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pharm 516 > osteoporosis > Flashcards

osteoporosis Flashcards

1
Q

routine screening for osteoporosis

A

> =65 y.o
earlier for above average risk (other than menopause)
USPTF and AFP recommend age 60 in higher risk women

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2
Q

osteoporosis def

A

T-score<=-2.5 at lumbar spine, total hip or femoral neck on bone mineral density scan
or hx of fragility fracture

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3
Q

osteopenia

A

-1.0 <-2.5

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4
Q

who to consider w/u for secondary osteoporosis

A

all premenopausal women with oeteoporosis
men
postmenopausal women with low z-scores ,-2.0 or less
women who do not respond adequately to initial therapy

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5
Q

Meds that cause secondary osteoporosis

A 
glucocorticoids
aromatase inhibitors
depo-medroxyprogesterone acetate
unfractionated heparin
GnRH agonist
anticonvulsants - phenobarbital, phenytoin,carbamezapin (accel vit D metabolism)
phenothiazine
methotrexate (not with low RA doses, 20 mg OK)
excessive vit A intake
cyclosporine-severe trabecular bone loss
tacrolimus
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6
Q

secondary causes of osteoporosis (food/disease)

A 
malnutrition/malabsorption
IBD (vit D largely absorbed in jejunum
celiac disease
gastric and bowel resection - ca absorbed in duodenum
eton - inhibits osteoblasts
vitamin D def/insuf
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7
Q

Role of Vitamin D

A

inc calcicum absorption in the gut
suppress PTH release
Dec renal ca and phosp excretion$)

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8
Q

generation of bioactive Vit D

A

exposure to UV light cholecalicferol (D3)
cholecalciferol and ergocalciferol (D2) obtained from diet
D2 and D3 converted in liver to 25-OH vit D (calcidiol- use in liver disease)
1,25-OHD (calcitrol) formed in kidneys through renal conversion (use in kidney disease, $$

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9
Q

25-OHD levels

A

normal > 30
deficiency < 20
insufficiency 20-30

high prevalence esp in elderly, northern latitudes, pregnancy, IBD, celiac disease

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10
Q

average daily cholecalciferol need

A

3000-5000/day

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11
Q

choleocalciferol

A

vitamin D3
preferred therapy
800-1000IU per day for insufficiency

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12
Q

VIt D deficiency therapy

A

50,000 IU Q week for 8 weeks, then 500-1000 IU if deficient

monitor Vit D metabolites levels 3 months after starting therapy - 25-OHD

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13
Q

Vit D supplement if kidney disease

A

Vitamin D metabolites - calcitrol (1-25 OHD)

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14
Q

endocrine causes of secondary osteoporosis

A

hyperthyroidism
hyperparathyroidism - surgical resection improves BMD
Cushings
Hyperprolactinemia

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15
Q

misc osteoporosis causes

A 
immobilization
smoker
post organ transplant (esp first 3-6 months
chronic disease - multiple myeloma (inc osteoclast activity)
RA
Chronic renal disease
chronic liver disease
systemic mastocytosis
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16
Q

Prevention/tx options for osteoporosis

A

Ca and Vit D
Weight bearing exercise
Meds: Bisphosphenates, SERM, PTH analogue, Calcitonin, Denosumab

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17
Q

calcium recommended intake

A

1000-1200mg WD for pre-meno and post-meno on anti-resorptive therapy
1500 mg QD for post-meno not on anti-resorptive

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18
Q

Vit D recommended intake

A

800 IU at least

19
Q

Bisphosphonate

A

analogue of naturally occurring pyrophosphate
accelerates osteoclast turnover
inc BMD and reduces vertebral and non-vert fracture rates
inexpensive, lont-term needs a holiday, usually 12-18 month holiday, no guidelines, base on BMD

20
Q

alendronate (fosamax)

A

10 mg QD, 70 mg po Q week
44% dec in vert frax
56% dec in hip fx over 4 years

21
Q

risedronate (Actonel)

A 
5 mg po q day
41% dec vert fx in 3 years, 39% dec nonvert fx
35 mg po q week, 75 mg po 2x/mo
as effective as daily dosing
well tolerated
22
Q

ibandronate (boniva)

A

oral 2.5 mg/day or 20 mg QOD
50% dec in vert gx, no dec in nonvert fx
150 mg PO once monthly
IV 3 mg q 3 mo

23
Q

zoledronic acid

A

5 mg IV once yearly

70% dec in ver fx, 41% dec hip fx

24
Q

IV bisphosphonate SE

A 
flu like syndrome after infusion
hypocalcemia after infusion
inc r/f afib
no inc r/f jaw necrosis
safety over 3 years not established
25
Q

GI SE of oral bisphosphinates

A

poorly absorbed, must take on empty stomach 30 before eating, 60 min for ibandronate
ESOPHAGITIS - remain upright for one H afteringestion
CI in those with achalasia and esophageal stricture
GERD is a relative CI

26
Q

duration of tx

A

consider trial of stopping after 5 years, unless very high risk

27
Q

osteonecrosis of the jaw

A

most with IV bisphosphenate, associated with dental procedures
stop oral therapy 3 months before procedures, on patients taking oral therapy > 3 years, then restarting after healing is complete
dental exam before starting IV therapy

28
Q

A fib and bisphos

A

higher a fib, pathogenesis not clear

29
Q

bisphosphonate in renal disease

A

not recommended with cr cl < 35, lots of secondary osteo, more appropriately managed by endo
these drugs stay in your body for a long time at baseline, greater r/f dynamic bone disease

30
Q

SERM

A

raloxifene: for prevention and tx of osteoporosis
binds estrogen receptors - antagonist/agonist
2.4 % inc of lumbar spine and hip
30-50 % reduction in vertebral fxs
NO reduction in NON-VERTEBRAL fx

31
Q

SERM SE

A

inc thrombosis risk, vasomotor sx
dec r/f invasive breast CA
2nd line agent behind bisphos, less potent anti resorptive agent, doesn’t help with hip fx

32
Q

calcitonin

A 
potent antiresorptive agent
rapid action on osteoclast
intranasal dose, dec vert fx risk by 33%
not as effective as bisphos or PTH
unclear long-term efficacy
analgesic effect for acute or chronic pain from fx
33
Q

parathyroid hormone (Teriparatide)

A 
recombinant PTH
intermittent dosing stimulates osteoblasts
inc GI Ca absorption
inc renal tubular resorption of Ca leading to bone formation
no more than 1-2 yr tx
dec vert and non-vert fx
dec fx risk after tx discontinued
very expensive, last resort
20 mcg/day SQ
34
Q

PTH SE

A

N/V, dizziness, hypercalcemia (CI kidney stones), leg cramps

35
Q

PTH monitoring

A

BMD one year after starting
Ca levels 1,6 and 12 mos
renal function
uric acid

36
Q

PTH and bisphos?

A

not recommended
coexistent therapy blunts response of PTH
3 month washout period of bisphos
sequential therapy may be beneficial

37
Q

candidates for PTH therapy

A

T score <-2.5 with fragility fx

those who fail other tx options or are not able to tolerate other tx modalities

38
Q

Denosumab

A

human IgG antibody to RANKL

controls osteoclast differentiation, activation and survival

39
Q

monitoring osteoporosis therapy

A

recheck BMD in 1 year, then q2 years
can also check levels of bone turnover after 6 mos
urinary NTX excretion - dec > 50%
serum carboxy-terminal collagen crosslings
if BMD stable or imp - successful
if BMD decreases - confirm compliance, look for further causes, can recheck in one year or change therapy

40
Q

monitoring therapy, pt on corticosteroid

A

baseline BMD
monitor q6mo, then q 6-12 months if not on therapy
annual follow-up measurements once on therapy

41
Q

oosteoporosis in Men

A

incidence of fx inc with age, though 10 yrs later than women
mortality from hip and vert fx higher in men
2nd causeID in 40-60% of fx

42
Q

osteo screening in men

A

screen >70, radiographis osteopenia, loss of height, fragility fx, long term steroids, intestinal disorders

43
Q

therapies for osteoporosis approved for men

A

bisphos and PTH analogue

pharm 516 (12 decks)

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