osteoporosis Flashcards
What non-param can we advise in osteoporosis?
- regular exercise
- fall prevention (minimize falling hazards and drugs that may lead to falling like benzos)
- smoking cessation
- diet measures (lots of protein, calcium and vitamin D, limit alcohol, 2 glasses, and limit caffeine 4 glasses)
what numbers of vitamin D do we need?
over 50 800- 2000 International units
under 50 400-1000 international units
do cancdians usualy have enough vitamin D in their diet?
no
when do we measure the serum 25-OH-D4?
it is measured for those who have impaired inetstinal absorption and those with osteoporosis requireing therapy?
what are the different types of vitamin D and which is preferred?
D3(cholecalciferol) and D2(ergocalciferol)
D3 is preferred
how often do we measure 25-OH-D4 levels once initiaing therapy?
once when beginning then in 3 months after starting therpay
what are some sideeffects of vitamin D
it is pretty well tolerated however we can get hypercalcemia, hypercalciuria, renal calcification and renal stones (usualy at high doses since it’s a fat soluble vitamin and doesn’t get peed out)
what is the daily intake of calcium for individuals over 50?
1200mg
can calcium be taken as one dose?
no has to be divided doses of 500
what are the calcium slats from most potent to least potent?
carbonate, citrate, gluconate, lactate
if we have decreased stomach acid or are on a PPi which calcium salt shoudl we take?
citrate
what calcium slat needs an acidic environment?
carbonate
Which salt is preferred and what’s a common side effect of it?
carbonate and it’s constipating
what is of note concerning when we take calcium?
it can affect the absorption of other meds so should be spaced out by 2 hours
empty or full stomach for calcium?
empty but with food if having sideeffcts
what are some side effects of calium
constipating, nausea, hypercalcemia, hypercaluria, ranal calcification, renal stones
what are some possible drugs it could affect absoprtion of it not spaced?
bisphosphates, cirpfloxacin, iron, levothryoine, and tetracycline
describe how initial BMD testing determines pharamcotherpay or not?
BMD testing can give us
- low risk (10-year fracture risk is < 10%)
no therpay reasses in 5 years - moderate risk is 10-20%
maybe therpay - high risk is >20%
evidence for pharamacotherpay
what factors could make you think that somone with moderate risk needs therpay?
long term use of systemic corticosteroids
what are the first line therapies with evidence for fracture prevention in postmensual women?
Antiresorptive therapies?
bisphosphates
-alendronate
-risedronate
-zoledronic acid
denusamab - prolia
SERM - rafloxifene
Hormone therpay - estrogen
Bone formation therpay:
Teriparatide
what types of fractures do most of the therpies prevent agasint?
vertebral (all)
hip (not raloxifene and teriparatide)
and non-vertabral ( not raloxifene)
whihc bisphosphates are oral and whihc are IV?
oral - alendronate and risedronate
IV - zoledronic acid
when are IV bisphophates indicated?
- can’t tolerate oral GI effcts
- aren’t adherenect on oral meds
- when oral therpy fails
what is a big concern with bisphoptaes ?
adherenece - when adherence falls below 80% the protection faades
MOA of bisphophates
they coat bones and unbale bone reabsorption
what adminstering oral bisphophates what should we counsel on?
- empty stocmach at least 30 mins before food
- take with a full glass of water and reman if an upright position for 30 minutes after
discuss Zoldonic acid administration and side effects
viatmin D must be given for 2 weeks before z.acid
may get flu-like symptoms after infusion for up to 48 hours after so can take acetaminophen before hand
if eldery encourage to dink 500 mL of water prior to infusion
when are bisphosphates CI?
hypocalcmia and those with CrCl < 35 mL/min
oral bisphopsphates - esophageal disorders
SE of bisphophates
common - GI upset, altered taste and nighttime leg cramps
uncommon
- reflux, esophagitic and esophagela ulcers (shouldn;t occur if taking oral correctly)
-osteonecrososi of jaw (ONJ)
- Atypical femoral shaft fractures(AFSF)
what are some risk factors for reflux, esophagitic and esophagela ulcers?
prior GI disases, concimtant NSAID use, receiving anti-reflux meds
what is an important counseling point for those taking oral bisphosphates?
if any pain in mouth or ahcnge in gums let HCP know!
what puts people at increased risk for AFSF?
long term bisphosphate use (more then 2 years)
benfit still outweights risk
what should we do if a patient has a AFSF while on bisphosphates?
swithc to anabolic agent like teriparatide
detail when a bisphosphates drug holiday should and should not be taken
after 5 years on therpay can consider one:
if high risk continue with therpay
if moderate risk:
1-3 year holiday with alendronte
1 year holdiay with risedronate
after holiday remeasure BMD and recaltualte the 10 year fractiue risk to determine therapy, we can continue therapy for 3-5 years if needed
how do we proceed after a drug holdiay?
after holiday remeasure BMD and recalculate the 10 year fracture risk to determine therapy, we can continue therapy for 3-5 years if needed
what is denusamab - prolia?
ist a biological injected
MOA of denosumab (prolia)
inhibtis RANKL whihc decrease osteoclast function and survival
denosumab CI
hypocalcemia and CrCl< 15 ml/min
denosumab SE
rare: ONJ, AFSF
first line for menopausal women?
serm; raloxifene
what population serm; raloxifene most used in
breat cancer patients
serm; raloxifene CI
pregancncy, history of VTE (actice or past), over 65 years old due to stroke /VTE risk
talk about hormone therpay such as estrogen and progesterone
risk outweight beneifits
not recommended due to CVA and VTE risk
When is PTH analog (anabolic): teriparatide used?
first line for post menuposal woemn for secondray prevention of vertebral and non-vetebral fractures
- when oral bisphsophates not tolerated or are CI
MOA of teriparatide?
mimics PTH so increase osteoblast activity
when is teriparatide CI?
pregenancy/ nursing
increase Ca2+
CrCL<30mL/min
what dose of steroid induced osteoporosis is dangerous
> =3 months of 2.5-7.5mf/ day po prednisone
when on long-term steroids what should we do?
all adults - should take calcium and vitamin D(600-8000 IU)
adults at moderate fracture risk
- should take oral bisphosphate and calcium and vitamin
How should we monitor patients on therapy
baseline - 3 months after starting therapy and repeated measurements after 1-3 years
