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PHAR 255 > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What are the two types of bone?

A

Cortical (80%)
Cancellous (trabecular) (20%)

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2
Q

What is the cortical?

A

Dense, forms outer shell

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3
Q

What is the cancellous?

A

Porous, forms interior structures

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4
Q

What are the 3 types of bone cells?

A

Osteoblasts
Osteoclasts
Osteocytes

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5
Q

What bone changes does advancing age cause?

A

Oxidative stress
Osteoblast senescence
Autophagy declines

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6
Q

What hormones are involved with the bones?

A

Estrogen
Androgens
Parathyroid - calcitonin
Glucocorticoid

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7
Q

What is calcium required for?

A

Mineralization of bone

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8
Q

What is vitamin D required for?

A

Helps regulate calcium

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9
Q

What does osteocyte death lead to?

A

Increased surface remodeling
Replacement with weaker mineralized connective tissue
Disruption in repair signaling
Decrease in bone vascularity

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10
Q

How much bone will women lose?

A

50% of trabecular and 35% of cortical bone

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11
Q

What are the most common fractures?

A

Vertebral, followed by hip and distal forearm

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12
Q

How often is the skeleton replaced?

A

Every 10 years

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13
Q

What are the risk factors associated with osteoporosis?

A

Race
Calcium intake
Age
Menopause
Fam history
Sex
Small stature
Weight

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14
Q

What drug has the biggest risk factor?

A

Glucocorticoid therapy

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15
Q

Presentation of osteoporosis

A

No symptomatic manifestations until fracture occurs
Osteoporosis does not cause pain - the fracture does

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16
Q

What might indicate a vertebral fracture?

A

Unexplained pain and height loss

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17
Q

What % of men and women die within 1 year of a hip fracture?

A

33% of men
28% of women

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18
Q

What is diagnostic of osteoporosis?

A

Vertebral compression fracture, hip fracture, or > 1 fragility fracture over 50 years of age

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19
Q

What is a fragility fracture?

A

Trauma of falling from a normal height

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20
Q

Difference in BMD T-score for osteoporosis and osteopenia

A

Osteoporosis: </= -2.5 SD normal peak
Osteopenia: -1 to -2.5 SD normal peak

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21
Q

Elements of physical test for osteoporosis

A

Weight loss of >10% since age of 25
Prospective height loss >2cm
Historical height loss >6cm
Rib to pelvis distance <2 fingers width
Occiput to wall distance >5cm

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22
Q

What are the recommended biochemical tests?

A

Calcium, corrected for albumin
Phosphate
Creatinine (eGFR)
ALP
TSH
25-OH-D
CBC

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23
Q

How is BMD testing done?

A

Dual-energy x-ray absorptiometry (DXA)

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24
Q

When is a t-score used?

A

For adults >50

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25
Q

When is a Z-score used?

A

For adults <50

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26
Q

What are the indications for BMD testing in adults?

A

Previous fracture, after age 40 years
Glucocorticoids (>3mo in last year, prednisone >/=5mg/day)
Falls >2 in last year
Current smoker
Alcohol >3 drinks

27
Q

what are the risk assessment tools for osteoporosis?

A

CAROC
FRAX
Estimate 10 year absolute risk

28
Q

Who is CAROC validated for?

A

Postmenopausal women and men >50

29
Q

Which risk assessment incorporates more factors?

A

FRAX

30
Q

What is the preferred assessment tool?

A

FRAX

31
Q

Why is exercise good for osteoporosis?

A

Stimulates osteoblast activity
Lower fall risk
Decrease fracture risk
Possibly better maintenance of BMD

32
Q

What is the recommended dietary allowance for calcium?

A

Men: >70 1200mg/day
Women: >50 1200mg/day

33
Q

What are the % of elemental calcium in each calcium salt?

A

Carbonate = 40
Citrate = 21
Lactate = 13
Gluconate = 9

34
Q

Which calcium salt is preferred with a PPI?

A

Citrate because carbonate requires some acidity

35
Q

What is the maximum amount of elemental calcium absorbed at once?

A

550mg

36
Q

What is the RDA for vitamin D?

A

</= 70: 600IU/day
>70: 800IU/day

37
Q

What is the preferred form of vitamin D?

A

D3 - cholecalciferol

38
Q

What are the antiresorptives?

A

Bisphosphonates
Denosumab
Raloxifene
Hormone therapy
Calcitonin

39
Q

What are the anabolic treatments?

A

Teriparatide
Romosozumab

40
Q

When should we recommend pharmacotherapy?

A

10 year fracture risk >/= 15% OR t-score <2.5

41
Q

What is the first line treatment?

A

Bisphosphonates

42
Q

What is the recommended treatment for very high risk patients?

A

Teraparatide or romosumab (anabolic)
Should be followed by a bisphosphonate

43
Q

What do Bisphosphonates do?

A

Halt BMD decline and slightly reverse loss

44
Q

What are the Bisphosphonates?

A

Alendronate
Risedronate
Zoledronic acid (IV form)

45
Q

How can alendronate be taken?

A

10mg daily or 70mg weekly

46
Q

How can risedronate be taken?

A

5mg daily or 35mg weekly or 150mg monthly

47
Q

How often is zoledronic acid given?

A

5mg/100ml IV yearly

48
Q

Administration instructions for Bisphosphonates

A

Space from all medications (poor F)
For IR: empty stomach with 1 cup of water, >30 minutes before food, drink and other meds. Remain upright for 30 minutes.
For DR: take with 1 cup of liquid immediately after breakfast. Remain upright for 30 minutes.

49
Q

What fractures are reduced the most by Bisphosphonates?

A

Vertebral
- hip reduced the least

50
Q

Common side effects of Bisphosphonates

A

GI complaints**
Headache
Dizziness
Musculoskeletal pain

51
Q

What are the serious side effects of Bisphosphonates?

A

Osteonecrosis of the jaw
Atypical sub-trochanteric fractures (abnormal place)
Severe musculoskeletal pain
Acute renal injury
Atrial fibrillation (not typical)
Esophagitis, reflux and ulcers
Esophageal cancer

52
Q

Contraindications of Bisphosphonates

A

Esophageal abnormalities
Inability to stand/sit up for 30 minutes
Hypocalcemia
CrCl <35ml/min

53
Q

What is the second line agent?

A

Denosumab (prolia)

54
Q

What is duration of therapy for Denosumab?

A

Indefinite treatment recommended
Benefits lost upon discontinuation

55
Q

Dosing for Denosumab

A

60mg once every 6 months

56
Q

Side effect of Denosumab

A

Very well tolerated
Serious:
- hypocalcemia
- osteonecrosis of the jaw
- atypical fractures
- effect on immune system - increase risk of infection
- rebound fracture risk upon discontinuation

57
Q

CI for Denosumab

A

Hypocalcemia
Pregnancy or lactation

58
Q

What is raloxifene?

A

Only used for women
- third line prevention for postmenopausal women
- women with increased risk of invasive breast cancer
Typically lifelong therapy

59
Q

Side effects of raloxifene

A

Flushing
Flu-like sx
Leg cramps
Peripheral edema
Increase in triglycerides

Serious:
VTE
Stroke

60
Q

CI of raloxifene

A

Pregnancy
History of VTE

61
Q

DI of raloxifene

A

Decrease absorption of levothyroxine
Bile acid sequesterants decrease absorption of raloxifene

62
Q

Where is ralofifenes main benefit?

A

Primarily vertebral fractures
- also ineffective in pre menopausal women

63
Q

How long is teriparatide used for?

A

2 years (daily injections)

64
Q

How long is romosozumab used for?

A

1 year (monthly injections)

PHAR 255 (8 decks)

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