Osteoporosis

Question 1

Osteoporosis is a bone disorder of… (4)

Answer 1

• low density
• impaired architecture
• compromised strength
• increased fx risk

Question 2

Men & women begin to lose bone mass starting in what decade?

Answer 2

3rd-4th bc of reduced bone formation

Question 3

What 4 lifestyle factors should you recommend to your pts?

Answer 3

• regular exercise
• nutritious diet
• avoid tobacco/alcohol
• fall prevention

Question 4

What causes age-related osteoporosis?

Answer 4

Hormone, Ca, Vit D deficiencies –> accelerated bone turnover & reduced osteoblasts

Question 5

What causes drug-induced osteoporosis?

Answer 5

steroids, TRH, antiepileptics

Question 6

What are 8 RFs for fx?

Answer 6

• advancing age
• previous fx
• steroid therapy
• low body weight
• parental hx of hip fx
• excessive alcohol
• smoking
• RA

Question 7

What are 2 predictive tools used for osteoporosis?

Answer 7

• FRAX tool

- Garvan calculator

Question 8

What is the T score for osteoporosis?

Answer 8

At or below -2.5

Question 9

What is the T score for osteopenia?

Answer 9

Btwn -1 & -2.5

Question 10

How do you dx osteoporosis in children, premenopausal women, & men under 50?

Answer 10

Based on z-score at or below -2.0 in combo w/ other RFs or fx

Question 11

What is the medication of choice in regards to antiresorptive therapy?

Answer 11

Bisphosphonates, along w/ Ca & Vit D

Question 12

What are the 2 basic forms of Ca?

Answer 12

• Ca carbonate

- Ca citrate

Question 13

What are the ADEs of carbonate?

Answer 13

• Gas, upset stomach, bloating, constipation

- Kidney stones

Question 14

What are the ADEs of both carbonate & citrate?

Answer 14

• Hypophosphotemia

- Hypercalciumia

Question 15

What are ADEs of Vit D3?

Answer 15

• Hypercalcemia –> cardiac rhythm disturbance, HA, weakness

- Hypercalcuria

Question 16

What is considered the natural vitamin D form vs the plant-derived form?

Answer 16

• Vit D2 = plant form

- Vit D3 = natural form

Question 17

Where is Vit D hydroxylated? What does it form?

Answer 17

In the liver
Forms 25(OH)D

Question 18

What are indications for exogenous vit D?

Answer 18

• renal osteodystrophy
• hypoparathyroidism
• refractory rickets

Question 19

What are 4 examples of bisphosphonates?

Answer 19

• Alendronate
• Ibandronate
• Risedronate
• IV Zoledronic acid

Question 20

When is IV & oral ibandronate indicated?

Answer 20

Only for postmenopausal osteoporosis

Question 21

Bisphosphonates: MOA

Answer 21

Mimic pyrophosphate (bone resorption inhibitor)

Question 22

When & how is alendronate administered?

Answer 22

In the AM on empty stomach w/ 6-8 ounces of water

Question 23

What precautions should you take w/ alendronate & risedronate?

Answer 23

• Do not eat
• Remain upright for at least 30 mins following dose
• Do not coadminister w/ any other meds

Question 24

What precautions should you take w/ ibandronate?

Answer 24

Delay eating & remain upright for at least 60mins

Question 25

How should you take "delayed-release" risedronate?

Answer 25

Immediately following breakfast

Question 26

What are common ADEs of bisphosphonates? (oral vs IV)

Answer 26

- Oral: Nausea, dyspepsia | - IV: flu-like illness

Question 27

What are bone turnover markers?

Answer 27

- Resorptive: Type 1 collagen degradation, enzymes | - Formation: matrix proteins, enzymes

Question 28

What are rare ADEs of bisphosphonates?

Answer 28

- perforation, ulceration, GI bleed - musculoskeletal pain - atypical fx - ONJ - subtrochanteric femoral fx

Question 29

What are the contraindications of bisphosphonates?

Answer 29

- CrCl < 30-35 - Serious GI conditions - Pregnancy

Question 30

ONJ black box warning

Answer 30

Occurs more commonly in pts w/ CA, chemo, radiation, &/or steroid therapy receiving higher-dose IV bisphosphonate therapy

Question 31

Who is applicable to go on a "drug holiday"?

Answer 31

- women w/out evidence of low-trauma fx who have responded well to bisphosphonate therapy - those w/ BMD increasing into osteopenic range can be considered

Question 32

What is a "drug holiday"?

Answer 32

Bisphosphonate therapy is removed & pt is followed serially w/ bone turnover markers & central DXA BMD

Question 33

What did the FLEX study demonstrate?

Answer 33

Maintenance of BMD in postmenopausal women after cessation of alendronate therapy Therefore pts should have long-term benefits, despite cessation. However, continue to monitor.

Question 34

What is calcitonin? What may it provide pain relief w/?

Answer 34

- Endogenous hormone released from thyroid gland when Ca is elevated - 3rd line tx for those at least 5 yrs post menopause - relief w/ acute vertebral fx

Question 35

What drug classes does both raloxifene & bazedoxifene belong to?

Answer 35

- 2nd gen mixed estrogen agonist/antagonist (EAA) | - Selective estrogen receptor modulators (SERMs)

Question 36

Who is bazedoxifene used for?

Answer 36

Postmenopausal women w/ a uterus No progestogen needed

Question 37

What is teriparatide?

Answer 37

Recombinant product representing 1st 34 amino acids in PTH

Question 38

Who is teriparatide used for?

Answer 38

- Postmanopausal women, men, & pts on steroids at high risk - Very low bone density T score < -3.5

Question 39

What are surgical options for those w/ pain btwn 6-52 wks after a vertebral fx?

Answer 39

- Vertebroplasty - Kyphoplasty *Cement is injected into fx

Question 40

What are ADEs of a vertebroplasty or kyphoplasty?

Answer 40

Cement leakage into SC --> nerve damage & vertebral fx around the cement

Question 41

What is abaloparatide? What does it do? Who is it used for?

Answer 41

- Synthetic analog of PTH - Stimulates bone formation - Postmenopausal w/ osteoporosis at high risk for fx or who failed other therapies

Question 42

What did the ACTIVE trial demonstrate?

Answer 42

Reduced vertebral & nonvertebral fractures, & increased bone density w/ abaloparatide

Question 43

What is denosumab? MOA?

Answer 43

- RANKL Inhibitor | - Binds to RANKL inhibiting osteoclatogenesis

Question 44

Who is denosumab used for?

Answer 44

postmenopausal women & chemo induced osteoporosis

Question 45

What are ADEs of denosumab?

Answer 45

- musculoskeletal pain | - increased cholesterol, cystitis, decreased Ca, skin problems

Question 46

Define osteomalacia

Answer 46

- Soft bones, bone is undermineralized | - Rickets is equivalent

Question 47

What causes osteomalacia?

Answer 47

- prolonged vit D deficiency - disorders that cause hypophosphatemia - meds (anticonvulsants)

Question 48

What are consequences of osteomalacia?

Answer 48

- Fx - Deep bone pain - proximal weakness - low BMD

Question 49

What are the Vit D levels like in osteomalacia?

Answer 49

Extremely low 25(OH)

Question 50

How do you tx osteomalacia?

Answer 50

Oral ergocalciferol