Osteoporosis II: Treatment

Question 1

T.F you need a calcium supplement

Answer 1

false. a balanced diet usually gives enough calcium

Question 2

t/f you need a vitamin D supplement

Answer 2

pretty much. most canadians are vitamin D deficient. 800-2000 unites are needed. shouldn’t overdose though

Question 3

what form of vitamin D is the best form of supplementation?

Answer 3

vitamin D3. It is made of animal byproducts, so if youre vegan you need D2 but the absorption isn’t as good.

Question 4

t/f you need to do some light weightlifting as exercise for bone health

Answer 4

false. you just need to exercise in general. LOAD BEARING EXERCISE in any fashion, including walking for 30 minutes will help

Question 5

the most common supplement is calcium carbonate, however it is hard to absrob it if you are on a PPI? what is a good alternative calcium supplement if on an antacid

Answer 5

calcum citrate has better absorption in people on antacids

Question 6

5 classes of treatment options for osteoporosis

Answer 6

bisphosphonates

serms

denosumab

PTH/PTHrP analogues

Sclerostin inhibitors

Question 7

MOA of bisphosphonates (first line)

Answer 7

• inhibits osteoclast activity (inhibit lysosomal enzymes and acid production), increase soteoclast apoptosis

Question 8

key method of bisphosphonates

Answer 8

can be taken orally, but theres poor absorption. yyou must take it in the morning with a full glass of water. stay upright for 30 mintues. do not take it with any other food.

• another option is that you just once a week IV it

Question 9

t/f bisphosphonates have been clinically shown to reduce hip fracturs

Answer 9

true. reduce the relative risk by 30-50%

Question 10

side effects and contraindications of bisphosphonates

Answer 10

Question 11

osteonecrosis of the jaw is defined as exposure of themandibular jaw that lasts >8 months.

linked to __ surgery, prior
head and neck ___ with
long term (high dose)
___ use

Answer 11

linked to dental surgery, prior
head and neck radiation with
long term (high dose)
bisphosphonate use

its very rare outside of oncology

Question 12

what type of femur fracture is associated with biphosphonate use?

Answer 12

ATYPICAL emure fracture. usually, you break the surgical or anatomical neck of the femoral head, but in atypical fractures, you brek the long part of the bone.

• even though bisphosphonate use is meant to build bone up, you are inhibiting all osteoclastic activity, including routine osteoclast activity, and thus you are less liekly to be doing maintenance bone restoration.

Question 13

denosumab is an anti-___ therapy. mechanism of action.

Question 14

denosumab is good for people with kidney disease who can’t be taking bisphophonates. what are the alternative contraindications of denosumab and side effects?

Answer 14

contraindications; hypocalcemia, pregnancy

side effects; osteonecross of the jaw, femoral fracture, REBOUND VERTEBRAL FRACTURE, hypocalcemia.

Question 15

what must you check before putting a pateint on denosumab

Answer 15

check vitamin D levels. they must be sufficienct, so that you don’t give them with a double hit of hypocalcemia.

Question 16

Raloxifene is a ___ ___ receptor agonist. What parts of the body does it exhibit different functions?

Answer 16

it’s a selective estrogen receptor agonist. it works on bone, but not in the breast. prevents vertebral fractures, but not hip fractures. can be used logn term

Question 17

T/f raloxifene can prevent hip fractures

Answer 17

false. bisphosphonates prevent against hip fracture but this SERM does not. it does prevent against vertebral fractures thoguh.

Question 18

side effets of raloxifene

Answer 18

hot flashes and VTE.

• kind of like esotrgen effects

Question 19

Teriparatide is a bone builder that is definitely not first line because of the increase risk of ___ ___. In what group would you consider this drug? in what group is it contraindicated?

Answer 19

increase risk of osteosarcoma. DO NOT USE if someone has/had a skeletal cancer or metastases.

• not first line, but used if people have multiple fragility fractures and are refractory to other meds like bisphosphonates

Question 20

Romosuzumab is an ___ agent. What antibody does it target?

Answer 20

ANABOLIC aagent. monoclonal anti- SCLEROSTIN antibody

• reduces vertebral and NON VERTEBRAL fractures. superior to alendronate. but NOT FIRST LINE– only for refractory cases
• no atypical femoral fractures or ostenecrosis of the jaw, but does increase risk of CVD and ACS incidences.

Question 21

T/F romosuzmab side effects inclute atypical femoral fracturs or osteonecrosis of the jaw

Answer 21

false. no atypical femoral fractures or osteonecrosis of the jaw, but may increase CVD and ACS. that’s why it’s not first line.

Question 22

indicatsion for treatment with teriparatide; intermittent pth causing osteoblast agonism.

Answer 22

t

Question 23

MOA of teriparatide;

Answer 23

an intermittent PTH agonist that creaets an anabolic stimulus for bone.

Question 24

Osteoporosis Canada recommends __ or
__ or __ or __ as first line
options

Answer 24

Osteoporosis Canada recommends bisphosphonate or
denosumab or raloxifene or estrogen as first line
options

Question 25

outlien general monitoring therapy protocol

Answer 25

bone density check usually every 3-5 years. should be stable. also measure bone turn over markers (CTX), which should be lower.

• most meds are not lifelong, usually you’re on them for a few years, and thne yyou take a drug holiday. during the holiday, you’re still doing conservative and nonharacological mangement.

Question 26

note; for BMD reports; you must look at the % change, not just the T score.

Question 27

what is the general medication flow chart for osteoporosis?

Answer 27

oral bipshophanate –> IV bisphosphonate –> docusamab –> agonist agent antibody.

Question 28

what generally constitudes “treatment failure”

Answer 28

1. fracture on therapy
2. large decrease on BMD despite therapy – more than 5% loss