Osteoporosis Flashcards
Osteoporosis Therapy Classes
Bisphosphonates
RANK Ligand Inhibitor
Sclerotin Inhibitor
Parathyroid Hormone Analogs
Calcitonin
Tissue-specific Estrogen Complex
Selective Estrogen Receptor Modulators/Estrogens (SERMs)
What are necessary for bone homeostasis
calcium and vitamin D
(Vitamin D increases calcium absorption)
Best way to manage osteoporosis
Prevention!
Can Ca and Vit D prevent fractures
not sure, controversial
What forms of Vit D should u recommend
D2 (ergocalciferol) or D3 (cholecalciferol)
How to get intake of Calcium
1 is dairy products; ingesting Ca foods or fortified foods
How to get intake of Vit D
Sunlight, diet, and supplements, Fish, eggs, and fortified dairy
AE of Calcium Supplements
constipation and kidney stone formation
Drug interactions of calcium supplementation
PPIs and Histamine Type 2 receptor antagonists
Ca dosing recommendations
Women <50yoa and men 50-70yoa à 1000mg calcium daily (food + supplements)
Women >51yoa and men >71yoa à 1200mg of calcium daily (food + supplements)
Options for Ca supplementation
Ca Carbonate or Calcium citrate
More detail:
Carbonate: 40% elemental calcium, less expensive, taken with meals- needs acid to be absorbed
Citrate: 21% elemental calcium, acid-independent absorption- does not need to be taken with meals
What options for Ca supplements do you want to avoid
Unrefined oyster shells or coral calcium –> can have high levels of lead and heavy metals
Tolerable Upper Intake Level (UL) for Ca and Vit D for ages 19-50
2,500 for Ca
4,000 for Vit D
Tolerable Upper Intake Level (UL) for Ca and Vit D for ages 51+
2,000 for Ca
4,000 for Vit D
What should you be careful of w dosing of Ca and Vit D and what is less of a concern?
hypercalcemia and kidney stones
Not as worried about MI
Best way to increase calcium and max limit
Dietary calcium
Not above 1500 mg/day
Women 51+ yo should consume how much Ca
1200 mg/day
What are we trying to balance w Osteoporosis
Inhibition of osteoclasts and increasing osteoblast activity
Big Meds as RF for Osteoporosis
PPI and Corticosteroids
**not on exam but figured good as quick refresher!
Bisphosphonates: Name Ending
-Onates
Bisphosphonates MOA
Bind to active sites of bone remodeling –> decrease bone resorption and inhibit osteoclasts
all Bisphosphonates have poor what?
Oral bioavailability
What Bisphosphonates can be given to both men and women
Alendronate (Fosamax, Binosto) Risedronate (Actonel), Zolendronic Acid (Reclast)
What Bisphosphonates can only be given to females?
Ibandronate (Boniva), Risedronate (Atelvia)
Which bisphosphonate has same generic name but different brand names that are different for sexes?
Risedronate
Risedronate (Atelvia) –> females only
Risedronate (Actonel) –> females and males
Which bisphosphonates are IV?
ibandronate and zoledronic acid
Bisphosphonates AE
Osteonecrosis of the Jaw**
Others: hypoCa, fragility fractures, esophageal cancer, atrial arrythmias
What pts can we not give Bisphosphonates
renal insufficiency (primary mode of elimination)
Hypocalcemia, oral prep in pts not upright or swallowing disorder
Patient Education for Bisphosphonates
Take first thing in the AM with PLAIN water
Remain upright for at least 30 min to reduce GI SE and acid reflux
what happens if pt stops Bisphosphonates
drug(s) have residual benefits after discontinuation –> will continue to monitor pt bone density
RANK ligand inhibitor name
Denosumab (Prolia)
Denosumab (Prolia) MOA
Human monoclonal antibody that inhibits osteoclast formation and reduces bone resorption
Denosumab (Prolia) Indications
tx of osteoporosis and bone mets in males AND females
Denosumab (Prolia) is given how
subQ injection
are Denosumab (Prolia) effects reversible?
Yes
Bone mineral density declines to pre-tx levels w/in 2 years of discontinuation and increases bone turnover w/in 3 m of discontinuation
Denosumab (Prolia) AE
*Rash, dermatitis
*Infections
*Upper GI symptoms
*Hypocalcemia
What pts should be not give Prolia to
hypocalcemic
when should we give Prolia
Reserved for patients unresponsive to or unable to tolerate bisphosphonates
AND
*Patients receiving androgen deprivation therapy for prostate cancer
*Patients receiving aromatase inhibitor for breast cancer
what tx for osteoporosis is no longer 1st line prevention
Estrogen Therapy
what does estrogen therapy increase the risk of
*Increased risk of CVA, clots, and breast cancer
*Long-term estrogen increases risk of ovarian cancer
what kind of formulations does estrogen therapy come in
*Many formulations and dosage forms approved for prevention
*Including estrogen + progestin products
estrogen therapy stats that is helps w
(not sure how in depth we need to know so added it all!)
Treatment in 10k women for 1 year with estrogen + progestin prevents 6 hip and 6 vertebral fractures
*8 more cases of breast cancer
*9 more strokes
*12 more cases of DVT
Treatment in 10k women for 1 year with estrogen alone prevents 7 hip and 6 vertebral fractures
*11 more strokes
*7 more cases of DVT
When to avoid estrogen therapy
*History of stroke
*History of coronary events
*History of thromboembolism
*Breast cancer
When to consider estrogen therapy
prematurely menopausal women (<50 years old) or if symptomatic
Selective Estrogen Receptor Modulator (SERMs): Name
*Raloxifene
Raloxifene MOA
acts like estrogen on bone
AND
estrogen antagonist in uterus and breast
Raloxifene is approved tx for what
osteoporosis
Raloxifene AE
*Hot flashes
*Leg cramps
*Peripheral edema
*Thromboembolic events
When to avoid Raloxifene
*History of stroke
History of thromboembolic events (Boxed warning)**
*Hypertriglyceridemia
*History of breast cancer
*High risk for hip fracture
Raloxifene is contraindicated in what pt population? not indicated?
Contra: pregnancy and hx of or current thromboembolic disorde
Not indicated: Not indicated or recommended for for premenopausal women
Raloxifene is useful in what pt population besides osteoporosis
women at high risk of breast cancer (but does not eliminate risk)
*Extra Flashcard: Parathyroid Hormone Analogs Names
teriparatide (Forteo®) and abaloparatide (Tymlos®)
AND are $$$
Calcitonin Drug Names
Miacalcin®, Fortical®
Calcitonin MOA
Peptide hormone that binds to osteoclasts and inhibits bone resorption
May have analgesic effect
Calcitonin is more derived from what source
Salmon; more potent than mammalian
Calcitonin routes
IM, SQ, intranasal
Calcitonin AE
*Nausea and flushing with injection
*Runny nose and epistaxis with nasal spray
when to give calcitonin
Reserved for postmenopausal women who are postmenopausal by at least 5 years
*Who are unable to tolerate bisphosphonates
*AND have bone pain from compression fractures
who not to give calcitonin to
High risk of hip fractures
what does calcitonin reduce fracture risk of
small increase in vertebral bone mineral density with a slightly reduced risk of vertebral fractures
Reminder to look at green table for fracture site prophylaxis (this was more for reference)
Reminder to look at green table for fracture site prophylaxis (this was more for reference)
OTC supplements for bone health
*Glucosamine
*Chondroitin
*MSM (methylsulfonylmethane)
*SAMe (S-adenosy-L-methionine)
*Natural anti-inflammatory compounds
*Turmeric
*Ginger
*Boswellia
how often do you assess BMD for osteoporotic pts
every 2-3 years
Drug holiday timeline if not at high risk of fracture
3-5 years (found in notes of her pwpt)
Duration of therapy guidelines for Osteoporosis drugs are set by
American Association of Clinical Endocrinologists (AACE)
Drug Holiday time lines for bisphosphonates
*Bisphosphonate drug holidays (consider if condition stable)
*Moderate risk—5 years; (IV zoledronic acid - 3 annual doses)
*High risk— 6-10 years; (IV zoledronic acid - 6 annual doses)
What osteoporosis drug should NOT have a drug holiday
Denosumab (Prolia)
Reminder to Look at Duration of Therapy Flow Chart (slide 38)
Reminder to Look at Duration of Therapy Flow Chart (slide 38)
What type of fracture are all mentioned osteoporosis drugs good at preventing
vertebral
What drugs are good at preventing wrist fractures
Alendronate and Risendronate
