Osteoporosis

Question 1

Adequate Ca++ intake

Answer 1

1200 mg daily

Question 2

Dosing supplemental Ca++

Answer 2

500-1000 mg divided in doses through-out the day

Question 3

Recommended dose vit d

Answer 3

800 IU daily

Question 4

Celiac dz & osteoporosis

Answer 4

When celiac is major contributor to osteopenia, follow gluten free diet

Question 5

Smoking & osteoporosis

Answer 5

Accelerates bone loss

Question 6

Indications for treatment osteoporosis

Answer 6

–postmenopausal, fragility Fx, T 3% or combined MDR osteoporotic Fx > 20%

Question 7

Check prior to Tx osteoporosis

Answer 7

Vit D, Ca++

Question 8

1st line PO bisphosphonates

Answer 8

Alendronate
Risendronate

*both=efficacy in reducing vertebral 7 hip Fx

Question 9

Severe osteoporosis

Answer 9

T

Question 10

Contra bisphosphonates

Answer 10

• -no PO ~ if esophageal disorder (Can use IV formulation)
• -cannot stay upright for at least 30-60 min
• -GFR

Question 11

IV bisphosphonates of choice

Answer 11

Zoledronic acid: demonstrated to reduce vertebral & hip Fx

Ibandronate also available, but no data of proven efficacy

Question 12

Pt with severe osteoporosis & GFR

Answer 12

Denosumab

Question 13

Indication to stop bisphosphonates

Answer 13

Severe bone pain

Question 14

Teriparatide dosing interval

Answer 14

SQ daily

Question 15

Denosumab dosing frequency

Answer 15

Q 6 months SQ

Question 16

Postmenopausal osteoporosis & no Hx of fragility fx, but intolerant of bisphosphonates OR increased risk breast CA

Answer 16

Raloxifene–antiresorptive effects are less than bisphosphonates

Question 17

What is teriparatide

Answer 17

Recombinant PTH

Question 18

Monitoring response to therapy

Answer 18

*DEXA misses most of the changes that reduce risk fx

Repeat DEXA @ 2 yrs. if stable/improved, less frequently thereafter

Don’t use markers of bone turnover

Test more frequently in conditions associated with more rapid bone loss (ex: glucocorticoid )

Question 19

Pt on bisphosphonates has worsening T score or fragility Fx

Answer 19

Compliance?
GI absorption?
Inadequate Ca++/vit. D
Development of other bone dz / secondary causes of bone loss
Consider repeat DEXA in 1 year

Question 20

Pt on bisphosphonates and has

Answer 20

Continue same drug, repeat DEXA in 2 yrs

Question 21

Pt on bisphosphonates and has > 5% DECREASE in bone density

Answer 21

Switch from PO to IV bisphosphonates (usu zolendronic acid)

Otherwise, consider switching to denosumab or teriparatide

Question 22

Pt with severe osteoporosis who continues to Fx 1 year after bisphosphonates

Answer 22

Teriparatide

Question 23

SERM of choice

Answer 23

Raloxifene

Inhibit bone resorption, reduce risk vertebral Fx. Reduces risk breast CA. Increased VTE & hot flashes. No apparent effect on CAD or endometrium
*Tamoxifen for breast CA likely provides same benefit, but no data to back it up

Question 24

Why is HRT no longer recommended for osteoporosis

Answer 24

Increased risk breast CA, stroke, VTE, CAD

Question 25

Calcitonin & osteoporosis

Answer 25

Relatively modest effects on bone density | Long term use may increase risk CA

Question 26

Esophageal risks of bisphosphonates

Answer 26

Can lead to pill esophagitis, esophageal ulcers | May be disabling, lead to hospitalization. NSAID increases risk

Question 27

Higher rate of UGIB... Risendronate vs alendronate

Answer 27

Neither /same risk

Question 28

Potential ADE of bisphosphonates... Particularly IV formation

Answer 28

Hypocalcemia, magnitude & duration worse in those with hypoparathyroidism, Vit D deficiency, or inadequate Ca++ intake

Question 29

What should be taken in pt on bisphosphonates

Answer 29

Ca++, vit D.... But Ca++ should NOT be taken WITH the bisphosphonates b/c will interfere with absorption

Question 30

Pain and bisphosphonates

Answer 30

May occur years later... Myalgias, arthralgias. If pt still on bisphosphonates & these occur, stop the bisphosphonates

Question 31

Renal function and bisphosphonates

Answer 31

No go if GFR

Question 32

Eye ADE of bisphosphonates

Answer 32

Pain, blurred vision, conjunctivitis, uveitis, scleritis

Question 33

Bisphosphonates and arrhythmia

Answer 33

Usu related to hypocalcemia. Unclear if the Rx causes AF

Question 34

Pt in bisphosphonates develops jaw pain

Answer 34

Eval for exposed bone, osteonecrosis of the jaw. STOP bisphosphonates. Highest risk: MM, metastatic breast CA treated with high dose IV bisphosphonates, duration therapy, dental extractions, poorly fitting dentures, glucocorticoid , smoking, DM,

Question 35

How address pt who requires bisphosphonates but has dental extractions necessary?

Answer 35

Delay bisphosphonates by at least a few months; discuss risk and Sn/Sx with pt in detail

Question 36

Is a dental visit prior to bisphosphonates necessary

Answer 36

Not mandatory

Question 37

What if pt is taking bisphosphonates and it is discovered that a dental extraction is required

Answer 37

Course of action not clear

Question 38

Bisphosphonates and femur FX

Answer 38

Atypical femur fx = rare complication of bisphosphonates , associated with prolonged use (>7 yrs). Tx up to 5 yrs typically not associated with Fx, so do not defer bisphosphonates in those at high risk of osteoporotic fx Absolute risk of fx is low3-50 per 100k treated *pt with atypical fx in one leg is at increased risk for same in contra lateral leg

Question 39

Pt on bisphosphonates develops groin pain or pain in thigh

Answer 39

Worry about atypical femoral fx--is a stress fx, but bisphosphonates inhibit NML intracortical remodeling. When bisphosphonates are stopped, the risk of atypical fx declines