OsteoporosisSH Flashcards
Osteoporosis
Prevention / lifestyle
Men 50 -70 y/o: 1000 mg / day
Men ≥ 71 & women ≥ 51 : 1200 mg/day
Vitamin D: ≈ 800 units per day
Milk ( 8oz ) 300 mg calcium
Celiac Dz: contributor to osteopenia: recommend gluten free diet
Weight bearing exercises
Reduc risk factors: smoking, coffee, alcohol use, glucocorticoids
Guidelines
Females 65 and over and 70 and over to get density testing
- post menopausal ≥ 50yo : earlier testing
-men > 50 with risk factors.
BMD: bone mineral density : DEXA ( quick painless preferred method )
DEXA scan gives
T score
Normal = > -1
Between -1 to 2.5 osteopenia
Below - 2.5 osteoporosis
Meds that causes osteoporosis
Corticosteroids
Antiepileptic drugs: phenytoin , pheno barb
•Aromatase inhibitors: Armidex, Femara, Aromasin : hormone therapy decrease production of estrogen. Estrogen is a protective agent.
GnRH : decreasing testosterone. Just like estrogen is a protective agent for female and their bones, testosterone is a protective agent for males for their bones.
PPI: decreases ca in system.
TZD: fracTures
SGLT inhibitors
SSRI
Depo Provera
Heparin
Lithium : can causes hypoparathyroidism and that can cause osteoporosis
Some chemo : MTX
Osteoporosis Tx
SERMS: selective estrogen receptor modulators
• Evista ( Raloxifene ): used for POSTMENOPAUSAL patients.
SE: #1 CLOTS, hot flashes , leg cramps, D/C 72 hours prior to and during immobilization.
DDI: cholestyramine ( decreases evista abs)
Levothyroxine ( evista can decrease levothyroxine level )
Counseling: with or without food. DVT sx monitor. Never use if hx of clots or pregnant. Not recommended pre menopausal. Use compression stockings.
Bisphosphonates
1st line agent for men and women
MOA: inhibit osteoclast mediated bone resorption.
Stay in system for long period of time.
SE: GI N/V/D abdominal pain.
- GERD / ulcers
- pain( bone, muscle joints )
-osteonecrosis of the jaw. - uses peridot to for prevention of osteonecrosis of the jaw. Protects gums.
- All bisphonates cause hypocalcemia.
Bisphosphonates B/G
Caution: hypocalcemia, inability to stand or sit upright, CKD
• Alendronate ( fosamax ) ( Binosto ) ( Tabs/Soln)
• Risendronate ( Actonel ) - tabs
• Risedronate delayed release ( atelvia ) - only Bisphosphonates that can be taken with food. All others on empty stomach.
• ibandronate ( Boniva)
• zoledronic acid ( reclast ) - IV 5 mg once a year used for osteoporosis
•zoledronic acid ( zometa ) IV 4 mg q 3 - 4 weeks. NOT indicated for osteoporosis
• pamidronate ( Aredia ) - IV NOT for osteoporosis
All can causes hypercalcemia, oral must stay upright. All worry about renal cant with CKD
Alendronate
Fosamax
Dose 5-10 mg QD or 35 to 70 mg once weekly
Indications: osteoporosis in POSTMENOPAUSAL females
Osteoporosis in men
Osteoporosis secondary to glucocorticoids
Paget disease :
Caution: if CrCl < 35 ml/Min dont give it
Risendronate
Actonel / Atelvia
Paget’s disease
Osteoporosis for males
Glucocorticoid induced osteoporosis
Risendronate delayed release ( atelvia )
Caution: do not give if CrCl < 30 ml/min
Ibandronate
Boniva
Indication : tx and prevention of post menopausal osteoporosis
Caution: hypocalcemia , CrCl < 30
Zoledronic acid
Reclast ( IV )
5 mg in a 100 mL ready to infuse soon
Avoid in renal impairment: dont use if CrCl < 35
Drink lots of water before this IV infusion. WHY? To protect kidneys.
4mg zometa : used for hypercalcemia
< 30 CrCl avoid zometa
Pamidronate
Aredia ( IV only )
Not indicated for osteoporosis
Hypercalcemia
Multiple myeloma
Osteolytic
Pagets diseae
Denosumab
( prolix, Xgeva ) ( SQ )
If worried about CrCl and cant give Bisphosphonates you can give Denosumab instead
MOA: human IgG2 monoclonal a which inhibits or rather binds to the RANK ligand ( RANKL ) and prevents osteoclasts fomaton.
Contraindications: hypocalcemia
SE: hypocalcemia, osteonecrosis of the jaw
Use every 6 months.
Refrigerated
Calcitonin
( miacalcin )
- nasal spray IM subQ
Osteoporosis
Pagets
Hypercalcemia
Post menopausal osteoporosis
Caution: salmon allergy
Do not shake nasal spray.
1 spray per day. So alternate nostrils day to day.
Refrigerate: can be out 35 days
Teriparatide
Forteo
Used for osteoporosis for only a total of 2 years.
Given subQ daily
For women: estrogen
Estrogen not recommended as first line. Can cause clots, breast cancer, endometrial cancer , hypercalcemia
DDI: inducers decrease effect.
• St. John’s wort, carbamazepine, rifampin
If patient has no hx of history of hysterectomy and pt getting estrogen, make sure they get it combined with estrogen and progesterone. Progesterone will help protect from endometrial cancer. If already had hysterectomy they can be on estrogen alone
Estrogen used for HRT and osteoporosis
Estropipate ( ogen )
Activella ( estradiol + norethindrone )
Prefest ( estradiol + norgestimate )
Medroxyprogesterone + estrogen ( premphase )
Estrogen patches
Vivelle - dot ( estradiol ) : twice weekly
Alora( estradiol ) : twice weekly
Menostar ( estradiol ) once weekly
Climara ( estradiol ) once weekly
Climara pro ( estradiol + levonorgestrel ) once weekly
POSTmenopauasal women REview
Oral Bisphosphonates are first line - cant give if not upright or esophageal disorders
Can’t take oral maybe IV. If renal issues cant even give IV
Denosumab : prolia ( subq) : can give if renal impairment ( CrCl < 30 or 35) . Not a Bisphosphonates.
Teriparatide ( forteo ) : can only give for 2 years
Raloxifene: if the patient needs breast cancer prophylaxis - it’s a SERM ( SE: clots!)
For men
Oral Bisphosphonates first line
Teriparatide ( forteo ) : only for patients with high fracture risk. Refrigerate. Max 2 years of use
Hypercalcemia, orthostatic hypotension
Denosumab ( prolia ) for men at high risk of fracture due to androgen deprivation therapy for prostate cancer.
Testosterone replacement for men with low serum levels
