Osteoporosis Flashcards
BMD alone is___
considered a risk factor
Clinical indication alone is limied
Which anti resorptive agent is weak?
Etidronate, not considered first line
Reassess fracture risk after____
3 (IV) or 5 years (PO) of bisphosphonate therapy
Consider extending if still high risk, longest duration of therapy studied is 10 years
When is bisphosphonate therapy best started?
Based on limited data, 2-12 weeks after fracture repair
Vertebral fractures risk _____ within the first year of tx, and non vertebral fracture risk _______ 3 years
1: decreases
2: decrease may take up to
Non pharm for osteoporosis
For prevention: diet (ca, vitamin D, protein), body weight (>20 bmi), limit caffeine and alcohol, smoking cessation, oral hygeine, fall prevention, exercise
Osteoporosis screening
Screen all those >65(F), >70(M), with 1 risk factor using a BMD test
Risk factors for Osteoporosis
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.
Risk factor tools
FRAX and CAROC
Initiate therapy at mod-high risk
When D/C denosumab,
initiate alternative within 6 months of last dose
Bisphosphonate drugs
Alendronate, risedronate, Zoledronic acid (IV)
Bisphosphonate MOA
binds to hydroxyapatite, increases osteoclast apoptosis, which decreases bone resorption and increases BMD
1st line
Bisphosphonate counselling tip
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
Bisphosphonate A/E
upper GI sx (ab pain, N/V, dyspepsia, flatulence), MSK pain (cramps, myalgia), headache
Rare: eosophagitis, GI ulcers, atypical femur fracture
Bisphosphonate CI
CrCl <30 (Risedronate), <35 (alendronate), inability to sit/stand for >30 minutes, esophageal abnormalities, uncorrected Ca
Bisphosphonate DI
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
RANKL inhibitor MOA
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
Denosumab A/E
Flatulence, nausea, decrease Ca, injection site rxn, limb pain, eczema, rash, cellulitis
Rare: ONJ, atypical femur fracture
Denosumab CI
CrCl <15mL/min, uncorrected Ca
Denosumab DI
immunosuppressants (increased risk of infections)
Bisphosphonates vs Denosumab
No difference in hip, non vertebral, and vertebral fractures
SERM MOA
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
SERM A/E
Raloxifene A/E: vasodilation (hot flashes), leg cramps, peripheral edema, flu like sx
Rare: VTE/PE, DVT risk similar to estrogen, fatal stroke
Serm CI
pregnancy, active or past VTE, >65 yr due to stroke/VTE risk
SERM DI
cholestyramine (decreases raloxifene), levothyroxine (space 12 hr), warfarin (decreases INR
PTH analogue MOA
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
Teriparatide (PTH) A/E
Upper GI, HA, dizziness, palpitations, leg cramps, arthalgia, injection site erythema, hypotension, increased Ca
Rare: hypotension, ?osteosarcoma
Teriparatide CI
Pre-existing Ca increase, CrCl <30mL/min, metabolic bone dx (pagets, hyperthyroidism), increased alk phos, pregnancy, nursing
Teriparatide DI
Digoxin (increases digoxin level from increased Ca)
Max 500mg Ca a day
Estrogen therapy
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
Calcium and Vitamin D
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
