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Geriatric Pharmacist Boot Camp > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Bone Remodeling

A 
• Osteoblasts—bone forming cells
• Osteoclasts—bone resorbing cells
• Osteocytes—bone communication cells
Bone remodeling regulated by estrogens,
androgens, vitamin D, parathyroid hormone (PTH), and others, including the cytokine RANK-ligand (RANKL)
• Secondary hyperparathyroidism may also
cause bone remodeling
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2
Q

Regulation of Remodeling

A

Bone Remodeling mediated by:

  1. Serum Ca
  2. Vitamin D
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3
Q

Life Style Risk Factors

A
  • Low calcium/vitamin D intake
  • Smoking
  • Prior fractures
  • Immobilization/low physical activity
  • History of falls
  • Low body weight
  • Excess alcohol (≥ 2-3 per day)
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4
Q

Risk factors

A 
Female, age, race
•35% women ≥ 80 years of age
• White/Hispanic > Native American > African
American > Asian
• 11% men ≥ 80 years of age
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5
Q

Conditions Risk factors

A
  • Menopause (premature)
  • Malabsorption
  • RA and Lupus
  • Fall risk conditions
  • Vit D deficiency
  • Cognitive impairment
  • Height loss
  • Family history
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6
Q

Medication Risk Factors

A
  • Glucocorticoids - 5mg+ prednisone equivalent for 3+ months
  • Anti-androgens
  • Thyroid supplementation
  • Antiepileptic drugs
  • Aluminum
  • PPIs
  • Thiazolidinediones
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7
Q

Who to screen?

A
  • All women by age 65
  • All men over age 70
  • All post-menopausal (PM) women ≥ 50 years
  • Men age ≥ 50 years with risk factors
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8
Q

gold standard

A
  • Central DXA X-ray gold standard
  • Peripheral devices used for screening only
  • Lumbar spine and hip (femoral neck, total hip)
  • Reported as standard deviations (SD) from either:
  • Matched population: Z-score
  • “Normal”, young population: T-score
  • Each SD = 10% ↓ bone mass, 1.5-2.5 x ↑ fracture risk
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9
Q

Risk Prediction: FRAX®

A

Used to predict fracture risk:

  1. Limited DXA access
  2. Determine DXA need
  3. NOT already treated
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10
Q

Diagnostic Criteria Osteopenia

A

Osteopenia (low bone mass)

T-score: -1 to -2.5

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11
Q

Diagnostic Criteria Osteoporosis

A 
• T-score: -2.5 or less
• Fragility fracture
• Spine, hip, humerus, pelvis, or wrist
• Independent of T-score
• Osteopenia + elevated FRAX OR fragility
fracture
• 10-year probability ≥ 3 % for hip fracture
• ≥ 20 % for major osteoporotic fracture
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12
Q

Normal bone density

A

T score +1 to -1

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13
Q

Osteoporosis Prevention and Treatment

A

• Calcium and Vit D
• Exercise, Smoking Cessation, Low Alcohol Intake, Fall Prevention,
Hip Protectors, Physical Therapy

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14
Q

Dosing & Formulations

A
  • 1,000-1,200 mg/day (no more than 1,500 mg/day)
  • < 600 elemental per dose (500 – 600 mg twice daily)
  • Citrate in low acid
  • No oyster shell!
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15
Q

% of Elemental Calcium in Supplements

A

Carbonate (40% elemental)
Citrate (21% elemental)
Gluconate (9% elemental)

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16
Q

Considerations

A
  • ↑ Constipation = ↑ elemental Ca
  • Kidney stones
  • Dietary sources preferred
  • QS dietary intake (average 600 mg/day)
  • OP patients are high bone risk—Ca benefit outweighs any CV risk
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17
Q

Osteoclasts

A

Move from immature to mature cells
when their RANK receptor is
stimulated by the RANK-Ligand

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18
Q

RANKL inhibitors

A

Block maturation, activation, shorten lifespan of clasts, increase apoptosis

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19
Q

Calcitonin

A

Prevents clasts from adhering to bone

20
Q

Bisphosphonates

A

Incorporate into bone to impair clast function and cause apoptosis

21
Q

Estrogen and SERMs

A

Increase clast apoptosis, decrease RANK-Ligand

22
Q

Osteoblasts function

A

Bone forming cells

23
Q

PTH analogs affect on Osteoblasts

A

activate blasts

24
Q

Estrogen and SERMs affect on Osteoblasts

A

decrease blast apoptosis

25
Q

Sclerostin inhibitor

A

increases osteoblast activity

26
Q

Denosumab is drug of choice for?

A

Denosumab—drug of choice for osteoporosis with renal insufficiency

27
Q

Osteoporosis Treatment Algorithm First Line for Most

A

alendronate,
risedronate,
zoledronic acid,
denosumab

28
Q

Osteoporosis Treatment for Low Risk (younger, no fractures, low mod T-score)

A

Oral Agents
ibandronate
alendronate,
risedronate

29
Q

Treatment for Highest Fracture Risk (FRAX hip
>4.5% or major OP
>30%, multiple
fractures, T-score ≤ -3.0)

A 
abaloparatide, 
denosumab,
romosozumab,
teriparatide,
zoledronic acid
30
Q

Treatment for High Risk Spine Fracture, low risk Hip or nonvertebral fractures

A

ibandronate or raloxifene

31
Q

Does 1 fracture = therapy failure

A

1 fracture DOES NOT = therapy failure
• Suggest fracture risk is high
• May change treatment selection and/or duration

32
Q

What is stable bone mineral density (BMD)

A

• Stable BMD = not worsened by more than ~4% in spine or ~6% in hip

33
Q

Recheck BMD?

A

every 1-2 years after starting therapy and then every 2 years

34
Q

Bisphosphonates for Postmenopausal Osteoporosis

A
  • Alendronate Fosamax®,
  • Ibandronate Boniva®,
  • Risedronate Actonel®,Atelvia®
  • Zoledronic acid (Reclast®) 5 mg IV every 2nd year 5 mg IV once yearly
35
Q

Bisphosphonates Caution in renal impairment

A

at risk of dehydration, on diuretics or nephrotoxic drugs NR if CrCl < 35 mL/min

36
Q

Duration of Bisphosphonate Use

A

• Risedronate VERT-MN trial (VERT-NA extension) DC at 3, 5 or 7 years BMD ↓ after DC BUT higher than baseline
•Alendronate FLEX trial (FIT-extension)
DC at 5 years vs. continuation to 10 years
BMD ↓ after DC BUT remained higher than baseline. No fracture differences……unless T-score at 5 years < -2.5 (2x higher!)
•Zoledronic Acid Horizon-PVT trial
DC at 3 or 6 years vs. continuation to 9 years. BMD ↓ after DC BUT remained higher than baseline No notable differences in fracture

37
Q

Bottom Line on “Holidays”

A
  • Lower Risk: Stop after 3 years (ZA) or 5 years (oral agents)
  • Higher Risk: Continue for 6 years (ZA) or 10 years (oral agents)
  • End holiday if fracture, significant BMD loss
38
Q

Continuum of Bisphosphonates

A

3-5 Year Evaluation

39
Q

RANK-L inhibitor: Denosumab

A
  • 60 mg SQ in upper arm, thigh, abdomen every 6 months by a healthcare provider
  • No drug holiday recommended
  • Must correct Ca and Vit D before initiation 25-day half-life
  • Drug of choice in renal impairment
40
Q

PTH Analogs: Abaloparatide, Teriparatide

A
  • Anabolic agents
  • Use should be immediately followed by anti-resorptive therapy (bisphosphonate, denosumab)
  • Use should not follow anti-resorptive therapy—lower BMD increases
  • Must correct Ca and Vit D before initiation
  • Nausea, orthostatic hypotension, leg cramps
  • 2-year duration only
41
Q

Sclerostin Inhibitor: Romosozumab

A

•210 mg once monthly (two consecutive 105 mg injections) in the upper arm, thigh, or abdomen by a healthcare professional
12 month duration
•Must correct hypocalcemia prior to use, supplement Ca and Vit D
•Boxed Warning—increased risk of MI, stroke, and CV death

42
Q

Why Estrogens aren’t used

A

↑ fatal and nonfatal MI , stroke, VTE, breast cancer

43
Q

Why Selective Estrogen Receptor Modulators aren’t used for Osteoporosis

A

↑ VTE
Stroke risk in women 70+: not recommended
Concomitant therapy is not recommended (exception: raloxifene and breast cancer reduction)

44
Q

When to Stop Treating?

A 
When to consider:
• Prognosis & limited life expectancy
• Goals of care
• Immobility/low fall or fracture risk
• Administration concerns
• All can be stopped without taper
45
Q

Osteoporosis: Clinical Pearls

A

•Upon dc of an anabolic agent, therapy with an antiresorptive agent is
recommended
• Switching from bisphosphonate to an anabolic agent can be done
• Switching from denosumab to an anabolic agent is NOT recommended
• Dietary calcium > supplement

Geriatric Pharmacist Boot Camp (7 decks)

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