Osteoporosis

Question 1

What are patient characteristics that are risks for osteoporosis?

Answer 1

Advacned age
Ethnicity (white or asian)
Family history
Sex (F > M)
Low body weight

Question 2

What are medical conditionals that make someone at risk for osteoporosis?

Answer 2

Diabetes
Eating disoreders
GI issues (malabsorption)
Hyperthroidism
Hypogonadism in men
MENOPAUSE!!!!!
Rheumatoid arthritis

Question 3

What are some lifestyle factors that make someone more at risk for osteoporosis?

Answer 3

Smoking
Excessive alcohol
Low calcium intake
low vitamin intake
Physical inactivity

Question 4

Medications that increase risk of osteoporosis?

Answer 4

Anticonvulsants (carbamazepine, phenytoin, phenobarbital)
Depo shot
GnRH agonist
Lithium
PPI (long term use)
Steroids (>/= pred 5 mg for >/= 3 months)
Thyroid hormones
Loop
SSRIs

Question 5

What is the GOLD standard to measure bone mineral density?

Answer 5

DEXA scan will give you a T scor or Z score

Normal T score >/= -1
Osteopenia -1 to -2.4
Osteoporosis </= -2.5

Question 6

What can you use to measure the osteoporotic fracture risk over the next 10 years?

Answer 6

FRAX tool

Question 7

Who should have their bone mineral density measured?

Answer 7

Women >/= 65 years old
Men >/= 70 years old
Younger patients with high risk for fracture

Question 8

What are some medications that could put an osteoporosis patient at high risk for falls?

Answer 8

Benzos
meds that cause sedation (opioids, hypnotics, sedatives)

Question 9

What supplementation can be used to prevent osteoporosis?

Answer 9

Calcium 1000-1200 mg elemental calcium daily
Vitamin D (to help absorb the calcium)

Question 10

Which calcium supplementation is acidic dependent and SHOULD beb taken with food?

Answer 10

Calcium Carbonate
40% elemental calcium

Question 11

What calcium supplementation is not acidic dependent and can be taken with or without food?

Answer 11

Calcium citrate
21% elemental calcium

Question 12

What is the 1st line treatment and prevention in most osteoporosis patients?

Answer 12

Bisphosphonates

• stay upright for 30 minutes after and drink with 6-8 oz of water

Question 13

What is an alternative prophylaxis for osteoporosis if a patient cannot tolerate bisphosphonates and has a VERY high risk for vertebral fractures?

Answer 13

Raloxifene (evista)
Bazedoxidene/estrogens(Duvee)

Question 14

What is an alternative to bisphonates for medium risk patient?

Answer 14

Denosumab (Prolia)

Question 15

What is an alterative to bisphosphonates in very high risk patients?

Answer 15

Parathyroid hormone analogs
Teriparatide (Forteo)
Abaloparatide (Tymlos)

Question 16

What are the injectable bisphosphonates?

Answer 16

Ibandronate (Boniva) every 3 months
Zoledronic Acid (Reclast) yearly

***these are preferred if esophagitis is present

Question 17

Fosamax SE

Answer 17

Aldendronate
CI: hypocalcemia
Warning: ONJ jaw decay or necrosis (dental procedures!)
Esophagitis!!!! esophageal ulcers, erosdions

***hypocalcemia MUST be corrected before use
Do not use if CrCl < 35

SE: dyspepsia, dysphagia, heartburn, N/V, hypocalcemia, hypophosphatemia

***separate antacids, calcium, iron, magnesim by at least 2 hours

Question 18

Boniva

Answer 18

Ibandronate
CI: hypocalcemia
Warning: ONJ, femur fractures, esophagitis (tablet), hypocalcemia, renal impairment CrCl < 30

**separate from antacids, calcium, magnesium, iron for at least 2 hours

Question 19

Reclast

Answer 19

Zoledronic Acid
CI: hypocalcemia
CrCl < 35
Warning: renal impairment

**no esophageal symptoms due to IV injection

Question 20

Raloxifene (Evista)

Answer 20

Used for prevention and treatment of Osteo

BW: VTE risk
CI: pregnancy!!!!!!!!
SE: hot flashes, peripheral edema, arthralgia, leg cramps

**separate from levothyroxine for several hours!

Question 21

Conjugated estrogens/ Bazedoxifene (Duavee)

Answer 21

Prevention of osteoporosis for postmenopausal women WITH a uterus

BW: endometrial cancer (estrogen), DVT risk
CI: breast cancer and pregnanct, active VTE

SE: nausea, diarrhea, dyspepsia

*****not used in cancer!!! Contraindicated in breast cancer!!!!

Question 22

Calcitonin (Miacalcin)

Answer 22

inhibits bone resorption by osteoclasts

Warning: hypocalcemia, risk of malignancy, Salmon-derived product

nasal spray OR injection

Question 23

Which bisphosphonate ONLY reduces vertebral fractures?

Answer 23

Ibandronate (Boniva)

Question 24

What drugs used for osteoporosis is a RANKL inhibitor to prevent osteoclast formation?

Answer 24

Denosumab (Prolia)

Question 25

What treatment for osteoporosis is a parathyroid hormone analog to increase bone formation?

Answer 25

Teripartide (Forteo)
Abaloparatide (Tymlos)

Question 26

Prolia

Answer 26

Denosumab
CI: hypocalcemia
Warning: ONJ, hypocalcemia
SE: HTN, fatigue, edmea, dyspnea, HA, N/V/D, hypophosphatemia

Question 27

What osteoporosis medications increase risk for ONJ?

Answer 27

Bisphosphonate (PO)
Denosumab

Question 28

What osteoporosis medications have a warning for HYPOCALCEMIA?

Answer 28

Bisphosphonates
Cacitonin (Miacalcin)
Denosumab (Prolia)

Remosozumab

Question 29

What osteoporosis treatment has a risk for HYPERCALCEMIA?

Answer 29

Parathryoid hormone analgues

Question 30

An osteoporosis patient comes in with worsened T score (-3 to -5). She is currently on Fosamax weekly. She is 41 years old and has the BRCA gene. She has no other past medication history beyond fractures. What would be a good recommendation for her therapy?

Answer 30

Add Raloxifene to help prevent fractures AND breast cancer

Question 31

Teriparatide

Answer 31

SC injection daily
Warning: osteosarcoma, hypercalcemia

SE: arthralgias, leg cramps, nausea, dizziness,

***keep refridgerated and protect from light

Question 32

What are some counseling points with Calcitonin nasal spray?

Answer 32

-Keep unused bottles refridgerated
-allow bottle to reach room temp before use
-discard after 30 days
- 1 spray in 1 nostril daily, alternate nostrils each day