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Special Populations > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

What are the primary types of osteoporosis?

A
  1. Type 1- postmenopausal
  2. Type 2- age related
  3. idiopathic
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2
Q

What are s/s of osteoporosis?

A
  1. factures
  2. loss of height
  3. kyphosis
  4. pain
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3
Q

What are the impacts of begets vertebral fractures?

A
  1. increases the risk of vertebral fracture 5x
  2. increases the risk of hip fracture 2x
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4
Q

What are the symptoms of begets vertebral fractures?

A
  1. pain
  2. kyphosis
  3. abdominal symptoms
  4. functional limitations
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5
Q

What gender is more likely to experience hip fracture?

A

men > women

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6
Q

What should clinical evaluation for osteoporosis include?

A
  1. medical history (risk factor assessment, s/s)
  2. bone mineral density testing
  3. FRAX (fracture risk) score
  4. physical examination
  5. vertebral testing
  6. laboratory tests, as appropriate
  7. height assessment
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7
Q

What are the risk factors for osteoporosis?

A
  1. aging
  2. menopause
  3. early menopause
  4. caucasian/ asian
  5. family hx
  6. alcohol abuse
  7. cigarette smoking
  8. prolonged activity
  9. small, thin frame
  10. nutritional
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8
Q

What are medical conditions that increase fracture risk?

A
  1. RA/ autoimmune disorders
  2. chronic renal failure
  3. GI disorders
  4. metabolic bone disorders
  5. endocrine disorders
  6. liver disorders
  7. neurological disorders
  8. insulin-dependent DM
  9. organ transplant
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9
Q

What medications can increase fracture?

A
  1. glucocorticoid (oral and high dose inhaled)
  2. aromatase inhibitors
  3. gonadotropin releasing hormones
  4. immunosupporessants
  5. cytotoxic drugs
  6. Lithium
  7. long-term heparin
  8. depo-provera
  9. TPN
  10. PPIs/SSRIs
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10
Q

What are medical risk factors for falls?

A
  1. inadequate vision
  2. dementia
  3. fragility
  4. urinary incontinence
  5. orthostatic hypotension
  6. medications
  7. vitamin D deficiency (<30ng/ml)
  8. arrhythmias
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11
Q

What are the environmental risk factors for falls?

A
  1. low level lighting
  2. loose throw rugs
  3. lack of assisted devices
  4. obstacles
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12
Q

What are the neuromuscular risk factors for falls?

A
  1. poor balance
  2. weak muscles
  3. reduced proprioception
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13
Q

What sites measured during bone density assessment are most predictive of fracture?

A
  1. lumbar spine
  2. proximal femur
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14
Q

What is a T score?

A

the number of standard deviations below or above the average peak bone mass in young adults

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15
Q

What is a normal T score?

A

> /= -1

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16
Q

What T score indicates osteoporosis?

A

</= -2.5

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17
Q

What T score indicates osteopenia?

A

-1 to -2.5

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18
Q

What T score indicates severe or established osteoporosis?w

A

</= -2.5 AND fracture

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19
Q

Each standard deviation decrease in BMD is associated with a _____ fold increase in fracture risk

A

2 fold

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20
Q

What is the preferred site for assessing hip fracture risk?

A

proximal femur

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21
Q

What is the preferred site for assessing therapeutic response?

A

lumbar spine

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22
Q

Where is the earliest evidence of bone loss seen?

A

AP spine

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23
Q

What can be used for diagnosis in the absence of spine or hip measurement in older women with OA?

A

forearm
heel

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24
Q

What type of BMD assessment can identify patients at risk and predict risk of fractures?

A

peripheral x-ray or ultrasound

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25
Q

Who does the US Preventative Services Task Force recommend routine screening for?

A
  1. women >65
  2. women < 65 if 10 year fracture risk >/= that of 65 y/o caucasian woman without additional risk factors
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26
Q

Who should have a BMD test?

A
  1. women > 65
  2. men >70
  3. younger post-menopausal women
  4. women in menopausal transition
  5. men 50-69 with risk factors
  6. postmenopausal women discontinuing estrogen
  7. considering pharmacologic therapy
  8. condition or med associated with low bone mass
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27
Q

What is used to diagnose all women age 70 and all men 80+?

A

vertebral imaging

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28
Q

What are other indications for vertebral imaging?

A
  1. women age 65-69 with BMD -1.5 to lower
  2. men age 75-79 with BMD -1.5 or below
  3. postmenopausal women 50-64
  4. men age 50-69 with low trauma fracture, hx height loss of 1.5 in or more, prospective height loss of 0.8 in or more, long-term glucocorticoid treatment
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29
Q

What is the role of bone turnover markers?

A
  1. predict risk and rate of bone loss independently of bone density
  2. predict risk reduction and BMD increases after 3-6 months of treatment
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30
Q

What are universal recommendations?

A
  1. risk reduction (avoid tobacco, alcohol, high caffeine)
  2. adequate intake of calcium and vit D
  3. weight-bearing exercise
  4. fall prevention
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31
Q

How much elemental Ca is recommended for women >51 and men >71?

A

1200mg/day

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32
Q

How much elemental Ca is recommended for men 50-70?

A

1000mg/day

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33
Q

What is the role of Ca supplementation?

A
  1. delays bone loss later in life
  2. does NOT prevent accelerated postmenopausal bone loss
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34
Q

How is total dietary calcium calculated?

A

dairy Ca + 250mg non dairy Ca

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35
Q

What is the best source of elemental Ca?

A

calcium carbonate

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36
Q

How should calcium carbonate be taken?

A

with meals

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37
Q

What are SEs with calcium supplementation?

A

constipation
gas

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38
Q

What calcium supplement can be given with PPIs and H2RAs?

A

calcium citrate

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39
Q

How should calcium citrate be taken?

A

on an empty stomach

40
Q

How should calcium phosphate be taken?

A

with meals

41
Q

What is the maximum amount of calcium that can be taken at one time?

A

600mg

42
Q

How much liquid should you drink when taking calcium supplements?

A

8 oz

43
Q

What form of calcium has an increased risk of MI compared to dietary calcium?

A

supplemental

44
Q

According to the NOF how much Vit D should be given for osteoporosis in patients < 50 y/o?

A

400-800 IU/day

45
Q

According to the NOF how much Vit D should be given for osteoporosis in patients >/= 50 y/o?

A

800-1000 IU/day

46
Q

According to the IOM how much vit D should be given to prevent osteoporosis in patients <70?

A

600 IU/day

47
Q

According to the IOM how much vit D should be given to prevent osteoporosis in patients >71?

A

800 IU/day

48
Q

What is the ideal vit D concentration in blood?

A

30ng/ml

49
Q

How much vit D should be given if there is a documented deficiency?

A

50,000 IU weekly OR 600 IU QD x 8-12 weeks
THEN 1500-2000 IU/ day

50
Q

Who is a candidate for medications to treat osteoporosis?

A

Postmenopausal women and men over 50 with:
1. hip/vertebral fracture
2. other fractures and low bone mass
3. T-score < -2.5
4. low bone mass and secondary causes associated with high risk of fracture
5. low bone mass and 10-year probability of hip fracture of >/= 3% or a 10-year probability of any osteoporosis-related fracture >/=20%

51
Q

What medications slow or stop the break down of bone-remodeling?

A
  1. ET or HT
  2. SERMs
  3. bisphosphonates
  4. calcitonin-salmon
  5. Denosumab
52
Q

What medications are bone forming?

A
  1. parathyroid hormone and analogs
  2. sclerostin inhibitor
53
Q

What bisphosphonates are used for the prevention and treatment of osteoporosis?

A
  1. Alendronate (FOSAMAX)
  2. Risedronate (ACTONEL)
  3. Ibandronate (BONIVA)
54
Q

What is the dosing of Alendronate for the prevention of osteoporosis?

A

PO 5mg QD or 35mg weekly

55
Q

What is the dosing of Alendronate for the treatment of osteoporosis?

A

PO 10mg QD or 70mg weekly

56
Q

What is the dosing of Risedronate for prevention and treamtment?

A

PO 5mg QD or 35mg weekly or 150mg monthly or 75mg 2 days of the month

57
Q

What is the dosing of Ibandronate for prevention and treatment?

A

PO 2.5 mg QD or 150mg monthly
IV 3mg Q 3 months

58
Q

Who is indicated to take bisphosphonates?

A
  1. men and women
  2. first choice with a previous fracture or high fracture risk
59
Q

How should bisphosphonates be taken?

A
  1. 30-60 minutes upright with plain water before food, beverage, and medication of the day
  2. taken along with Ca and vit D
60
Q

What are SEs with bisphosphonates?

A
  1. irritation of the esophagus
  2. stomach pain
  3. chest pain
  4. heartburn
  5. nausea
61
Q

What are concerns with bisphosphonates?

A
  1. esophageal disorders
  2. low Ca levels
  3. severe kidney disease
  4. allergy
  5. use of aspirin/ NSAIDs
  6. osteonecrosis of the jaw
  7. atypical femur fracture
62
Q

What bisphosphonate is indicated for treatment only of osteoporosis?

A

Zoledronic Acid (RECLAST)

63
Q

What is dosing of Zoledronic Acid?

A

5mg infusion yearly; pretreated with acetaminophen

64
Q

How long should bisphosphonates be used?

A

after initial 3-5 years of tx, a risk assessment should be performed

65
Q

What SERM is approved for prevention and treatment of osteoporosis?

A

Raloxifene (EVISTA)

66
Q

What are SEs with Raloxifene?

A
  1. hot flashes
  2. leg cramps
  3. vaginal discharge
67
Q

What are concerns with Raloxifene?

A

DVT
small increase in fatal stroke
not great for hip fracture

68
Q

What is the dosing of Raloxifene?

A

60mg PO QD with or without meals

69
Q

What SERM treats vasomotor symptoms and prevents osteoporosis in post-menopausal women and is used only for women at significant risk of osteoporosis, nonestrogen therapies are not appropriate?

A

20mg Bazedoxifene and 0.45mg conjugated equine estrogen DUAVEE

70
Q

What is calcitonin-salmon indicated for?

A

treatment for women and men who are unwilling or unable to use HT SERMs or bisphosphonates

71
Q

What is dosing for calcitonin-salmon?

A

200 IU per spray each day alternate nostrils OR
injectable

72
Q

What are SEs with calcitonin-salmon?

A

transient, resolve with continues therapy
1. runny nose
2. nasal crusting
3. nose bleed
4. nasal ulceration
5. nausea

73
Q

What is an additional benefit of calcitonin-salmon?

A

relieves pain of recent spinal fractures and need for analgesics

74
Q

What patients can HRT/ERT be used in?

A

prevention and management of osteoporosis related to menopause

75
Q

What are SEs of ERT/HRT?

A
  1. menstrual bleeding
  2. breast tenderness
  3. mood disturbances
  4. weight gain
76
Q

What are concerns with ERT/HRT?

A
  1. breast cancer
  2. endometrial cancer
  3. deep vein thrombosis
  4. heart disease
  5. stroke
77
Q

What does the FDA advise patients about hormone therapies?

A

encourages women at risk for osteoporosis to discuss alternative non-estrogen therapy for osteoporosis first

78
Q

Who is Denosumab (PROLIA) indicated for?

A

postmenopausal women with osteoporosis at high risk of fracture (hx of osteoporotic fracture, multiple risk factors for fracture, failed other therapy, FRAX 3+)

79
Q

What is the MOA of Denosumab?

A

RANK-L inhibitor

80
Q

What are SEs with Denosumab?

A
  1. back pain
  2. pain in extremity
  3. musculoskeletal pain
  4. hypercholesterolemia
  5. cystitis
81
Q

Why does Denosumab have a REMs program?

A

post-marketing SEs:
1. serious hypocalcemia
2. serious infection
3. serious dermatologic events
4. osteonecrosis of the jaw
5. atypical fracture
6. fracture healing complications
7. acute pancreatitis
8. hypersensitivity

82
Q

What drugs are PTH analogs?

A

Teriparatide FORTEO
Abaloparatide (TYMLOS)

83
Q

How long should PTH analogs be used for?

A

no more than 2 years

84
Q

Who is indicated for Teripatide?

A
  1. treatment of postmenopausal women with high risk of fracture
  2. men with primary hypogonadal osteoporosis at high risk of fracture
    High risk: osteoporotic fractures, multiple risk factors, extremely low BMD -3, unresponsive/intolerant to other therapies
85
Q

How is Teripatide dosed?

A

20mcg SQ QD up to 24 months

86
Q

What are SEs with Teripatide?

A
  1. nausea
  2. leg cramps
  3. dizziness
87
Q

What drug is not recommended to be used with Teripatide due to opposing MOAs?

A

bisphosphonates

88
Q

What are the warnings with Teripatide?

A
  1. hypercalcemia
  2. Paget’s disease of bone
  3. growing children/young adults
  4. pregnant/nursing women
  5. hx bone cancer/ bone mets
  6. radiation to skeleton
89
Q

What is the indication for Abaloparatide TYMLOS??

A

postmenopausal women with osteoporosis at high risk for fracture (hx of fracture, multiple risk factors, or failed/intolerant to other osteoporosis therapy

90
Q

How is Abaloparatide dosed?

A

80mcg SQ QD

91
Q

What is the MOA of Romosozumab -aqqg?

A

sclerostin inhibitor, stimulated boe formation

92
Q

What BBW does Romosozumab-aqqg EVENITY have?

A

potential risk of MI, stroke, and CV death

93
Q

What indication does EVENITY have?

A

osteoporosis in postmenopausal women at high risk of fracture

94
Q

What are SEs with Romosozumab-aqqg?

A
  1. increases risk of heart attack, stroke, and death from heart/ blood vessel diseases
  2. allergic reaction
  3. signs of low Ca (muscle cramps, seizures, numbness/tingling)
  4. new/strange groin, hip, or thigh pain
  5. headache
  6. osteonecrosis of the jaw (rare)
95
Q

What factors increase the likelihood of osteonecrosis of the jaw?

A
  1. long-term use of EVENITY
  2. dental problems
  3. ill-fitting dentures
  4. anemia
  5. blood clotting problems
  6. infection
  7. chemo/radiation
  8. other meds that cause jawbone problems
96
Q

What should be used in combination with ALL osteoporosis therapies?

A

Calcium and vit D

97
Q

What products can be used in combination to tx osteoporosis?

A
  1. severe osteoporosis= bisphosphonate+ERT
  2. Calcitonin-salmon adjunct for pain with recent spinal fractures
  3. Osteoanabolic agents should be followed with a bisphosphonate/ Denosumab

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