Osteoporosis, Menopause, Testosterone Flashcards
Chapter 49
1
Q
What is Osteoporosis?
A
- Weakening of bones (low bone mineral density)
2
Q
In what patient population does osteoporsis occur more commonly?
A
- Post-menopausal Females
3
Q
What are the most common locations for fractures?
A
- Wrist (can be an early indicator of poor bone health)
- Hip
- Spine
4
Q
What are some patient characterisitic risk factors for osteoporsis?
A
- Older age
- Race (Caucasuans and asian are higher risk)
- Family History
- Sex (F > M)
- Low Body Weight
5
Q
What are some medical diseases/condition risk factors for osteoporsis?
A
- Diabetes
- Eating Disorders
- GI Disease
- HYPERthyroidism
- Hypogonadism in Men (low testosterone)
- Menopause
- Autoimmune Disease
6
Q
What are some lifestyle risk factors for osteoporsis?
A
- Smoking
- Excessive Alcohol Intake (> 3 drinks per day)
- Low Calcium Intake
- Low Vitamin D intake
- Physical Inactivity
7
Q
What are some medication risk factors for osteoporsis?
A
- Antiseizure
- Aromatase Inhibitors
- Depo-medroxyprogesterone
- GnRH Agonist
- Lithium
- PPIs (increase pH = decrease Ca absorption)
- Steroids
- Thyroid Hormones (excessive amounts)
8
Q
What is the gold standard in diagnosing osteoporsis?
A
- DEXA or DXA scan (measures bone mineral density)
- DEXA gives a T-score which when above -1 means your bones are strong (< -2.5 = osteoporsis)
9
Q
What is FRAX?
A
- Fracture Risk Assessment Tool
- Estimates riks of osteoporsis fractuce in the next 10 years
10
Q
What are some factors that put a patient at a higher risk of falls?
A
- Hx of Falls
- Meds that cause sedation or orthostasis
- Neurologic Disorders that cause instability
- Impaired vision or hearing
11
Q
What can a Vitamin D Deficiency results in in both kids and adults?
A
- Kids: rickets
- Adults: osteomalacia
12
Q
What are some of the calcium supplementation products that are used for osteoporsis?
A
- Calcium Carbonate (TUMS) = 40% elemental Ca
- Calcium Citrate (Cal-Citrate) = 21% elemental Ca
13
Q
What are some additional notes for the calcium supplements used for osteoporsis?
A
- Tums: take WITH food, do NOT use PPIs
- Cal-Citrate: take WITH or WITHOUT food
14
Q
What is the criteria for initiating treatment for someone that has osteoporsis & high risk osteopenia?
A
- Osteoporsis: T-score < -2.5 in spine, femoral neck, total hip OR Presence of fragiity
- Osteopenia: Low Bone Density OR FRAX > 20% or 10 year hip fracture probability of > 3%
15
Q
What are some of the Drug Treatments for Osteoporsis?
A
- Bisphosphonates (1st line)
- Denosumab (Prolia)
- Teripartatide (Forteo), Abaloparatide (Tymlos)
- Raloxifene (Evista), Conjugated Estrogens/Bezadoxifene (Duavee)
- Estrogen, Calcitonin (Last Line or Not Recommended)
16
Q
What is the MOA of the bisphosphonates?
A
- Inhibits osteoclast activity and bone resorption
17
Q
What are some of the oral and Injectable Bisphosphonates/
A
- Alendronate (Fosamax) - oral
- Risedronate - oral
- Ibandronate (Bonvia) - oral and injectable
- Zoledronic Acid (Reclast) - injectable
18
Q
What is the dosing for prevention (postmenopasual females), treatment (males and postmenopausal females), & glucocorticoid induced osteoporsis for alendronate?
A
- Prevent: 5 mg PO daily or 35 mg PO weekly
- Treat: 10 mg PO daily or 70 mg PO weekly
- Gluco: 5 mg PO daily (not on estrogen is 10 mg)
19
Q
What is the dosing for prevention & treatment (males and postmenopausal females), treament (males) & glucocorticoid induced osteoporsis for Risedronate?
A
- Prevent & Treat: 5 mg PO daily, 35 mg PO weekly, 150 mg PO monthly
- Treat: 35 mg PO weekly
- Gluco: 5 mg PO daily
20
Q
What is the dosing for prevention & treatment (postmenopasual females) for Oral Ibandronate?
A
- Prevent & Treat: 150 mg PO monthly
21
Q
What is the dosing for treatment (postmenopausal females) for injectable ibandronate?
A
- 3 mg IV every 3 months
22
Q
What is the dosing for prevention (postmenopasual females), treatment (males and postmenopausal females), & glucocorticoid induced osteoporsis for Injectable Zolendronic Acid?
A
- Prevent: 5 mg IV every 2 years
- Treat: 5 mg IV every 1 year
- Gluco: 5 mg IV every 1 year
23
Q
What are some of the contraindications for the oral bisphosphonates?
A
- hypocalcemia - inability to stand or sit upright for at least 30 minutes
24
Q
What are some of the warnings for the bisphosphonates
A
- ONJ
- Esophagitis, Esophageal Ulcers, Erosions (why you need to sit upright for 30 mins after taking)
- Hypocalcemia
- Renal Impairment
25
What are some of the **side effects** for the **oral bisphosphonates**?
- Dypepsia
- Dysphagia
- Heartburn
- N/V
- **Hypocalcemia**
26
What are some **additional notes** for the **Oral Bisphosphonates**?
- Reduce vertebral and hip fracture risk (except with Ibrandronate - only vertebral)
- Drug Holidays after 3 - 5 years
- Separate from Calcium, Antacids, Iron, Magnesium by 2 Hours
- Atelvia (Risedronate): do not take with H2RAs or PPIs
27
What are the **Estrogen agonist/antagonist-containing products** that are used for **osteoporsis**?
- **Raloxifene (Exista)**
- Conjugated Estrogens/Bazedoxifene (Duavee)
28
What is the **MOA** for the **estrogen agonist/antagonist containing products** for **osteoporsis**?
- Decrease bone resorption
29
What are the **boxed warnings** for **raloxifene**?
- Increased risk of VTE (DVT/PE)
- Increased risl fo death due to stroke
30
What are some **contraindications** for **Raloxifene**?
- Pregnancy
- Hx or Current VTE
31
What are some **side effects** of **raloxifene**?
- Hot flashes
- Peripheral Edema
- Arthralgia
- Leg Cramps
32
What is the **prevention and treatment dosing (postmenopausal females)** for **Raloxifene**?
- 60 mg PO daily
33
What is the **boxedw warnings** for **Duavee**?
- Edometrial Cancer
- Increased risk of DVT and stoke (in women 50 - 79 yo)
34
What are some **contraindications** for **duavee**?
- Breast cancer
- Pregnancy
- Uterine Bleeding
- Hx or Active VTE
35
What is the **prevention (postmenopausal females *with a uterus*) dosing** for **Duavee**?
- 1 tablet PO daily
36
What are some **warnings** for **Duavee**?
- Increased risk of breast cancer and overain cancer
37
What is the **MOA** for **calcitonin**?
- Inhibits bone resorption by osteoclasts
38
What is the **treatment (females > 5 years postmenopause) dosing** for **calcitonin**?
- Nasal Spray: 1 spray in **one** nostril daily
- SC or IM: 100 units daily
39
What are the **warnings** for **Calcitonin**?
- Hypocalcemia
- Increased risk of malignancy
- Hypersensitivity reactions to salmon derived products
40
What are the **parathyroid hormone 1-34** that are used for **osteoporsis**?
- Teriparatide (Forteo)
- Abaloparatide (Tymlos)
41
What is the **MOA** for the **parathyroid hormone 1-34 drugs**?
- stimulates the osteoblast activity and increases bone formation
42
What are the **treatment (males and postmenopausal females) and Glucocorticoud induced osteoporsis dosing** for **Teriparatide**?
- Treat: 20 mcg SubQ **daily**
- Gluco: 20 mcg SubQ **daily**
43
What is the **treatment (males and postmenopausal females dosing** for **abaloparatide**?
- 80 mcg SubQ **daily**
44
What are the **warnings** for the **parathyroid hormone 1-34 drugs**?
- Osteosarcoma (Bone Cancer)
- Hypercalcemia
45
What are the **side effects** for the **parathyroid hormone 1-34 drugs**?
- Arthralgias
- Leg Cramps
- Nausea
- Orthostasis/Dizzness
46
What is the **MOA** of the **RANKL Inhibitors** used for **osteoporsis**?
- Binds to and blocks RANKL to **prevent osteoclast formation** = decrease in resorption and increase in density
47
What is the **RANKL inhibitor** that is used in **osteoporsis**?
- Denosumab (prolia)
## Footnote
**Xgeva** is Denosumab but used for Bone Cancer stuff
48
What is the **treatment (males and postmenopausal females) dosing** for **denosumab**?
| -
- 60 mg SubQ **every 6 months**
49
What is the **boxed warnings** for **denosumab**?
- Hypocalcemia with advanced kidney disease
50
What are the **contraindications** for **Denosumab**?
- Hypocalcemia
- Pregnancy
51
What are the **warnings** for **denosumab**?
- ONJ
- Femur Fractures
52
What are some of the **Side Effects** for **denusomab**?
- HTN
- Fatigue
- Edema
- N/V/D
- Decrease PO4
53
What does **menopause** occur?
- after the **last menstrual period** (~12 months ago)
54
What are some of the **common symptoms** of **menopause** and what is the reason that they happen?
- decrease in **estrogen & progesterone** = increase in FSH causing the vasomotor symptoms
- **Hot Flashes, Night Sweats**, Vaginal Dryness, Painful Intercourse
55
What are some of the **local hormone therapies** for **menopause**?
- 17-Beta Estradiol [Cream - **Estrace**; Ring - **Estring**; Tablet - **Vagifem**]
- Conjugated Equine Estrogens [Cream - **Premarin**]
56
What are some of the **systemic Hormone therapies** used for **meopause**?
- Estradiol (Climara, Vivelle-Dot)
- 17-Beta Estradiol
- Conjugated Equine Estrogen (Tablet, Injection - **Premarin**)
- MPA
- Medroxyprogesterone (**Provera**)
- Micronized Porgesterone (**Prometrium**)
57
What are some **boxed warnings** for the **systemic Hormone Therapies** used for **menpause**?
- Edometrial cancer (when estrogen is used without progestin in women with a urterus)
- Dementia (women > 65 yo)
- Increased risk of VTE and Stroke
- Breast Cancer
58
What are some **contraindications** for **systemic hormone therapies** used for **menopause**?
- Estrogen-containing products: Breast Cancer (any Hx), Uterine bleeding, Active VTE, Pregnant
59
What are some **warnings** for the **systemic hormone therapies** used for **menopause**?
- Increased risk of breast cancer
60
What are the **SSRIs and SNRIs** that can help with the **menopausal vasomotor symptoms**?
- Paroxitine [Brisdelle]
## Footnote
**2D6 inhibitor** so dont take with Tamoxifen or Warfarin
61
What is the **Neuokinin B Antagonist** that helps with the **menopausal vasomotor symptoms**?
- Fezolinetant (Veozah)
62
What are some **medications** that can **lower Testosterone**>
- Opioids (methadone)
- Chemo
- Cimetidine
- Spironolactone
63
What are some of the **Testosterone (C-III) Products** that are used?
- Testosterone Gel (AndroGel, AndroGel Pump) **Topical**
- Testosterone Cypionate (Depo-Testosterone) **Injection**
64
What are some **boxed warnings** to the **Testosterone products**?
- Seconday exposure to kids (kids should avoid contact with anything that has topical testosterone)
65
What are some of the **side effects** for **testosterone products**?
- Increased Appetite
- Acne
- Edema
- Hepatotoxicity
- Reduced Sperm Count
