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Exam 2-MSK > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Concept:

2 Types of Bone

A

Cortical: outer shell, makes up 75% of all bone mass

Trabecular:
spongy, interlacing network forming internal support
-Concentrated in vertebral bodies/bony pelvis; 25% all bone mass, however makes up most volume of bone
larger surface area
higher turnover rate than cortical bone
Most likely to show bone loss
Also most likely to show response to therapy

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2
Q

Concept:

Bone Life

A
  • Formation in balance with resorption
  • Bone mass peaks at age 30 both sexes
  • 0.4% bone lost per year in both genders, PLUS 2% cortical and 5% of trabecular per year in women for first 5-8 years post menopause
  • Immediately after menopause, most loss due to excess resorption. Later, most loss is due to decreased formation
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3
Q

Concept:
Secondary Osteoporosis:
Oral Glucocorticoid Induced

A
  • 25% of cases of osteoporosis
  • Up to 30% decrease in bone mineral density after 6 months
  • 400% increase in fractures at prednisone 7.5 mg/day
  • No “safe dose”
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4
Q

Concept:

Calcium and Vitamin D

A

Diet and Exercise
-Calcium (milk) helps build dense bones
-Vitamin D: Cheese, butter, fortified milk, healthy cereals, fatty fish
Calcium: food sources of calcium dairy products, green leafy veggies, and salmon and sardines

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5
Q

Childhood Dietary Recommendations

A

Age (Calcium/Vit D)
4-8 (1000/600)
9-18 (1200/600)

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6
Q

Adult Dietary Recommendations

A

Calcium

  • Women under 50 or men under 70
    - 1,000 mg/day
  • Women 50+ or men over 70
    - 1,200 mg/day

Vitamin D

  • age 70…need 600 IU/day
  • Age 70+ …need 800 IU/day
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7
Q

FRAX

A

Online fracture risk calculator

Developed by WHO

Gives 10-year probability of hip fracture and of major osteoporotic fracture

Treatment recommended for osteopenic patients with 10-year hip fracture risk > 3% or major osteoporotic fracture risk >20%

Only for treatment-naïve patients

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8
Q

Medication Management Options

A
  • Calcium and Vit. D
  • Bisphosphonates
  • HRT
  • Raloxifene
  • Calcitonin
  • N 1-34 PTH (teriparatide
  • denosumab
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9
Q

Calcium/Vitamin D

A

adjuvant therapy for all individuals (esp > 65 y/o)

WHI study – modest benefit in bone health

Statistically significant only with FULL doses and in older population

Otherwise – small increase in BMD with small decrease in hip fractures.

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10
Q

Carbonate vs Citrate

A

difference is in absorption; ALWAYS TAKE WITH FOOD!
Citrates (Citracel) absorb better! But need to take more pills.
Calcium carbonate (Tums) is fewer pills but must be taken with food!

elemental Calcium (read the serving size to see how many you need to get to the correct amount)
(500-600 mg can be absorbed at a time)
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11
Q

Bisphonsphonates

A

Alendronate, risedronate, ibandronate, zoledronic acid

MOA: Increase bone mass, reduce incidence of fractures by inhibiting osteoclast activity

Use: Effective for treatment and prevention of osteoporosis

Complications – osteonecrosis of the jaw (seen mostly in cancer pts getting IV bisphosphonates)

Warnings: pill induced esophagitis (reflux, GERD, other esophageal abnormalities); MUST take on empty stomach and remain upright for 30 - 60 min; Cat X in child-bearing age women (stays in bone 7-10 yrs); Uveitis/Scleritis (low-risk)

Monitoring: DXA -Bone turnover markers; Formation-Alk phos
Resorption: Urine NTX, Urine CTX
Medicare will cover-DXA w/o Tx-every two years; DXA w/ Tx-once a year

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12
Q

Biphosphonates: Alendronate (Fosamax)

A

Ind: Osteoporosis prevention (35mg) and Tx (70 mg/week); Paget’s Disease

ADRs: dyspepsia!! abd pain, acid reflux, contipation, diarrhea, msk pain, nausea; hypocalcemia; uveitis/scleritis

BLACK BOX: thigh or groin pain requires eval for trochanteric fracture

Make sure they get their dental workup before starting and let their dentist know

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13
Q

Bisphosphonates: Osteonecrosis of the Jaw

A
  • Usually after dental extraction
  • More common with IV bisphosphonates
  • Cases in oral alendronate-1:1000 per year – 1:100000
  • Most cases in pts after 5 years of use
  • Recommend good oral hygiene, dental exam or extractions prior to starting bisphosphonates if possible
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14
Q

Biphosphonate:

Risedronate (actonel, Atelvia)

A

Dosing- weekly to twice a month or a month

same instructions as general

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15
Q

Zoledronate (Reclast

A
  • Yearly 5mg IV infusion over >15minutes
  • Reduced spine fractures by 70%, hip fractures by 41% over 3 years
  • Flu-like infusion reactions in 32% of patients with the first dose, 7% with the second dose, 3% with the third dose

**ONJ- higher incidence!

Different dosing and formulation for cancer
Ind: hypercalcemia of malignancy, MM, bone mets

Monitor renal fxn

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16
Q

Ibandronate (Boniva)

A

Once a month oral dose; once IV every three months

60 minute wait time before eating or drinking

17
Q

Pamidronate (Aredia)

A

IV bisphosphonate

  • less potent than zoledronic acid
  • similar uses
18
Q

Biphosphonates: Concerns and Issues

A
  • GI side effects
  • Infusion reactions
  • Osteonecrosis of the jaw
  • Arrhythmias
  • Bone quality
  • Uveitis/scleritis
19
Q

Concept:

Osteoporosis Incidence

A

osteoporosis-related fractures in women is greater than the incidence of MI, CVA, and breast cancer combined

20
Q

Concept:

Hip Fracture Pt Outcomes

A

24% die within one year.

20% require long-term nursing home care.

15% regain limited function.

Only 20-40% return to pre-fracture level of independence.

Men tend to have poorer outcomes.

21
Q

Hormones

A

MOA: Regulates bone re-modeling by suppressing osteoclast-mediated bone resorption

-estrogen-progesterone therapy no longer first-line approach for osteoporosis treatment in postmenopausal women due to increased risk of breast cancer, stroke, VTEs, and possibly CAD.

Indications: persistent menopausal symptoms, inability to tolerate other options, failure to respond to other options.

Initial recommendations – start hormone therapy within 5-10 years after menopause

22
Q

SERMs

A

MOA: Mixed estrogenic and antiestrogen properties depending on tissue

Raloxifene (Evista)

  • increases BMD
  • Decreases incidence of vertebral fractures (ARR: 2.4%; RRR: 55%)
  • lowers risk of breast Ca without stimulating endometrial hyperplasia

ADRs: increased risk of DVTs and increased vasomotor symptoms
(hot flashes, etc)

Black box: DVT, stroke risk

23
Q

Calcitonin (Miacalcin, Fortical)

A

MOA: Inhibits bone resorption

Ind: women > 5 years post menopause who cannot take estrogen; Not terribly effective for osteoporosis; Increases vertebral BMD modestly

ADR: Fracture risk…meh

24
Q

Teriparatide (Forteo)

A

MOA: synthetic parathyroid hormone; helps build bone by stimulating osteoblast activity
-Effects blunted by bisphonphonates being started first

Ind: Female –postmenopausal OP with high fracture risk
Male - primary or hypogonadal OP with high fracture risk
(not first line, but can use in major osteoporosis)

ADRs: Transient + persistent hyperCa+;
HA; Transient myalgia/arthralgia

CI: Paget’s disease, pregnant/nursing, pediatrics/young adults, prior radiation therapy, bone mets, skeletal malignancies, hypercalcemia

Black Box: Osteosarcoma risk

25
Q

Denosumab (Prolia, Xgeva)

A

MOA: Monoclonal antibody that blocks RANK ligand which stimulates osteoclasts; Principal final mediator of osteoclastic bone resorption

Indications:
Prolia: treatment of postmenopausal women with osteoporosis at high risk for fracture
(reduces non-verterbral and non-vertebral fractures)
Xgeva: giant cell bone tumors; increase bone mass and precent SREs with bone mets from solid tumors

Every 6 months SubQ
Take w/ Ca+ and Vit D

ADRs: cellulitis, eczema, flatulence, fatigue, asthenia, hypophosphatemia, nausea, dyspnea, arthralgia, headache

Warnings: hypocalcemia, ONJ, rash, infection, atypical fracture

Preg Cat D

26
Q

Guidelines Drugs

A
  1. Use alendronate, risedronate, zoledronic acid or denosumab first line
  2. Use ibandronate as a second-line agent
  3. Use raloxifene as a second- or third-line agent
  4. Use calcitonin last line

Use first-line teriparatide for patients with VERY HIGH fracture risk or patients in whom bisphos therapy failed

Advise against the use of combination therapy

27
Q

Guidelines: Monitoring

A

Monitoring- Obtain a baseline DXA, and repeat DXA every 1 to 2 years until findings are stable; follow-up DXA every 2 years or at a less frequent interval

Monitor changes in spine or total hip bone mineral density (BMD)

Follow-up of patients should be in the same facility, with the same machine, and, if possible, with the same tech

Bone turnover markers may be used at baseline to identify patients with high bone turnover and can be used to follow the response to therapy

Exam 2-MSK (3 decks)

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