Osteoporosis Flashcards
What are the primary types of osteoporosis?
- Type 1- postmenopausal
- Type 2- age related
- idiopathic
What are s/s of osteoporosis?
- factures
- loss of height
- kyphosis
- pain
What are the impacts of begets vertebral fractures?
- increases the risk of vertebral fracture 5x
- increases the risk of hip fracture 2x
What are the symptoms of begets vertebral fractures?
- pain
- kyphosis
- abdominal symptoms
- functional limitations
What gender is more likely to experience hip fracture?
men > women
What should clinical evaluation for osteoporosis include?
- medical history (risk factor assessment, s/s)
- bone mineral density testing
- FRAX (fracture risk) score
- physical examination
- vertebral testing
- laboratory tests, as appropriate
- height assessment
What are the risk factors for osteoporosis?
- aging
- menopause
- early menopause
- caucasian/ asian
- family hx
- alcohol abuse
- cigarette smoking
- prolonged activity
- small, thin frame
- nutritional
What are medical conditions that increase fracture risk?
- RA/ autoimmune disorders
- chronic renal failure
- GI disorders
- metabolic bone disorders
- endocrine disorders
- liver disorders
- neurological disorders
- insulin-dependent DM
- organ transplant
What medications can increase fracture?
- glucocorticoid (oral and high dose inhaled)
- aromatase inhibitors
- gonadotropin releasing hormones
- immunosupporessants
- cytotoxic drugs
- Lithium
- long-term heparin
- depo-provera
- TPN
- PPIs/SSRIs
What are medical risk factors for falls?
- inadequate vision
- dementia
- fragility
- urinary incontinence
- orthostatic hypotension
- medications
- vitamin D deficiency (<30ng/ml)
- arrhythmias
What are the environmental risk factors for falls?
- low level lighting
- loose throw rugs
- lack of assisted devices
- obstacles
What are the neuromuscular risk factors for falls?
- poor balance
- weak muscles
- reduced proprioception
What sites measured during bone density assessment are most predictive of fracture?
- lumbar spine
- proximal femur
What is a T score?
the number of standard deviations below or above the average peak bone mass in young adults
What is a normal T score?
> /= -1
What T score indicates osteoporosis?
</= -2.5
What T score indicates osteopenia?
-1 to -2.5
What T score indicates severe or established osteoporosis?w
</= -2.5 AND fracture
Each standard deviation decrease in BMD is associated with a _____ fold increase in fracture risk
2 fold
What is the preferred site for assessing hip fracture risk?
proximal femur
What is the preferred site for assessing therapeutic response?
lumbar spine
Where is the earliest evidence of bone loss seen?
AP spine
What can be used for diagnosis in the absence of spine or hip measurement in older women with OA?
forearm
heel
What type of BMD assessment can identify patients at risk and predict risk of fractures?
peripheral x-ray or ultrasound
Who does the US Preventative Services Task Force recommend routine screening for?
- women >65
- women < 65 if 10 year fracture risk >/= that of 65 y/o caucasian woman without additional risk factors
Who should have a BMD test?
- women > 65
- men >70
- younger post-menopausal women
- women in menopausal transition
- men 50-69 with risk factors
- postmenopausal women discontinuing estrogen
- considering pharmacologic therapy
- condition or med associated with low bone mass
What is used to diagnose all women age 70 and all men 80+?
vertebral imaging
What are other indications for vertebral imaging?
- women age 65-69 with BMD -1.5 to lower
- men age 75-79 with BMD -1.5 or below
- postmenopausal women 50-64
- 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
What is the role of bone turnover markers?
- predict risk and rate of bone loss independently of bone density
- predict risk reduction and BMD increases after 3-6 months of treatment
What are universal recommendations?
- risk reduction (avoid tobacco, alcohol, high caffeine)
- adequate intake of calcium and vit D
- weight-bearing exercise
- fall prevention
How much elemental Ca is recommended for women >51 and men >71?
1200mg/day
How much elemental Ca is recommended for men 50-70?
1000mg/day
What is the role of Ca supplementation?
- delays bone loss later in life
- does NOT prevent accelerated postmenopausal bone loss
How is total dietary calcium calculated?
dairy Ca + 250mg non dairy Ca
What is the best source of elemental Ca?
calcium carbonate
How should calcium carbonate be taken?
with meals
What are SEs with calcium supplementation?
constipation
gas
What calcium supplement can be given with PPIs and H2RAs?
calcium citrate
How should calcium citrate be taken?
on an empty stomach
How should calcium phosphate be taken?
with meals
What is the maximum amount of calcium that can be taken at one time?
600mg
How much liquid should you drink when taking calcium supplements?
8 oz
What form of calcium has an increased risk of MI compared to dietary calcium?
supplemental
According to the NOF how much Vit D should be given for osteoporosis in patients < 50 y/o?
400-800 IU/day
According to the NOF how much Vit D should be given for osteoporosis in patients >/= 50 y/o?
800-1000 IU/day
According to the IOM how much vit D should be given to prevent osteoporosis in patients <70?
600 IU/day
According to the IOM how much vit D should be given to prevent osteoporosis in patients >71?
800 IU/day
What is the ideal vit D concentration in blood?
30ng/ml
How much vit D should be given if there is a documented deficiency?
50,000 IU weekly OR 600 IU QD x 8-12 weeks
THEN 1500-2000 IU/ day
Who is a candidate for medications to treat osteoporosis?
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%
What medications slow or stop the break down of bone-remodeling?
- ET or HT
- SERMs
- bisphosphonates
- calcitonin-salmon
- Denosumab
What medications are bone forming?
- parathyroid hormone and analogs
- sclerostin inhibitor
What bisphosphonates are used for the prevention and treatment of osteoporosis?
- Alendronate (FOSAMAX)
- Risedronate (ACTONEL)
- Ibandronate (BONIVA)
What is the dosing of Alendronate for the prevention of osteoporosis?
PO 5mg QD or 35mg weekly
What is the dosing of Alendronate for the treatment of osteoporosis?
PO 10mg QD or 70mg weekly
What is the dosing of Risedronate for prevention and treamtment?
PO 5mg QD or 35mg weekly or 150mg monthly or 75mg 2 days of the month
What is the dosing of Ibandronate for prevention and treatment?
PO 2.5 mg QD or 150mg monthly
IV 3mg Q 3 months
Who is indicated to take bisphosphonates?
- men and women
- first choice with a previous fracture or high fracture risk
How should bisphosphonates be taken?
- 30-60 minutes upright with plain water before food, beverage, and medication of the day
- taken along with Ca and vit D
What are SEs with bisphosphonates?
- irritation of the esophagus
- stomach pain
- chest pain
- heartburn
- nausea
What are concerns with bisphosphonates?
- esophageal disorders
- low Ca levels
- severe kidney disease
- allergy
- use of aspirin/ NSAIDs
- osteonecrosis of the jaw
- atypical femur fracture
What bisphosphonate is indicated for treatment only of osteoporosis?
Zoledronic Acid (RECLAST)
What is dosing of Zoledronic Acid?
5mg infusion yearly; pretreated with acetaminophen
How long should bisphosphonates be used?
after initial 3-5 years of tx, a risk assessment should be performed
What SERM is approved for prevention and treatment of osteoporosis?
Raloxifene (EVISTA)
What are SEs with Raloxifene?
- hot flashes
- leg cramps
- vaginal discharge
What are concerns with Raloxifene?
DVT
small increase in fatal stroke
not great for hip fracture
What is the dosing of Raloxifene?
60mg PO QD with or without meals
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?
20mg Bazedoxifene and 0.45mg conjugated equine estrogen DUAVEE
What is calcitonin-salmon indicated for?
treatment for women and men who are unwilling or unable to use HT SERMs or bisphosphonates
What is dosing for calcitonin-salmon?
200 IU per spray each day alternate nostrils OR
injectable
What are SEs with calcitonin-salmon?
transient, resolve with continues therapy
1. runny nose
2. nasal crusting
3. nose bleed
4. nasal ulceration
5. nausea
What is an additional benefit of calcitonin-salmon?
relieves pain of recent spinal fractures and need for analgesics
What patients can HRT/ERT be used in?
prevention and management of osteoporosis related to menopause
What are SEs of ERT/HRT?
- menstrual bleeding
- breast tenderness
- mood disturbances
- weight gain
What are concerns with ERT/HRT?
- breast cancer
- endometrial cancer
- deep vein thrombosis
- heart disease
- stroke
What does the FDA advise patients about hormone therapies?
encourages women at risk for osteoporosis to discuss alternative non-estrogen therapy for osteoporosis first
Who is Denosumab (PROLIA) indicated for?
postmenopausal women with osteoporosis at high risk of fracture (hx of osteoporotic fracture, multiple risk factors for fracture, failed other therapy, FRAX 3+)
What is the MOA of Denosumab?
RANK-L inhibitor
What are SEs with Denosumab?
- back pain
- pain in extremity
- musculoskeletal pain
- hypercholesterolemia
- cystitis
Why does Denosumab have a REMs program?
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
What drugs are PTH analogs?
Teriparatide FORTEO
Abaloparatide (TYMLOS)
How long should PTH analogs be used for?
no more than 2 years
Who is indicated for Teripatide?
- treatment of postmenopausal women with high risk of fracture
- 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
How is Teripatide dosed?
20mcg SQ QD up to 24 months
What are SEs with Teripatide?
- nausea
- leg cramps
- dizziness
What drug is not recommended to be used with Teripatide due to opposing MOAs?
bisphosphonates
What are the warnings with Teripatide?
- hypercalcemia
- Paget’s disease of bone
- growing children/young adults
- pregnant/nursing women
- hx bone cancer/ bone mets
- radiation to skeleton
What is the indication for Abaloparatide TYMLOS??
postmenopausal women with osteoporosis at high risk for fracture (hx of fracture, multiple risk factors, or failed/intolerant to other osteoporosis therapy
How is Abaloparatide dosed?
80mcg SQ QD
What is the MOA of Romosozumab -aqqg?
sclerostin inhibitor, stimulated boe formation
What BBW does Romosozumab-aqqg EVENITY have?
potential risk of MI, stroke, and CV death
What indication does EVENITY have?
osteoporosis in postmenopausal women at high risk of fracture
What are SEs with Romosozumab-aqqg?
- increases risk of heart attack, stroke, and death from heart/ blood vessel diseases
- allergic reaction
- signs of low Ca (muscle cramps, seizures, numbness/tingling)
- new/strange groin, hip, or thigh pain
- headache
- osteonecrosis of the jaw (rare)
What factors increase the likelihood of osteonecrosis of the jaw?
- long-term use of EVENITY
- dental problems
- ill-fitting dentures
- anemia
- blood clotting problems
- infection
- chemo/radiation
- other meds that cause jawbone problems
What should be used in combination with ALL osteoporosis therapies?
Calcium and vit D
What products can be used in combination to tx osteoporosis?
- severe osteoporosis= bisphosphonate+ERT
- Calcitonin-salmon adjunct for pain with recent spinal fractures
- Osteoanabolic agents should be followed with a bisphosphonate/ Denosumab
