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Pharm Spring 2023 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What is osteoporosis

A
  1. Low bone density + impaired bone structure
  2. Primarily effects females >50 years old and increasing with age
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2
Q

What is a T-score

A
  1. Measured bone mineral density to average peal BMD of health, young adult of same sex and ethnicity
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3
Q

What do the T-scores represent

A

DEXA will be used to measure BMD
1. Negative at or above -1 = denser bones
2. Normal > or equal to 1
3. Osteopenia = -1 to 2.4
4. Osteoporosis = <-2.5

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4
Q

What is FRAX

A

Fracture Risk Assessment Tool (FRAX)
1. Estimates osteoporotic fracture risk in the next 10 years
*plus other major bones

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5
Q

What are the medications that can worsen osteoporosis

A
  1. Anticonvulsants
  2. Select antiretroviral therapy
  3. Canagliflozin *
  4. Heparin
  5. Glucocorticoids
  6. Furosemide
  7. Lithium
  8. Depo medroxyprogesterone
  9. Proton pump inhibitors
  10. SSRIs
  11. Excessive thyroid supplementation*
  12. Thizaolindinediones *
    *key offenders
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6
Q

What is the etiology of osteoporosis

A
  1. Genetics
  2. Diet
  3. Lifestyle
  4. Hormonal
  5. Aging
    Will cause bone loss, then impaired bone quality and decreased bone density which leads to low trauma fractures
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7
Q

What are osteoblasts and osteoclasts

A

blasts = bone formation
Clasts = bone resorption

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8
Q

How is OPG (osteoprotegrin) related to osteoporosis

A
  1. OPG is stimulated by estrogen and inhibits RANKL
    *RANKL is needed for osteoclast maturation
  2. Estrogen is decreased in menopause
    *which leads to a decrease of osteoclast formation and osteoporosis
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9
Q

What is WNT and Sclerostin

A

WNT (lipid modified glycoprotein)
1. Regulates proliferation and differentiation of stem cells
2. WNT is stimulated by PTH which signals to increase osteoblasts and bone build up
Sclerostin
1. Produced in osteocytes to stop bone formation

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10
Q

What is the influence of estrogen on osteoporosis

A
  1. Suppresses the proliferation and differentiation of osteoclasts
    *will inhibit the breakdown of bone increase OPG
  2. Increase osteoclast apoptosis
  3. Decrease production of RANKL
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11
Q

What is the influence of testosterone on osteoporosis

A
  1. Affects bone resorption
  2. Increases osteoblast differentiation and proliferation
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12
Q

What effects does estrogen have on osteoblasts and osteoclasts

A

Blasts
1. Decrease apoptosis
2. Decrease oxidative stress
*will have maintenance of bone formation
Clasts
1. Increase in apoptosis
2. Decrease RANKL
*decrease bone resorption

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13
Q

What is the pathophysiology of osteoporosis

A

Ages 30-45
1. Men and women lose bone at a similar rate
Post-menopause
1. Bone loss is accelerated due to decrease in estrogen

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14
Q

What happens when calcium levels are not maintained

A
  1. When increased calcium absorption / reabsorption is not enough to maintain adequate calcium levels = bone resorption
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15
Q

What is the diagnosis criteria for osteoporosis

A
  1. Previous Low trauma fracture
    *hip or spine regardless of BMD
  2. T-score at or below -2.5
  3. T-score between -1 and -2.5 with fragility fracture
  4. T-score between -1 and -2.5 with high FRAX probability
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16
Q

What is the most appropriate prevention therapy for osteoporosis (Younger, health postmenopausal women)

A
  1. Estrogen alone (if no uterus)
    *bisphosphonate (used if estrogen is CI)
    *Raloxifene (for postemenopausal women with an elevated risk of breast cancer)
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17
Q

What are bisphosphonates used for

A
  1. To prevent bone loss
  2. For women with low BMD scores <-1
  3. Used for who do not meet criteria for osteoporosis treatment
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18
Q

When are medication recommend to prevent bone loss in postmenopausal women

A
  1. Premature menopause
  2. Low BMD (T-score <1.0)
  3. Low BMD score and other risk factors for fracture
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19
Q

What is the primary goal of prevention of osteoporosis

A
  1. Optimize calcium and vitamin D intake
  2. Regular exercise
  3. Ensure proper body weight
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20
Q

When should osteoporosis treatment be considered

A

Postmenopausal women/men aged 50 or older with
1. Hip or vertebral fracture
2. Central DXA t-score of -2.5 or lower
3. Osteopenia with a 10 year FRAX of 3% or more
4. Osteopenia with a 10 year FRAX of any major osteoporitc related fracture of 20% or more

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21
Q

What are some non pharmacological treatments of osteoporosis

A
  1. Adequate calcium and vitamin D
  2. Reduce alcohol
  3. Reduce caffeine
  4. Smoking cessation
  5. Weight bearing exercise
  6. Fall prevention
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22
Q

What are the first line agents of osteoporosis treatment

A

Always take with vitamin D and calcium
Bisphosphonates
1. Alendronate (fosamax)
2. Risedronate (Actonel)
3. Zoledronic acid
Denosumab

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23
Q

What are some alternative therapies for osteoporosis

A
  1. Raloxifene
  2. Ibandronate
  3. Teriparatide
  4. Abaloparatide
  5. Romosozumab
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24
Q

What are the ADRs and drug interactions of calcium supplementation

A

ADRS
1. Constipation
2. Kidney stones
Drug interactions
1. PPIs may decrease absorption
2. Calcium can decrease absorption of many medications

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25
Q

What is the recommend doses for calcium supplementation

A
  1. Should not exceed 500 to 600 mg (BID) of elemental calcium
    *total 1,200mg elemental calcium per day (post-menopausal women)
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26
Q

What is the dosing recommendation and drug interactions of vitamin D

A

Dose = 1,000 units
Drug interactions
1. Can increase absorption of aluminum

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27
Q

What is the MOA of Bisphosphonates (oral)

A

Inhibits osteoclasts activity and bone resorption

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28
Q

What are the dosing schedule of bisphosphonates (oral)

A

Dosing varies if prevention, treatment or glucocorticoid induced OP
1. Alendronate (fosamax)
*daily but varies if female is taking estrogen
*combination with cholecalciferol available
2. Risedronate (actonel)
*daily, weekly, monthly
3. Ibandronate (boniva)
*monthly, only decreases vertebral fx

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29
Q

What are the CI OF oral bisphosphonates

A
  1. Hypocalacemia
  2. Inability to stay or sit upright for at least 30 minutes
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30
Q

What are the warnings of oral bisphosphonates

A
  1. Jaw osteonecrosis
  2. Atypical femur fx
  3. Esophagitis, esophageal ulcers, erosions, perforation
  4. Hypocalcemia
  5. Renal impairment
31
Q

What are the AE of oral bisphosphonates

A
  1. Dyspepsia
  2. Dysphagia
  3. Heartburn
  4. N/v
  5. Hypocalcemia
32
Q

What is the correlation between oral bisphosphonates and bioavailability

A
  1. Not absorbed very well
    *should not be administered with other meds
  2. Will have decrease GI SE
33
Q

How should someone take an oral bisphosphonates

A
  1. Take with 6 ounces of plain water
  2. Wait 30 minutes before eating or drinking anything else
  3. Patient should remain upright or standing for 30 minutes
    *if missed dose can take next day
34
Q

What are some things to keep in mind with the oral bisphosphonates

A
  1. Check calcium and vitamin D prior
  2. Dental work should be done prior to start
  3. Caution with sodium restriction
  4. Delayed release (Risedronate) requires acidic gut for absorption
    *do not use W/H2RAs or PPIs
35
Q

What is the MOA of injectable bisphosphonates

A

Inhibit osteoclast activity and bone resorption

36
Q

What is the dosing schedule of Ibandronate and zoledronic acid (Injectable Bisphosphonates)

A

Ibandronate
1. Treatment = 3mg IV every 3 months
Zoledronic acid
1. Prevention = 5mg IV every 2 years
2. Treatment = 5 mg IV once yearly
3. Glucocorticoid induced osteoporosis = 5 g IV once yearly over >15 mins

37
Q

What are the CI of injectable bisphosphonates

A

Hypocalcemia
1. Zoledronic acid = CrCl<35mL/min or acute renal impairment

38
Q

What are the warnings of injectable bisphosphonates

A
  1. Same as oral (no GI problems)
  2. Renal impairment
  3. Ibandronate = do not use if CrCL <30 mL/min
  4. Zoledronic acid = use cation in aspirin sensitive asthma
39
Q

What are the AE of injectable bisphosphonates

A
  1. Same as orals (no esophageal problems)
  2. Acute phase reactions (flu -like sx)
  3. Zoledronic acid = edema, hypotension, fatigue, dehydration
    *injectables are preferred if esophagitis is present
40
Q

What is the MOA of denosumab (prolia)

A
  1. Monoclonal antibody that binds to RANKLand block interaction with RANK to prevent osteoclasts formation
    *Causes decrease in bone resorption and increase in bone mass
41
Q

What is the dosing and CI of denosumab

A

Dose = 60 mg SC every 6 months
CI = hypocalcemia, pregnancy

42
Q

What are the warnings of Denosumab (Prolia)

A

Warnings
1. Osteonecrosis of the jaw
2. Atypical femur fx
3. Hypocalcemia
4. Infections

43
Q

What are the AE of Denosumab

A
  1. HTN
  2. Fatigue
  3. Edema
  4. Dyspnea
  5. Headache
  6. N/V/D
  7. Decreased PO3
44
Q

What are some pearls of denosumab

A
  1. If discontinued, bone loss can be rapid $$$
45
Q

What is the MOA of selective estrogen receptor modulators (SERM) Raloxifene

A
  1. Decrease bone resorption by activating OPG
    *estrogen agonist at bone receptors and antagonist at breast receptors leading to breast cancer preventive properties
46
Q

What is the dosing and BBW of SERMS Raloxifene

A

Dosing = 60 mg PO daily
BBW
1. Increased risk of VTE
2. Increased risk of death due to stroke

47
Q

What are the CI of SERMS Raloxifene

A

History or current VTE
Pregnancy

48
Q

What are the AE of SERMS Raloxifene

A
  1. Hot flashes
  2. Peripheral edema
  3. Arthralgia
  4. Leg cramps
  5. Flu sx
  6. Blood clots
49
Q

What are some pearls of SERMS Raloxifene

A
  1. Separate from levothyroxine by several hours
  2. Discontinue 72 hours prior to and during prolonged immobilization
50
Q

What is the MOA of equine (horse) estrogen SERM combination (Duavee)

A

Decreases bone resorption

51
Q

What is the dose and BBW of equine (horse) estrogen / SERM combination (Duavee)

A

Dosing = prevention in postmenopausal women with uterus, 1 tab 0.45/20 mg PO daily
BBW
1. Endometrial cancer
2. Increase risk of CVT and stroke
3. Dementia

52
Q

What are the CI of equine (horse) estrogen / SERM combination (Duavee)

A
  1. Breast cancer
  2. Pregnancy
  3. Undiagnosed uterine bleeding
  4. MI or stroke
53
Q

What are the warnings of equine (horse) estrogen / SERM combination (Duavee)

A
  1. Increase risk f breast and ovarian cancer
  2. Increase risk of retinal vascular thrombosis
  3. Lipid effects
54
Q

What are the AE of equine (horse) estrogen / SERM combination (Duavee)

A
  1. Nausea
  2. Diarrhea
  3. Abdominal pain
  4. Muscle spams
55
Q

What are some pearls of equine (horse) estrogen / SERM combination (Duavee)

A
  1. Lowest effective dose for the sorted duration possible
    *not recommended for women >75 years old
    *do not use to prevent CVD
56
Q

What is the MOA of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A

Stimulates osteoblast activity and increases bone formation

57
Q

What is the dosing of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A

Cumulative lifetime duration < 2 years
1. For postemenopausal and glucocorticoid induced = forteo 20mg daily
2. Postemenopausal = tymlos 80 mcg sc daily
*also use anti-resorption agent (bishophasphonnate)

58
Q

What are the BBW of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A
  1. Osteosarcoma (bone cancer)
59
Q

What are the warnings of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A

Hypercalcemia
1. Orthostatic hypotension
2. Caution with urinary stones
43. Avoid in bone malignancy

60
Q

What are the AE of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A
  1. Arthralgias
  2. Leg cramps
  3. Nausea
  4. Orthostasis / dizziness
61
Q

What are the pearls of PTH analogs (teriparatide / forteo, abaloparatide / Tymlos)

A

Keep refrigerated
Forteo protect from light

62
Q

What is the MOA of Romosuzumab (evenity)

A

Inhibits Sclerostin
*protein that blocks bone formation

63
Q

What is the dosing and BBW of Romosuzumab (evenity)

A

Dosing = 210 mg sc (two separate injections) once monthly
*duration is limited to 12 months bc OF
BBW
1. Increased risk of MI, stroke, cardiovascular death

64
Q

What are the CI, AE, and pearls of Romosuzumab (evenity)

A

CI = Hypocalcemia
AE = arthralgia, headache, injection site reaction
Pearls = keep refrigerated

65
Q

What is the MOA of calcitonin (miaclacin)

A
  1. Inhibits bone resorption by osteoclasts
66
Q

What is the dousing and warnings of calcitonin (miaclacin)

A

Dosing
1. One spray in one nostril daily
2. Injection 100 units daily
Warnings
1. Hypocalcemia
2. Increased risk of malignancy w/long term use
3. Hypersensitivity reaction to salmon derived products

67
Q

What are the AE and pearls of calcitonin (miaclacin)

A

AE
1. Back pain
2. Myalgia
Pearls
1. Less effective than other options
2. Long-term risk of cancer increases

68
Q

What are the aniremodeling drug (prevent breakdown /metabolism)

A
  1. Bisphosphonates
  2. Denosumab
  3. Raloxifene
  4. calcitonin
69
Q

What are the osteoanabolcic drugs (promote build up of bones)

A
  1. PTH analogs
  2. Romosuzumab
70
Q

What are the effects of parathyroid hormone (PTH) on calcium

A
  1. When the parathyroid gland detects low calcium
    *PTH production increases which causes
    *calcium reabsorption from the kidneys
71
Q

What are the oral bisphosphonates

A
  1. Alendronate (Fosamax)
  2. Risedronate (Actonel)
  3. Ibandronate (Boniva)
72
Q

What are the different injectable bisphosphonates

A
  1. Ibandronate (Bonvia)
  2. Zoledronic acid (Reclast)
73
Q

What is Raloxifene used for?

A

Prevention and treatment of osteoporosis

Pharm Spring 2023 (27 decks)

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