osteoporosis

Question 1

medications that are a risk factor for osteoporosis

Answer 1

corticosteroids, long term PPI, calcineurin inhibitors, heparin/LMWH, TZDs, SGLT2i’s, GnRH agonists, anticonvulsants, aromatase inhibitors

Question 2

who to screen for osteoporosis

Answer 2

• all women >65, men >70
• postmenopausal women <65, men 50-69 in high risk: glucocorticoid therapy (prednisone >5 mg/day x 3 months), recent low trauma facture, other risk factors

Question 3

indications for treatment

Answer 3

1. osteoporosis (t score -2.5)
2. osteopenia with FRAX >3% hip, >20% major osteoporotic fracture
3. any history of low trauma spine or hip fracture

Question 4

recommendations for adults taking prednisone >2.5 mg/day x 3 months

Answer 4

optimize calcium (1000-1200 mg/day) and vitamin D (600-800 IU/day) and lifestyle modifications

Question 5

when do we consider osteoporosis prophylaxis with bisphosphonates, in patients taking prednisone >5 mg/day x 3 months

Answer 5

1. osteopenia
2. 10 yr risk of major osteoporotic fracture of 10-19%
3. 10 yr risk of hip fracture 1-3%
4. very high prednisone doses >30 mg/day

Question 6

vitamin D maintenance dose

Answer 6

800-1000 IU daily

Question 7

vitamin D repletion dose

Answer 7

50,000 IU weekly x 8-12 weeks

Question 8

calcium dose <50 years

Answer 8

1000 mg daily

Question 9

calcium dose >50 years

Answer 9

1200 mg daily

Question 10

which calcium requires acidic environment/taken with meals?

Answer 10

calcium carbonate

Question 11

which vitamin D may be more effective for reducing fracture risk

Answer 11

cholecalciferol

Question 12

secondary causes of osteoporosis?

Answer 12

hyperparathyroidism, hyperthyroidism, RA, MS, liver disease, celiac disease, adrenal insufficiency

Question 13

name of selective estrogen receptor modulator

Answer 13

raloxifene

Question 14

name of RANKL inhibitor

Answer 14

denosumab

Question 15

name of PTH analogs

Answer 15

teraparatide, abaloparatide

Question 16

mechanism of bisphosphonates

Answer 16

mimic pyrophosphate, an endogenous bone resorption inhibitor: bind to bone and inhibit osteoclasts

Question 17

bisphosphonates, renal consideration

Answer 17

contraindicated in severe renal impairment

Question 18

which bisphosphonate is not indicated to prevent/treat hip or nonvertebral fractures

Answer 18

ibandronate (vertebral fractures only)

Question 19

zoledronic acid dosing

Answer 19

5 mg IV yearly treatment.
5 mg IV q2 years prevention.

Question 20

bioavailability of bisphosphonates

Answer 20

<1%, even more reduced with coffee or OJ

Question 21

adverse effects of bisphosphonates

Answer 21

esophagitis or acid reflux, hypocalcemia, abdominal pain, constipation, diarrhea, atypical femur fracture, ONJ

Question 22

risk factors for ONJ

Answer 22

malignancy
use of chemo and corticosteroids
>65 yo
h/o periodontal and dental abscesses
bacterial infections
dental procedures
IV bisphosphonates

Question 23

signs/symptoms of ONJ

Answer 23

tissue loss, exposed bone, jaw pain, odontalgia, swelling

Question 24

bisphosphonate counseling

Answer 24

take on empty stomach with a full glass of water and sit upright for 30 minutes. do not take with any other medications. supplemental calcium/vitamin D if deficiency

Question 25

denosumab mechanism

Answer 25

binds to RANKL which inhibits osteoclastogenesis and increases osteoclast apoptosis

Question 26

when is denosumab used

Answer 26

patients with high risk of fracture or have failed/intolerant/ contraindicated bisphosphonates

Question 27

denosumab dosing

Answer 27

60 mg SQ q6 months admin by healthcare professional

Question 28

denosumab indications

Answer 28

postmenopausal, males and glucocorticoid induced: prevention and treatment of vertebral, nonvertebral and hip fractures

Question 29

denosumab, renal considerations

Answer 29

no dose adjustment necessary, but if CrCL<30 watch closely for hypocalcemia

Question 30

denosumab adverse effects

Answer 30

nausea, diarrhea, constipation, fatigue, asthenia, arthralgia, hypocalcemia, ONJ, serious skin infections, atypical femur fractures

Question 31

denosumab counseling

Answer 31

take supplemental calcium and vitamin D

Question 32

denosumab monitoring

Answer 32

SCr, Ca, Phos, Mg

Question 33

PTH analog mechanism

Answer 33

stimulate osteoblasts, increase GI absorption & renal tubular reabsorption of calcium (cling onto calcium)

Question 34

PTH analog indications

Answer 34

postmenopausal, males: prevent and treat vertebral, nonvertebral

Question 35

typical dosing PTH analogs

Answer 35

teriparatide 20 mcg SQ daily abaloparatide 80 mcg SQ daily

Question 36

PTH analog, renal considerations

Answer 36

no dose adjustment

Question 37

when are PTH analogs used

Answer 37

1. severe osteoporosis (T score -3.5) 2. unable to tolerate bisphosphonates 3. fail other therapies

Question 38

PTH analog adverse

Answer 38

ORTHOSTATIC HYPOTENSION, hypercalcemia, arthralgia, asthenia, dyspepsia, metastases, history of skeletal malignancies

Question 39

PTH analog counseling

Answer 39

rise slowly from sitting position, rotate injection sites

Question 40

PTH analog pearl/duration

Answer 40

not to exceed 2 years due to osteosarcoma risk

Question 41

romosozumab mechanism

Answer 41

binds to sclerostin, an inhibitor of bone formation

Question 42

romosozumab indication

Answer 42

postmenopausal, treat vertebral, nonvertebral and hip fractures

Question 43

when is romosozumab used

Answer 43

in postmenopausal women at high risk for fracture or intolerant to/failed other therapies

Question 44

romosozumab dosing

Answer 44

2 consecutive SQ injections (total dose 210 mg) monthly

Question 45

romosozumab duration

Answer 45

not to exceed 12 months

Question 46

romosozumab, renal considerations

Answer 46

no renal adjustments

Question 47

romosozumab warning

Answer 47

avoid in patients with significant CV history: increases risk of MI, stroke-- do not initiate in patients who had a MI or stroke

Question 48

mechanism of raloxifene

Answer 48

selective estrogen receptor modulator: prevents bone loss, decreases bone resorption

Question 49

raloxifene indications

Answer 49

postmenopausal, treat and prevent vertebral fractures reduce risk of invasive breast cancer in postmenopausal women

Question 50

when to consider raloxifene

Answer 50

younger postmenopausal women at high risk for osteoporosis and breast cancer

Question 51

raloxifene renal considerations

Answer 51

caution CrCL<50

Question 52

raloxifene dosing

Answer 52

60 mg once daily

Question 53

raloxifene common adverse effects

Answer 53

hot flashes, leg cramps, peripheral edema, flu like, arthralgias, swetting

Question 54

raloxifene serious adverse

Answer 54

increased risk for VTE and stroke

Question 55

raloxifene contraindication

Answer 55

history of/current VTE

Question 56

raloxifene drug interactions

Answer 56

warfarin, cholestyramine, diazepam, diazoxide, lidocaine

Question 57

calcitonin MOA

Answer 57

antagonizes PTH which inhibits osteoclast formation + analgesic effect

Question 58

calcitonin indication

Answer 58

women >5 years post menopause as last line, short term treatment + pain relief for vertebral fractures

Question 59

calcitonin dosing

Answer 59

intranasally 1 puff daily, 4 weeks

Question 60

when to repeat DXA in healthy postmenopausal

Answer 60

every 10 years unless risk factors change

Question 61

when to repeat DXA while on therapy

Answer 61

every 2 years

Question 62

when to take drug holiday if low risk

Answer 62

5 years PO, 3 years IV

Question 63

when to take drug holiday if high risk

Answer 63

10 years PO, 6 years IV