Osteoporosis Flashcards by Megan Jacobson

Define the following:

Bone disorder of…

low bone density
impaired bone architecture
compromised bone strength
increased fracture risk

Osteoporosis

How well did you know this?

Not at all

Perfectly

At what age do men and women begin to lose bone mass due to reduced bone formation?

30s-40s

How well did you know this?

Not at all

Perfectly

____________ deficiency during menopause increases _________ activity, increasing bone _________ more than ___________.

Estrogen deficiency during menopause increases osteoclast activity, increasing bone resorption more than formation.

How well did you know this?

Not at all

Perfectly

Why are men at a lower risk for developing osteoporosis and osteoporotic fractures?

They have

larger bone size
greater peak bone mass
increase in bone width with aging
fewer falls
shorter life expectancy

How well did you know this?

Not at all

Perfectly

What does male osteoporosis result from?

aging or secondary causes

How well did you know this?

Not at all

Perfectly

incorporate a bone-healthy lifestyle beginning at birth and continuing throughout life
emphasize regular exercise, nutritious diet, tobacco avoidance, minimal alcohol use
fall prevention to prevent and treat osteoporosis

The following are…

prevention techniques that should be used at all ages

How well did you know this?

Not at all

Perfectly

What 3 deficiencies lead to accelerated bone turnover and reduced ostoblast formation that causes age related osteoporosis?

VItamin D
Calcium
Hormones

How well did you know this?

Not at all

Perfectly

What results from systemic corticosteroids, thyroid hormone replacement, antiepileptic drugs (phytoin, phenobarbital), depot medroxyprogesterone acetate?

Drug incuded osteoporosis

How well did you know this?

Not at all

Perfectly

What are the two predictive tools?

FRAX tool & Garvan calculator

How well did you know this?

Not at all

Perfectly

World Health Organization (WHO) created tool which uses risk factors to predict the percent probability of fracture in the next 10 years

Which predictive tool?

FRAX tool

How well did you know this?

Not at all

Perfectly

Which predictive tool?

uses four risk factors (age, sex, low-trauma fracture, and falls) with the option to also use BMD.
Calculates 5- and 10-year risk estimates of any major osteoporotic and hip fracture.

Garvan Calculator

How well did you know this?

Not at all

Perfectly

Which predictive tool?

Tool corrects some disadvantages of FRAX
includes falls and number of previous fractures

Garvan calculator

How well did you know this?

Not at all

Perfectly

What is the diagnostic standard for osteoporosis/ bone mineral density?

dual-energy x-ray absorptiometry (DXA)

How well did you know this?

Not at all

Perfectly

Diagnosis of osteoporosis is based on what 3 things?

low trauma fracture

central hip

and/or

spine DXA using WHO-T score thresholds

How well did you know this?

Not at all

Perfectly

What is the T-score range for Osteopenia?

-1 and -2.5

How well did you know this?

Not at all

Perfectly

What is the T score range for Osteoporosis?

< or equal to -2.5

How well did you know this?

Not at all

Perfectly

Dx of osteoporosis in children, premenopausal women and men < 50 y/o should be based on a Z score at or below what?

-2.0

How well did you know this?

Not at all

Perfectly

What are the medications of choice for osteoporosis?

biphosphonates with calcium and Vit D

How well did you know this?

Not at all

Perfectly

What are the 2 basic forms of Calcium?

calcium carbonate

calcium citrate

How well did you know this?

Not at all

Perfectly

Which type of calcium is indicated on the label of calcium supplements?

elemental calcium

How well did you know this?

Not at all

Perfectly

What are the adverse effects of carbonate?

gas, upset stomach, bloating, constipation

rare kidney stones

How well did you know this?

Not at all

Perfectly

What are the 2 adverse effects for both types of calcium?

hypophosphotemia

hypercalciumia

How well did you know this?

Not at all

Perfectly

Metabolism of which drug?

*Hepatic metabolism to 25 (OH) Vit D and then renal metabolism to 1,25 (OH) Vit D

How well did you know this?

Not at all

Perfectly

Adverse effects of Vitamin D3 (Cholecalciferol- natural form)

Hypercalcemia: cardiac rhythm disturbance

weakness

Hypercalcuria

How well did you know this?

Not at all

Perfectly

Which drug is indicated for VItamin D deficiency?

**Vitamin D₂ (ergocalciferol) plant-derived form**

What is the plant-derived form of Vitamin D?

Vitamin D2 (ergocalcifereol)

Where is Vitamin D first hydroxylated and what does it form?

Liver, forms 25(OH)D (calcifediol)

When should you use Vitamin D (calcitriol: 1, 25, (OH))? 3 instances

1. Renal **osteodystrophy** 2. Hypopara**thyroidism** 3. Refractory **rickets**

Which **biophosphonate** is indicated only for **postmenopausal osteoporosis?**

ibandronate (IV and oral) "you get stretch marks **(bands) after menopause**"

**MOA of biphosphonates**

**Mimic pyrophosphate:** an endogenous **bone resorption inhibitor** **Decreased osteoclast** maturation, number, recruitment, bone adhesion and life span

What is the **half-life of biphosphonates**?

10 yrs: becomes incorporated into the bone

Administered in the morning on an **empty stomach** with **6–8 ounces of plain water**. Do not eat and r**emain upright for at least 30 minutes** following administration. **Do not coadminister** with any other medication or supplements, including calcium and vitamin D. Which drug?

Alendronate

Administration instructions **same as for alendronate,** except **must delay eating and remain upright for at least 60 minutes.** Which drug?

Ibandronate

Administration instructions same as for alendronate, except **_delayed-release product_ is taken immediately following _breakfast._** Which drug?

RIsedronate

**Can premedicate with acetaminophen** to decrease infusion reactions. _**Contraindicated if CrCl \<35 mL/min\*\***_ Which drug?

Zoledronic Acid

Monitoring for biphosphonates

bone turnover markers

ADEs of biphosphonates

nausea, dyspepsia, transient flu-like illess (IV)

Rare adverse effects of biphosphonates

perforation, ulceration, GI bleeding **(PUG)** Musculoskeletal pain atypical fx ONJ

COntraindications of biphosphonates

**CrCl 30-35mL/min** **serious GI conditions:** esophagus abnormalities delaying emptying-stricture or **achalasia** esophageal varices **barrett's esophagus** **Pregnancy**

**Black box warning of biphosphonates regarding ONJ**

ONJ occurs more commonly in patients with **cancer, chemotherapy, radiation, and or glucocorticoid therapy receiving higher-dose intravenous bisphosphonate therapy.**

Another ADE of biphosphonates

**Subtrochanteric femoral (atypical) fracture**

Who can take a **"drug holiday"**?

women w/o evidence of a **low-trauma fx** pts who have **responded well to biphosphonate therapy** Those w/BMD increasing into the osteopenic range **(T-score \> -2)**

What is a **"drug holiday"?**

Patients are **taken off their bisphosphonate therapy** and **followed serially with bone turnover markers and central DXA BMD**

Endogenous hormone **released from the thyroid gland** when **serum calcium is elevated** Treatment for women who are at least **5 years past menopause** **Third-line treatment** May provide **pain relief with acute verterbral fracture** What is this describing?

**Calcitonin**

**Refrigerate nasal spray** until opened for daily use, **then room temperature.** **Prime with first use** **Which drug?**

**Calcitonin**

For **postmenopausal women** **with an uterus;** **no progestogen needed** Which drug?

Bazedoxifene

decreases bone resorption, increasing bone mineral density and decreasing fracture incidence Which drugs?

2nd gen mixed estrogen agonist/antagonist **(EAA)** selective estrogen receptor modulators **(SERMs)** **Raloxifene, Bazedoxifene**

Why is estrogen therapy used short-term to manage menopausal sx?

risks of estrogen therapy \> bone benefits

Replacement of ___________ (male) or _________ (female) have demonstrated increases in BMD, but no data on fracture prevention exist

Replacement of _testosterone_ (male) or _methyltestosterone_ (female) have demonstrated increases in BMD, but no data on fracture prevention exist

**Recombinant product** representing the **first 34 amino acids in human PTH** Increases bone formation, the bone remodeling rate, and osteoblast number and activity. Both **bone mass and architecture are improved** Indicated for **postmenopausal women, men, and patients on glucocorticoids at high risk (Bone density T score \< -3.5)** Which drug?

**Teriparatide (Anabolic Therapy)**

Commercially available as a **prefilled "pen" delivery device** **first dose** should take place with the **patient either sitting or lying down in case orthostatic hypotension occurs** Which drug?

Anabolic Therapies: Teriparatide

approved for treatment of **high-risk postmenopausal osteoporosis** **Synthetic analog of human parathyroid hormone (PTH)** related peptide acting as an anabolic agent to stimulate bone formation Which drug?

Abaloparatide (Tymlos)

**What did the ACTIVE trial demonstrate about Abaloparatide (Tymlos)**

**reduced new vertebral and nonvertebral fractures** and **increased bone mineral density after 18 months**

When\_\_\_\_\_\_\_\_\_\_\_ is discontinued, antiresorptive treatment should be considered as \_\_\_\_\_\_\_\_\_\_\_\_\_\_to protect against bone loss.

When _abaloparatide_ is discontinued, antiresorptive treatment should be considered as _sequential therapy_ to protect against bone loss

**MOA:** Binds to RANKL on the surface of osteoclast precursor cells and mature osteoclasts **Inhibits osteoclatogenesis and increases osteoclast apoptosis** Which drug?

**RANKL inhibitor: Denosumab**

Indications: **Postmenopausal women** and possibly **chemotherapy induced osteoporosis**

**RANKL inhibitor: Denosumab**

ADEs: back, extremity, and **musculoskeletal pain** **increased cholesterol, cystitis, decreased serum calcium, skin problems** **Which drug?**

**RANKL Inhibitor: Denosumab**

What are the 4 1st line tx for osteoporosis?

Alendronate Risedronate Zoledronic acid Denosumab **"AZRD"**

Alt tx for osteoporosis

Ibandronate, raloxifene, and teriparatide

Agent of last resort

Calcitonin

When should you consider a **Vertebroplasty and Kyphoplasty**

Patients with debilitating pain between 6 and 52 weeks after a vertebral fracture might undergo **vertebroplasty or kyphoplasty**

bone cement is injected into the fractured vertebral space

Vertebroplasty and Kyphoplasty

ADEs: cement leakage into the spinal column, which can result in complicating nerve damage, and vertebral fracturing around the cement

Vertebroplasty and Kyphoplasty

Define osteomalacia

"soft bones" condition seen in adults in which the **bone is significantly undermineralized**

\_\_\_\_\_\_\_\_\_ is the childhood equivalent of osteomalacia.

Rickets

Cause of osteomalacia

MCC: severe, prolonged vitamin D deficiency disorders that cause hypophosphatemia, medications like long-term antoconvulsant therapy

Clinical px of **osteomalacia**

**pathologic fractures and/or deep bone pain,** proximal muscle weakness, or no obvious symptoms but low BMD

Osteomalacia causes extremely low __________ concentration.

Osteomalacia causes extremely low _25(OH) vitamin D concentration (\<10 ng/mL [\<25 nmol/L])_ concentration.

Tx for osteomalacia

**Ergocalciferol once to twice weekly fofr at least 8 weeks** Once **25(OH) vitamin D concentrations are \> 30 ng/mL (75 nmol/L),** chronic maintenance vitamin D therapy can be instituted Maintenance therapy: **oral ergocalciferol 1 or 2 times a mo** OR **nonprescription cholecalciferol once daily**