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Osteoporosis & Hormone Therapy Flashcards

1
Q

What’s osteopenia?

A

Defined as a T-score btw -1 & -2.5

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2
Q

What’s Osteoblasts?

A

Cells involved in bone formation

OsteoBlast - Build Bones

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3
Q

What’s Osteoclasts?

A

Break-down of bone

OsteoClasts - Crack bone

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4
Q

What’s DEXA or DXA?

A

Bone scan performed by a dual energy x-ray absorptiometry machine

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5
Q

Risk factors for low bone density? Which is most important?

A

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

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6
Q

Drugs that put u at risk of osteoporosis risk?

A

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)

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7
Q

Fall prevention measures?

A

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

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8
Q

What’s req for all low bone density rx meds?

A

Ca + Vit. D

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9
Q

What should be accessed first in to presenting with low bone density?

A

Dietary intake of Ca

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10
Q

When’s adequate Ca intake most critical?

A

Children

In pregnancy

During yrs around menopause

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11
Q

Results of Vit D deficiency in children? Adults?

A

Children - Rickets

Adults - Osteomalacia

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12
Q

How should Ca be dosed? Why?

A

Ca doses should be divided

Ca absorption is saturable

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13
Q

Which Ca has a better absorption? Issue with this Ca?

A

Calcium citrate (Citracal, others) - tab has 315mg Ca

Larger tablet to swallow

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14
Q

Ca citrate absorption and PPIs?

A

Ca citrate may be preferred with little or no stomach acid

May use with PPIs

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15
Q

Disadvantage of Ca carbonate (Oscal, Tums etc)? How does this affect how it’s taken?

A

Ca carbonate has acid-dependent absorption

Should be taken with meals

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16
Q

What’s the NIH recommended Vit. D intake for people up to 70 yrs?

A

600 IU daily

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17
Q

What’s the NIH recommended Vit. D intake for people 71+ yrs?

A

800 IU daily

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18
Q

What’s the preferred source of Vit. D2 in renal dx or short-term in adults with deficiency to replenish stores?

A

Cholecalciferol or Vit. D3

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19
Q

What’s the 1st line in most pts with low bone density?

A

Bisphosphonates

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20
Q

Alt to oral Bisphosphonates with those with GI problems?

A

Injectable Bisphosphonates

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21
Q

Alt. in adherence issues?

A

Annual infusion of Zoledronic acid (Reclast)

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22
Q

What’s the duration of Bisphosphonates use? Why?

A

Stop after 3-5 yrs

Due to risk of atypical femur fracture, esophageal CA & osteonecrosis of the jaw

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23
Q

Role of Teriparatide inj (Forteo) in therapy?

A

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

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24
Q

Role of estrogen in therapy?

A

No longer first line for osteoporosis

May be useful short-term, in younger women w/o CI, esp due to time limit on Bisphosphonates

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25
What's used most commonly in women who are at risk or have fear of breast CA?
Raloxifene (Evista)
26
MOA of Bisphosphonates?
Work by inhibiting osteoclast activity
27
Uses of Bisphosphonates?
Prevention (osteopenia) Tx (osteoporosis) Paget's dx Glucocorticoid-induced osteoporosis Zoledronic acid - used for hypercalcemia of malignancy
28
List Bisphosphonates
Alendronate (Fosamax, Binosto) Risedronate (Actonel, Atelvia) Ibandronate (Boniva)
29
Brand name of Alendronate?
Fosamax Binosto
30
Brand name of Risedronate?
Actonel Atelvia
31
Brand name of Ibandronate?
Boniva
32
Hows Alendronate (Fosamax, Binosto) dosed for osteoporosis?
70 mg PO weekly
33
SEs of Bisphosphonates?
Hypocalcemia (mild, transient) Back pain Arthralgias Dyspepsia N/V Dysphagia Heartburn Esophagitis
34
Injectable Bisphosphonates?
Zoledronic acid (Reclast)
35
Brand name of Zoledronic acid (injectable Bisphosphonates)?
Reclast
36
MOA of Raloxifene?
An Estrogen agonist/Antagonist, also called selective estrogen receptor modulator (SERM) and reduced bone resorption
37
Brand name of Raloxifene?
Evista
38
Role of Raloxifene (Evista)?
Used often in women at risk (or have fear of) breast CA
39
Effect of Raloxifene (Evista)?
Favorable lipid effects (reduced CH and LDL; no effect on HDL and TGs)
40
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
41
MOA of Calcitonin nasal spray and injection?
Inhibits osteoclastic bone resorption
42
SEs of Calcitonin nasal spray and injection?
Rhinitis Alt nostril daily
43
MOA of Teriparatide injection?
Stimulates new bone formulation and depresses osteoclast activity; recombinant human PTH 1-34
44
Brand name of Teriparatide injection?
Forteo
45
Role of Teriparatide (Forteo) injection in therapy?
For pts who are at very high risk for fracture
46
Daily dose and max duration of use for Teriparatide (Forteo) injection?
20mcg SC inj daily. Max of 2 yrs
47
SEs of Teriparatide (Forteo) injection?
Orthostasis/dizziness Increased HR (esp with 1st few doses) Injection site pain Hypocalcemia (transient, post-dose)
48
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
49
Agent under Monoclonal antibody used in low bone density?
Denosumab (Prolia)
50
Brand name of Denosumab?
Prolia
51
Which Denosumab is for hypercalcemia of malignancy
Xgeva
52
Role of Denosumab (Prolia) in therapy?
High risk
53
CI to Denosumab (Prolia) use?
Hypocalcemia - check levels prior to using drug
54
Ses of Denosumab (Prolia)?
Fatigue Hypocalcemia (correct) Eczema Rash Weakness Arthralgia/weakness/limb pain Nausea Dyspnea Cough
55
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
56
When should dental work be done?
B4 starting Bisphosphonates
57
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
58
What's shouldn't be used with Reclast inj?
Zometa ( same drug)
59
SE of Teriparatide (Forteo) injection, esp after the 1st few doses?
U may feel dizzy or have a fast heartbeat
60
Storage of Teriparatide (Forteo) injection? When should it be discarded?
Refrigerator (re-cap after each use) After 28 days, pen should be discarded
61
Site of injection of Teriparatide (Forteo) injection?
Thigh or abdomen (lower stomach area) Sites must be rotated
62
Max duration of Teriparatide (Forteo) injection use?
Don't exceed 2 yrs of use
63
Effect of decrease in estrogen?
Hot flashes Night sweat
64
Most effective therapy for vasomotor sx (hot flashes, night sweats)?
Estrogen, (cause decrease in LH => more stable temp control)
65
Role of Estrogen in therapy?
Most effective therapy for vasomotor sx (hot flashes, night sweats) To prevent postmenopausal osteoporosis
66
Should estrogen be given alone in women with a uterus?
No
67
How should estrogen be used?
Use lowest possible dose for the shortest possible time
68
Ses Estrogen + Progestin? Max duration?
Increases breast CA risk 3-5 yrs
69
Natural pdts used for vasomotor sx? (Hot flashes and night sweats)
Black cohosh Red clover Soy Flaxseed
70
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
71
SEs of estrogen?
Nausea Dizziness Bloating Breast tenderness/fullness
72
What's most useful for pts who have vaginal sx (dryness, painful intercourse)?
Vaginal pdt
73
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
74
Why are forms of Paroxetine preg cat D/X?
Cardiovascular risks in newborn
75
Brand name of Paroxetine used in hormone therapy for Hot flashes?
Brisdelle
76
List most common HRT pdts?
Vivelle, Vivelle-Dot Provera Premarin Premarin vaginal cream Prempro
77
Do estrogen HRT contain progestin? Why/ why not?
No!
78
Report any unusual vaginal bleeding, right away while on estrogen?
True
79
Risk of which dx states increases with the use of estrogen?
Heart attacks Strokes Breast CA Blood clots
80
What's Estrogen used for primarily? Duration of use?
Primarily in menopausal sx Should not be continued indefinitely
81
Whats should done on Vivelle-Dot patch application?
Mark the 2-day schedule
82
Site of Vivelle-Dot patch application?
Apply to lower abdomen, below waistline
83
Where shouldn't Vivelle-Dot patch be applied?
Never to the breast
84
Testosterone therapy demand is on the increase becuz?
Improved sexual interest (increased libido) and performance
85
Whys the use of Testosterone replacement controversial?
May increase prostate CA risk May also increase cholesterol levels May cause liver damage
86
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
87
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
88
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
89
Sites of application that may reduce accidental exposure to others eg women and children?
Thighs, underarms
90
BBW of testosterone pdt
Secondary exposure to testosterone in children and women
91
SE of testosterone pdt
Increased appetite Increased risk of Hepatoxicity
92
Look at pg 496 - AndroGel Pt Counseling
Ok
93
What's osteoporosis?
Defined as a T-score < -2.5

urinary 475 (10 decks)

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