
Encouraged as basic bone health for patients with low risk