Osteoporosis & Hormone Therapy Flashcards
What’s osteopenia?
Defined as a T-score btw -1 & -2.5
What’s Osteoblasts?
Cells involved in bone formation
OsteoBlast - Build Bones
What’s Osteoclasts?
Break-down of bone
OsteoClasts - Crack bone
What’s DEXA or DXA?
Bone scan performed by a dual energy x-ray absorptiometry machine
Risk factors for low bone density? Which is most important?
Genetic factors (most imp), Caucasians and Asian American women at highest risk
Advanced age
Low bone mineral density
Previous fracture (other than skull, facial bone, ankle, finger or toe)
More than 2 alcoholic drinks per day
Oral or IM glucocorticoid use > 3 months (daily dose of >= 5mg prednisone or equivalent)
Body wt < 127 pounds
Or low BMI < 21 kg/m^2
A decline in adult estrogen levels
Rheumatoid arthritis & lupus
Low level of physical activity & adequate nutrition - low over life span
Ca + Vit. D intake low over life span
Smoking
Drugs that put u at risk of osteoporosis risk?
Steroids (>= 5mg/d of prednisone equivalent for >= 3 months)
Depot medroxyprogesterone acetate
Anticonvulsants (CBZ, Fosphenytoin, phenobarbital, PHT, Primidone)
Warfarin & Heparin
Excess thyroid hormone
Loop diuretics
Aromatase inh
Nafarelin (Synarel) - used in endometriosis
Androgen blockers used for prostate CA
Proton pump inh used chronically (reduced Ca absorption due to reduced gastric PH)
Fall prevention measures?
Appropriate lighting
Floors are safe (thrips rugs/clutter/cords have been removed)
Storage (at reasonable heights)
Bathrooms have safety bars
Handrails are present on all stairs
Stairs are well-lit with non-skid treads or carpets
What’s req for all low bone density rx meds?
Ca + Vit. D
What should be accessed first in to presenting with low bone density?
Dietary intake of Ca
When’s adequate Ca intake most critical?
Children
In pregnancy
During yrs around menopause
Results of Vit D deficiency in children? Adults?
Children - Rickets
Adults - Osteomalacia
How should Ca be dosed? Why?
Ca doses should be divided
Ca absorption is saturable
Which Ca has a better absorption? Issue with this Ca?
Calcium citrate (Citracal, others) - tab has 315mg Ca
Larger tablet to swallow
Ca citrate absorption and PPIs?
Ca citrate may be preferred with little or no stomach acid
May use with PPIs
Disadvantage of Ca carbonate (Oscal, Tums etc)? How does this affect how it’s taken?
Ca carbonate has acid-dependent absorption
Should be taken with meals
What’s the NIH recommended Vit. D intake for people up to 70 yrs?
600 IU daily
What’s the NIH recommended Vit. D intake for people 71+ yrs?
800 IU daily
What’s the preferred source of Vit. D2 in renal dx or short-term in adults with deficiency to replenish stores?
Cholecalciferol or Vit. D3
What’s the 1st line in most pts with low bone density?
Bisphosphonates
Alt to oral Bisphosphonates with those with GI problems?
Injectable Bisphosphonates
Alt. in adherence issues?
Annual infusion of Zoledronic acid (Reclast)
What’s the duration of Bisphosphonates use? Why?
Stop after 3-5 yrs
Due to risk of atypical femur fracture, esophageal CA & osteonecrosis of the jaw
Role of Teriparatide inj (Forteo) in therapy?
In pts with osteoporosis with HIGH risk for fracture, or have already had an osteoporotic fracture, or have OP + need to take long-term steroids, or who can’t tolerate Bisphosphonates
Role of estrogen in therapy?
No longer first line for osteoporosis
May be useful short-term, in younger women w/o CI, esp due to time limit on Bisphosphonates
What’s used most commonly in women who are at risk or have fear of breast CA?
Raloxifene (Evista)
MOA of Bisphosphonates?
Work by inhibiting osteoclast activity
Uses of Bisphosphonates?
Prevention (osteopenia)
Tx (osteoporosis)
Paget’s dx
Glucocorticoid-induced osteoporosis
Zoledronic acid - used for hypercalcemia of malignancy
List Bisphosphonates
Alendronate (Fosamax, Binosto)
Risedronate (Actonel, Atelvia)
Ibandronate (Boniva)
Brand name of Alendronate?
Fosamax
Binosto
Brand name of Risedronate?
Actonel
Atelvia
Brand name of Ibandronate?
Boniva
Hows Alendronate (Fosamax, Binosto) dosed for osteoporosis?
70 mg PO weekly
SEs of Bisphosphonates?
Hypocalcemia (mild, transient)
Back pain
Arthralgias
Dyspepsia
N/V
Dysphagia
Heartburn
Esophagitis
Injectable Bisphosphonates?
Zoledronic acid (Reclast)
Brand name of Zoledronic acid (injectable Bisphosphonates)?
Reclast
MOA of Raloxifene?
An Estrogen agonist/Antagonist, also called selective estrogen receptor modulator (SERM) and reduced bone resorption
Brand name of Raloxifene?
Evista
Role of Raloxifene (Evista)?
Used often in women at risk (or have fear of) breast CA
Effect of Raloxifene (Evista)?
Favorable lipid effects (reduced CH and LDL; no effect on HDL and TGs)
SEs of Raloxifene (Evista)?
Hot flashes
Peripheral edema
Hot flashes
Arthralgias
Leg cramps/muscle spasms
Flu-like syndrome
Infection
Amenorrhea
Vaginal bleeding/discharge
Skin changes
MOA of Calcitonin nasal spray and injection?
Inhibits osteoclastic bone resorption
SEs of Calcitonin nasal spray and injection?
Rhinitis
Alt nostril daily
MOA of Teriparatide injection?
Stimulates new bone formulation and depresses osteoclast activity; recombinant human PTH 1-34
Brand name of Teriparatide injection?
Forteo
Role of Teriparatide (Forteo) injection in therapy?
For pts who are at very high risk for fracture
Daily dose and max duration of use for Teriparatide (Forteo) injection?
20mcg SC inj daily.
Max of 2 yrs
SEs of Teriparatide (Forteo) injection?
Orthostasis/dizziness
Increased HR (esp with 1st few doses)
Injection site pain
Hypocalcemia (transient, post-dose)
MOA of Monoclonal antibody?
Binds to nuclear factor-kappa ligand (RANKL) & prevents interaction btw RANKL & RANK, preventing osteoclast formation
Leads to decreased bone resorption and increased bone mass
Agent under Monoclonal antibody used in low bone density?
Denosumab (Prolia)
Brand name of Denosumab?
Prolia
Which Denosumab is for hypercalcemia of malignancy
Xgeva
Role of Denosumab (Prolia) in therapy?
High risk
CI to Denosumab (Prolia) use?
Hypocalcemia - check levels prior to using drug
Ses of Denosumab (Prolia)?
Fatigue
Hypocalcemia (correct)
Eczema
Rash
Weakness
Arthralgia/weakness/limb pain
Nausea
Dyspnea
Cough
Bisphosphonates use counseling?
Take 1st thing in the morning b4 u eat/ drink anything else except 6-8 ounces (1 cup) of plain water
Sit up or stand up and stay upright for at least 30 mins (60 mins with monthly Boniva)
Swallow tab whole
Bisphosphonates don’t work well if u’re not taking enough Ca + Vit. D
PPIs may increase fracture risk
Exercise
Common SE include GI upset, joint pain, back pain, dyspepsia or heartburn
Stop taking this medicine if u develop difficult or painful swallowing, chest pain or very bad heartburn
When should dental work be done?
B4 starting Bisphosphonates
Atelvia (long-acting form of Risedronate) use?
Take medicine AFTER breakfast
Sit/stand upright for 30 mins
Don’t use acid suppressing “heart burn” therapy with this medicine
Don’t take Ca, Iron, Mg or MVTE supplements till later in the day
What’s shouldn’t be used with Reclast inj?
Zometa ( same drug)
SE of Teriparatide (Forteo) injection, esp after the 1st few doses?
U may feel dizzy or have a fast heartbeat
Storage of Teriparatide (Forteo) injection? When should it be discarded?
Refrigerator (re-cap after each use)
After 28 days, pen should be discarded
Site of injection of Teriparatide (Forteo) injection?
Thigh or abdomen (lower stomach area)
Sites must be rotated
Max duration of Teriparatide (Forteo) injection use?
Don’t exceed 2 yrs of use
Effect of decrease in estrogen?
Hot flashes
Night sweat
Most effective therapy for vasomotor sx (hot flashes, night sweats)?
Estrogen, (cause decrease in LH => more stable temp control)
Role of Estrogen in therapy?
Most effective therapy for vasomotor sx (hot flashes, night sweats)
To prevent postmenopausal osteoporosis
Should estrogen be given alone in women with a uterus?
No
How should estrogen be used?
Use lowest possible dose for the shortest possible time
Ses Estrogen + Progestin? Max duration?
Increases breast CA risk
3-5 yrs
Natural pdts used for vasomotor sx? (Hot flashes and night sweats)
Black cohosh
Red clover
Soy
Flaxseed
CI to estrogen (in any form) use
Undiagnosed abnormal genital bleeding
Active or past breast CA
Known or suspected estrogen-dependent CA
Active or past deep vein thrombosis or pulmonary embolism
Active or recent arterial thromboembolic dx (stroke, MI)
Liver dysfxn / dx
Known or suspected pregnancy
SEs of estrogen?
Nausea
Dizziness
Bloating
Breast tenderness/fullness
What’s most useful for pts who have vaginal sx (dryness, painful intercourse)?
Vaginal pdt
Effect of Paroxetine (Brisdelle) - used in hot flashes - wrt warfarin and tamoxifen?
Increase the risk of bleeding (warfarin)
Blocks the effectiveness of Tamoxifen
(cuz Brisdelle is a CYP450 2D6 inh)
T4 don’t use with either warfarin or tamoxifen
Why are forms of Paroxetine preg cat D/X?
Cardiovascular risks in newborn
Brand name of Paroxetine used in hormone therapy for Hot flashes?
Brisdelle
List most common HRT pdts?
Vivelle, Vivelle-Dot
Provera
Premarin
Premarin vaginal cream
Prempro
Do estrogen HRT contain progestin? Why/ why not?
No!
Report any unusual vaginal bleeding, right away while on estrogen?
True
Risk of which dx states increases with the use of estrogen?
Heart attacks
Strokes
Breast CA
Blood clots
What’s Estrogen used for primarily? Duration of use?
Primarily in menopausal sx
Should not be continued indefinitely
Whats should done on Vivelle-Dot patch application?
Mark the 2-day schedule
Site of Vivelle-Dot patch application?
Apply to lower abdomen, below waistline
Where shouldn’t Vivelle-Dot patch be applied?
Never to the breast
Testosterone therapy demand is on the increase becuz?
Improved sexual interest (increased libido) and performance
Whys the use of Testosterone replacement controversial?
May increase prostate CA risk
May also increase cholesterol levels
May cause liver damage
Role of testosterone therapy?
An accepted used in men with
Low prostate CA risk + low testosterone level + a related condition! such as low muscle mass
Men at high risk of prostate CA and use of testosterone therapy? BPH?
Men at high risk of prostate CA should NOT use of testosterone therapy
BPH sx would worsen
Agents under Testosterone pdts? Control substance class?
AndroGel 1%, 1.62%
Testim gel 1%
Androderm patch
Striant buccal tabs
Testosterone soln (Axiron)
Testosterone gel (Fortesta)
C III
Sites of application that may reduce accidental exposure to others eg women and children?
Thighs, underarms
BBW of testosterone pdt
Secondary exposure to testosterone in children and women
SE of testosterone pdt
Increased appetite
Increased risk of Hepatoxicity
Look at pg 496 - AndroGel Pt Counseling
Ok
What’s osteoporosis?
Defined as a T-score < -2.5
