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Adv. Immunology > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What is osteoporosis?

A
  • Progressive systemic disease (once it occurs, it won’t stop)
  • Low bone mass + impaired bone architecture + decreased bone strength = increase fracture risk + increased morbidity, mortality, decreased quality of life
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2
Q

What are some lifestyle risk factors for Osteoporosis?

A

o Diet (Ca and Vit D)
o Low physical activity
o Smoking
o Alcohol
o Caffeine

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3
Q

What are some diseases or conditions that are risk factors for osteoporosis?

A

o Menopause
o RA & other inflammatory dx
o Organ transplant
o Diabetes
o Malabsorptive states (Chron’s, celiac disease)
o Hyperthyroidism
o CKD
o Genetic Disorders

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4
Q

What are some patient characteristic risk factors for osteoporosis?

A

o Female sex
o Low bone mineral density
o Low body weight (<127 lbs)
o Hormonal status
o Parenteral history of hip fracture

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5
Q

What are some medications that could be risk factors of osteoporosis?

A

o Corticosteroids
o Long-term PPI use
o Heparin/LMWH
o Calcineurin inhibitors (cyclosporin, tacrolimus)
o GnRH Agonists (leuprolide, goserelin)
o Anticonvulsants
o Aromatase inhibitors
o Oral diabetes (SGLT2i, TZD)

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6
Q

Who do you screen for osteoporosis?

A
  • ALL women > 65 yo, men > 70
  • Post-menopausal women < 65, men 50-69 screen in high-risk patients
    • Glucocorticoid therapy (oral prednisone ≥ 5 mg/day, ≥ 3 months)
    • Recent low-trauma fracture
      • Other: Lifestyle, PMH, medication use, patient characteristics, low body weight, parental history of hip fracture, smoking
  • USPSTF recommends use of Clinical Risk Assessment Tools for post-menopausal women < 65
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7
Q

What indicates treatment for osteoporosis?

A

Any T-score ≤ -2.5 at the lumbar spine, femoral neck, or hip as determined by DXA

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8
Q

What indicates treatment for osteopenia?

A

FRAX score with 10-year risk for hip fracture ≥ 3% or for major osteoporotic fracture ≥ 20%

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9
Q

What is considered corticosteroid-induced osteoporosis?

A

ALL adults taking prednisone ≥ 2.5 mg/day for ≥ 3 months

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10
Q

When should osteoprophylaxis be considered in patients taking chronic steroids (≥ 5 mg/day prednisone ≥ 3 months)?

A

With any of the following:
o T-score between -1 and -2.5 (osteopenia)
o 10-yr risk of major osteoporotic fracture of 10-19%
o 10-yr risk of hip fracture between >1% and <3%
o Very high doses of steroids (e.g., > 30 mg/day prednisone)

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11
Q

What is the osteoporosis prophylaxis?

A

Oral biphosphonates

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12
Q

What are some alternatives to oral bisphophonates?

A

 IV bisphosphonates
 Denosumab
 Teriparatide
 Raloxifene

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13
Q

What is the recommended daily intake of calcium?

A

19-50 years: 1,000 mg

≥ 51 years: 1,200 mg

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14
Q

What is the daily intake of Vitamin D?

A

≥ 50 years: 800-1,000 IU

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15
Q

What is the repletion dosing of Vitamin D?

A

50,000 IU weekly for 8-12 weeks

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16
Q

Which calcium supplementation is the cheapest?

A

Calcium carbonate

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17
Q

Which calcium supplementation must be taken with meals?

A

Calcium carbonate

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18
Q

Which calcium supplementation is better absorbed?

A

Calcium citrate

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19
Q

What is the safe daily upper limit of Vitamin D supplementation?

A

ages 9+: 4,000 IU (100 mcg)/day

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20
Q

What are some possible adverse effects of Vitamin D supplementation?

A

hypercalcemia, soft tissue calcification, kidney stones, renal failure

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21
Q

What are some secondary causes of osteoporosis?

A
  • Hyperthyroidism
  • Hyperparathyroidism
  • Rheumatoid arthritis
  • Multiple sclerosis
  • Severe liver disease
  • Celiac disease
  • Adrenal insufficiency
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22
Q

Bisphosphonates

A

-Inhibits osteoclast
-Mimic pyrophosphonate: an endogenous bone resorption inhibitor
-First line

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23
Q

Name the Bisphosphonates

A

-Alendronate (Fosamax)
-Risedronate (Actonel, Atelvia)
-Zoledronic Acid (Reclast)
-Ibandronate (Boniva)

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24
Q

What are the indications for Alendronate (Fosamax)?

A

Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures

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25
Q

What are the typical dosing of Alendronate?

A

70 mg PO weekly or
10 mg PO daily

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26
Q

What are the indications for Risedronate (Actonel, Atelvia)?

A

Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures

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27
Q

What are the typical dosing of Risedronate (Actonel, Atelvia)?

A

35 mg PO weekly or
150 mg PO monthly

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28
Q

What is the indication for Zoledronic Acid (Reclast)?

A

Postmenopausal, males, and glucocorticoid-induced: treat and prevent, nonvertebral, and hip fractures

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29
Q

What is the typical dosing of Zoledronic Acid (Reclast)?

A

Treatment: 5 mg IV yearly
Prevention: 5 mg IV every 2 years

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30
Q

What is the typical dosing of Ibandronate (Boniva)?

A

Postmenopausal: treat and prevent vertebral fractures
(does not treat hip fractures)

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31
Q

What is the typical dosing of Ibandronate (Boniva)?

A

Oral: 150 mg once monthly

IV: 3 mg every 3 months

32
Q

What is the bioavailability of bisphosphonates?

A

oral bioavailability <1% (very poor), reduced up to 60% with coffee or orange juice (take 30 min before food)

33
Q

What is the half-life of bisphosphonates?

A

~10 years

34
Q

What are some common adverse effects of bisphosphonates?

A

-esophagitis (b/c of chemical irritant in bisphosphonates) or acid reflux
-hypocalcemia
-abdominal pain
-constipation
-diarrhea

35
Q

What are some rare adverse effects of bisphosphonates?

A

atypical femur fracture, osteonecrosis of the jaw (ONJ)

36
Q

What are some risk factors of Osteonecrosis of the Jaw?

A

-Presence of malignancy
-Use of chemotherapy and corticosteroids
-Age ≥ 65
-H/o periodontal and dental abscesses
-Bacterial infections
-Dental procedures (e.g. tooth extractions)
-Use of IV bisphosphonates

37
Q

What are some signs and symptoms of osteonecrosis of the jaw?

A
  • Tissue loss, exposed bone, jaw pain, odontalgia, and welling
38
Q

What are some prevention strategies of Osteonecrosis of the Jaw?

A
  • Regular dental hygiene and routine dental exams
  • Assessment of patients for risk factors
  • Completion of anticipated dental procedures prior to initiating bisphosphonates
  • Examine mucosa of patients with full or partial dentures
39
Q

What are some counseling points of Bisphosphonates?

A

 Must be taken on empty stomach, with full glass of water, upright for at least 30 minutes
 Avoid in patients that may have trouble following administration instructions
 Should be used with caution in patients with active esophageal disease or hypocalcemia
 Do not take with any other medications
 Supplemental calcium + vitamin D if inadequate diet/deficiency
 Consider weekly dosing over daily dosing

40
Q

Denosumab (Prolia)

A
  • Human monoclonal antibody: binds to RANKL (precursor to osteoclast activity) which inhibits osteoclastogenesis and increases osteoclast apoptosis
41
Q

What are the indications for Denosumab (Prolia)?

A

Postmenopausal, males, and glucocorticoid-induced: Treat and prevent vertebral, nonvertebral, and hip fractures

42
Q

What is the typical dosing of Denosumab (Prolia)?

A

60 mg subQ every 6 months

Administration by healthcare professional

43
Q

What is the half-life of Denosumab (Prolia)?

A

~25 days

44
Q

What are some common adverse effects?

A

Nausea, diarrhea, constipation, fatigue, asthenia, and arthralgia

45
Q

What are some serious adverse effects?

A

Hypocalcemia, serious skin infections, osteonecrosis of jaw, and atypical femur fractures

46
Q

Parathyroid Hormone & Analogs

A

o SECOND LINE
o Stimulate osteoblast function, increasing gastrointestinal calcium absorption, and increasing renal tubular reabsorption of calcium

47
Q

What is the indication for Teriparatide (Forteo)

A

Postmenopausal, males: Treat and prevent vertebral, nonvertebral

48
Q

What is the typical dosage of Teriparatide (Forteo)?

A

20 mcg SQ daily

49
Q

What is the indication for Abaloparatide (Tymlos)?

A

Postmenopausal, males: Treat and prevent vertebral, nonvertebral

50
Q

What is the typical dosing of Abaloparatide (Tymlos)?

A

80 mcg SQ daily

51
Q

When are parathyroid hormone (PTH) & Analogs used in?

A

-Severe osteoporosis (T-score of ≤ 3.5 even in the absence of fractures, or T-score of ≤ 2.5 plus a fragility fracture)
-Unable to tolerate bisphosphonates or who have contraindications to oral
-Fail other osteoporosis therapies (fracture with loss of BMD in spite of compliance with therapy)

52
Q

What are some common adverse effects of Parathyroid hormones & analogs?

A

Hypercalcemia
-Orthostatic hypertension
-Arthralgia
-Asthenia
-GI
-Dyspepsia

53
Q

What are some contraindications of parathyroid hormones & analogs?

A

Metastases, history of skeletal malignancies, hypercalcemia

54
Q

What are some counseling points of parathyroid hormones & analogs?

A

 Rise slowly from sitting position
 Rotate injection sites with each dose

55
Q

What is the duration of therapy of parathyroid hormones & analogs?

A

Should NOT exceed 2 years (due to risk for osteosarcoma)

56
Q

Romosozumab (Evenity)

A

 Monoclonal antibody; binds to sclerostin, an inhibitor of bone formation
 SECOND LINE

57
Q

What is the indication for Romosozumab (Evenity)?

A
  • Postmenopausal: Treat vertebral, nonvertebral, and hip fractures
  • Used in postmenopausal women at high risk for fracture OR intolerant to or who have failed other osteoporosis therapy
58
Q

What is the typical dosage of Romosozumab (Evenity)?

A

2 consecutive subQ injections (105 mg each) for a total dose of 210 mg once monthly

59
Q

What is the duration of therapy of Romosozumab (Evenity)?

A

should NOT exceed 12 months

60
Q

What are some common adverse effects of Romosozumab (Evenity)?

A

Joint pain, headache

61
Q

What is the black box warning of Romosozumab (Evenity)?

A

Should be avoided in patients with significant cardiovascular history
* May increase the risk of myocardial infarction, stroke, and cardiovascular death
* Should not be initiated in patients who have had a myocardial infarction or stroke within the preceding year
* If a patient experiences a myocardial infarction or stroke during therapy, romosozumab should be discontinued

62
Q

What are the counseling points of Romosozumab (Evenity)?

A

Patients should report signs of any serious ADE’s and take supplemental calcium + vitamin D

63
Q

Raloxifene (Evista)

A
  • Selective Estrogen Receptor Modulators
  • Estrogen agonist activity on bone–> prevent bone loss, decreases bone resorption
64
Q

What is the indication for Raloxifene (Evista)?

A

Postmenopausal: Treat and prevent vertebral fractures

Reduce risk of invasive breast cancer in postmenopausal women

65
Q

What is the typical dosing of Raloxifene (Evista)?

A

60 mg once daily

66
Q

What is the renal impairment cutoff for Raloxifene (Evista)?

A

CrCl < 50, use with caution

67
Q

What are some common side effects of Raloxifene (Evista)?

A
  • Hot flashes
  • Leg cramps
  • Peripheral edema
  • Flu-like syndrome
  • Arthralgias
  • Sweating
68
Q

What are some serious adverse side effects of Raloxifene (Evista)?

A

Increased risk for venous thromboembolism and stroke

69
Q

What are some contraindications of Raloxifene (Evista)?

A

History of or current venous thromboembolism

70
Q

What are some drug interactions of Raloxifene (Evista)?

A

Warfarin, cholestyramine, diazepam, diazoxide, and lidocaine

71
Q

Calcitonin

A

o Antagonizes PTH which inhibits osteoclast formation + analgesic effect

72
Q

What is the indication for Calcitonin?

A

Approved in women ≥ 5 years post menopause as LAST-LINE short-term treatment + pain relief for vertebral fractures

73
Q

What is the typical dosage of Calcitonin?

A

Intranasally 1 nasal puff (200 units) once daily

74
Q

What is the duration of therapy of Calcitonin?

A

4 weeks

75
Q

When should you repeat imaging?

A
  • Repeat DXA screen scan in healthy postmenopausal women every 10 years, unless risk factors change
  • Repeat DXA scan every 2 years while on therapy
76
Q

Bisphosphonate Drug Holiday

A
  • Why? To reduce drug related adverse effects from accumulation over time
  • The skeletal binding sites for bisphosphonates are virtually unsaturable leading to a reservoir that continues to be released for months or years after treatment is stopped

Adv. Immunology (3 decks)

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