Osteoporosis Flashcards
Most Common Long-Term Meds Associated with OP
-Glucocorticoids
-Gonadotropin-releasing hormone agonists
-Cancer chemotherapy drugs
-Aromatase inhibitors (anastrozole, exemestane, letrozole)
-Anticonvulsant therapy
-Anticoagulants (> 6 months UFH/LMWH)
AAAGGC
Clinical Presentation
Subjective
-Vertebral fracture (back pain radiating to leg)
-Non-vertebral fracture (severe pain, swelling, and reduced mobility
-Depression, fear, low self-esteem d/t limitations or deformities
Objective
-Decreasing height (> 1.5 inch d/t collapsing vertebrae)
-Dowager’s Hump (curved back, “kyphosis”)
-Fracture with minimal trauma
Screening Recommendations
-Women 65+, Men 70+
-All postmenopausal women 50+
-Adults who fracture at 50
-Adults with a condition or taking med associated with low bone mass
Non-Pharm TX
-Sunlight exposure
-Smoking cessation
-Alcohol moderation
-Balanced diet
-Weight bearing aerobic exercise
Fall Prevention Strategies
-Low heeled, sturdy shoes
-Hip protectors
-Remove safety hazards in home
-Avoid meds that can impair coordination
Calcium Recommended Daily Intake
51-70 =
-Female: 1200
-Male: 1000
71+
-Female/Male: 1200
Ca Supplements
Increases BMD but fracture prevention only if w/ vitamin D
Doses > 500-600 should be BID/TID (divided)
Citrate preferred for older adults (better abs)
AE: flatulence, constipation
Do not exceed > 1200-1500/day (kidney stones/CVD)
DDI: separate by 2+ hours
-Tetra, azithro, fluoroquin, bisphos, azoles, iron (IF TABA)
Calcium Carbonate
-Generally preferred salt
-Take with meals or juice
-Also acts as antacid
Calcium Citrate
-Absorption not affected by food/acid
-Less constipating
Vitamin D Recommended Intake
51-70 =
-Female/Male: 600 IU, 15 mcg
70+ =
-Female/Male: 800 IU, 20 mcg
Recommend sunlight 5-15 minutes/day
Vitamin D Replacement/Treatment
- 50,000 IU PO qweek x 8-12 weeks;
- Then once monthly or 1000-2000 IU PO daily thereafter
Goal: >= 30 for 25 OHD
AE: hypercalcemia, hypercalciuria
DDI:
* Phenytoin, barbiturates, CBZ, rifampin increase metabolism (PBCR)
* Cholestyramine, colestipol, orlistat, and mineral oil decrease absorption (MOCC)
Pharmacologic TX should be considered for:
- Postmenopausal women/men older than 50years who have a low-trauma hip or vertebral fracture
- T-score ≤ −2.5 at the femoral neck, total hip, or spine (osteoporosis)
- T-score between −1.0 and −2.5 (osteopenia) and a FRAX 10- year probability of major osteoporosis-related fracture ≥ 20% or hip fracture ≥ 3%
Pharmacologic Treatment Recommendations
OP
1. Bisphosphonates
2. Denosumab (if CI/AE)
Post-meno with OP
-Romosozumab or Teriparatide followed by bisphosphonate
Aldendronate: Bisphosphonates
Do not use if CrCl ≤ 35 mL/min
Fosamax 70 mg/w or 10 mg/day
*for prevention: half of doses
or 1 bottle of 70 mg oral solution weekly
Risedronate: Bisphosphonates
Do not use if CrCl ≤ 30 mL/min
TX/Prevention of post-meno OP
* 150 mg monthly (75 mg tablets taken 2 days in a row)
* 35 mg tablet weekly
TX of men with OP
* 35 mg tablet once weekly
Ibandronate: Bisphosphonates
Do not use if CrCl ≤ 30 mL/min
TX of postmenopausal OP
* 150 mg tablet monthly (on same day)
* 3 mg IV every 3 months (treatment only)
Prevention
* 150 mg tablet monthly (on same day)
Zoledronic Acid/Zoledronate
Do not use if CrCl ≤ 35mL/min
5 mg IV once yearly (for treatment) or 5 mg IV every 2 years (for prevention)
Bisphosphonates – Common ADR’s
Oral
-GI (abdominal pain, dyspepsia, esophagitis, ulcers, esophageal erosions)
-MSK/bone pain
For IV
-Ibandronate: myalgias, cramps, limb pain
-Zol acid: hypocalcemia (CI), flu-like, A fib, arthritis, arthralgias, headache
Rare
-Osteonecrosis of the Jaw
-Atypical hip fractures
Bisphosphonates – Additional Information for IV
Drug interactions
* Aminoglycosides
* Loop diuretics
* NSAIDs or other nephrotoxic drugs
Precaution: renal impairment, hypocalcemia
Bisphosphonates – Patient Education
-Avoid NSAIDs/aspirin
-Dental exam 2x/year
-Take 30 min+ before food with water
-Do not chew on tablet
-DC if trouble/pain swallowing or chest pain
Denosumab (Prolia®)
60 mg SQ every 6 months
AE: fedcrp ofuc
-Flatulence, dermatitis, eczema, rash
-Pain in back, extremities, MSK
-Increased cholesterol
-RARE: hypocalcemia, UTIs, ONJ, femur fracture
Teriparatide (Forteo®)
20 mcg SQ daily in thigh/abdomen
-store in fridge, once open = 28 day shelf life
AE: TERI NOD CC
-Nausea, dizziness (low BP)
-Leg cramps and muscle spasms
-Hypercalcemia
BBW: OSTEOSARCOMA (rats) ps mcm
-Avoid if Paget’s disease, previous skeletal radiation, bone metastases or skeletal malignancy, hypercalcemia
Pt Ed: remove needle after each use, clear solution
Abaloparatide (Tymlos®)
80 mcg SQ daily, store in fridge, 30 days RT
AE: able to hhopn
* Orthostatic hypotension
* Palpitations
* Hypercalcemia
* Nausea and headaches
Romosozumab (Evenity®)
210 mg SQ
AE: hia hoa
-Arthralgias, headache, and injection site reactions
-Hypersensitivity reactions
-ONJ and atypical fractures
BBW: Increased MACE
-DC if MI/CVA occurs, don’t start if MI/CVA in 1 yr
CI: hypocalcemia, CKD/dialysis
Raloxifene (Evista®)
60 mg PO QD
Useful for: hens b
-younger post-meno and low DVT risk
-CI to other meds
-high risk of breast cancer
AE: hot flashes, night sweats, edema, spasms
BBW: blood clots (CI in VTE)
DDI: levo, warfarin
Glucocorticoid-Induced Osteoporosis (GIO)
- Calcium 1200-1500 mg daily + vitamin D3 800-1200 IU daily
- BMD/DXA at therapy onset and every 6-12 months as needed
- Try first: alendronate, risedronate, and zoledronic acid
- If bisphosphonates are intolerable or there are contraindications: teriparatide or denosumab
