Osteoporosis Flashcards
What are the impt counselling points for Oral Bisphosphonates?
1) Take on an empty stomach w/ at least 240ml of plain water.
2) Wait at least 30 min before taking food. (alen- and risedronate)
Adverse effects of Bisphosphonates are:
- Atypical Femoral Fracture
- Osteonecrosis of the jaw / external auditory canal
- Severe bone, joint or muscle pain
- Ocular effects -> iritis, uveitis
- Hypo-Ca
- Gastrointestinal mucosa irritation
[Oral] N, abdo pain, heartburn
[IV] Flu-like Sx
Contraindications for Bisphosphonates are:
1) GI abnormalities (eg. uncontrolled GORD, bariatric surgery)
2) Unable to sit / stand for 30 min.
3) Aspiration risk
4) Hypo-Ca
5) Hypersensitivity
Special Pop.:
CrCL < 30 ml/min
Pregnancy and Lactation
What is the MoA of Denosumab?
Inhibits RANK Ligand (which is released by osteoblast to activate osteoclast).
Osteoclast is prevented from developing.
Adverse effects of Denosumab are:
Muscle, back, bone, joint pain
N/V/C/D
Slight tiredness
Raised cholesterol
Risk of multiple vertebral fracture on sudden discontinuation.
Contraindications for Denosumab are:
- Hypo-Ca
- Pregnancy
What is the MoA of Raloxifene?
1) Oestrogen receptor agonism +
2) Oestrogen receptor antagonism
-> not used in menopause
What are the benefits of Raloxifene (SERM) over Oestrogen?
Still has same effect on bone density.
Still has increased risk of thrombosis.
Still can cause hot flashes.
But reduces instead of increasing risk of breast cancer.
What is the MoA of Calcitonin?
Secreted by parafollicular cells of the thyroid gland.
- reduces blood Ca
- Inhibits osteoclastic bone resorption.
What is the possible routes of administration of Calcitonin?
IV, SC, IM or nasal spray
Adverse effects of Calcitonin are:
Red streaks on skin
Injection site rxn
Feeling of warmth
Redness of the face, neck, arms, and (occasionally) upper chest
Contraindications for Calcitonin are:
- Hypo-Ca
- Hypersensitivity
What is the MoA of Romosozumab?
Humanized mouse mAb against Sclerostin.
- removes sclerostin inhibition of the canonical Wnt signalling that regulates bone growth.
- Increase bone formation and decrease bone resorption.
Place in therapy for Romosozumab:
Women at high risk of fracture, OR
Failed, OR
are intolerant to other osteoporosis therapies.
Adverse Effects / Contraindications for Romosozumab are:
Contraindications:
- Hypersensitivity
- Uncorrected hypo-Ca (because of potential hypo-Ca)
- Hx of MI or stroke (increased risk)
Other side effects:
- AFF
- ONJ
What is the MoA of Parathyroid Hormone therapies given at intermittent, high doses?
- Stimulates new bone formation
- Increase bone strength
What is the maximum treatment duration for PTH?
24 months in lifetime.
- potentially increased risk of osteosarcomas.
Adverse Effects of PTH therapies are:
Serious calciphylaxis
Worsening of previous stable cutaneous calcification
Hyper-Ca
Transient orthostatic hypotension
Contraindications of PTH therapies are:
- Hypersensitivity
- Pre-existing hyper-Ca
- Skeletal malignancies or bone metastases
- Metabolic bone diseases (eg. Paget’s disease, hyperparathyroidism)
- Unexplained elevations of ALP
- Had Skeletal implant / external beam radiation therapy to the skeleton
- Genetic predisposition to osteosarcoma.
- Severe RENAL impairment
- Pregnancy
Target Serum Vitamin D levels for Osteoporotic patients are:
20-30 ng/ml (50-75 nmol/L)
but less than 50-100 ng/ml (125-250 nmol/L)
What Non-Pharmacological advice is appropriate for an Osteoporotic patient?
- Exercise: 30 min daily weight-bearing, muscle-strengthening & balance (2-3 x weekly)
- Stop / reduce:
1) Smoking
2) Caffeine and alcohol (<= 2 cups/units per day) - Reduce risk of falls
1) Patient education
2) interventions for impaired vision / cataract
3) Footwear
4) Home modifications - Ca intake
1) Supplement if dietary intake < 700mg / d
2) Decreased Ca absorption w/: PPI, fibre.
3) Decreased absorption of: Iron, tetracyclines, FQs, bisphosphonates, thyroid supplement. - Vit D intake
1) 800 IU / d
2) Decreased Vit D levels: rifampin, anticonvulsants, cholestyramine, orlistat, Al-containing products.
Monitoring parameters for osteoporotic treatment are:
- SCr
- Serum Calcium
- Serum 24(OH) Vitamin D
What other lab tests can help to exclude secondary causes of bone loss?
- Erythrocyte sedimentation rate (ESR)
- ALP
- Serum phosphate
- Urine Ca/Cr ratio
- Serum total testosterone
When should a patient be treated for Osteoporosis?
1) Presents w/ fragility #
2) No fragility #, but DXA BMD T-score <= 2.5
3) Osteopaenic and no fragility fracture, but w/ high # risk (FRAX >3% hip # risk or >= 20% major osteoporotic #)
