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Therapeutics 1 > Osteoprosis > Flashcards

Osteoprosis Flashcards

1
Q

Define: Osteocytes

A

bone communication cells, start bone remodeling process

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2
Q

Define: Osteoblasts

A

bone-forming cells

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3
Q

Define: Osteoclasts

A

bone-reabsorbing cells

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4
Q

Define: RANKL

A

receptor activator of nuclear factor kappa B ligand; emitted from osteoblast. RANKL bind on preosteoclasts -> osteoclasts

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5
Q

What are the risk factors for osteoporosis?

A

-advanced age (women > 65, men >70)
-cigarette smoking
-female
-excessive alcohol use (> 3 units (standard drink)/day)
-glucocorticoid use
-low bone mineral density
-low weight or BMI
-previous fracture as an adult
-parent history or fragility fracture

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6
Q

What drugs can increase the risk of osteoporosis?

A

-glucocorticoids
-excessive thyroid supplementation
-long-term PPI
-gonadotropin releasing hormone agonist/antagonist

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7
Q

When should a patient be screened for osteoporosis?

A

-women >= 65 yo
-men >= 70 yo
-postmenopausal women and men > 50-69 based on risk factors
-postmenopausal women and men >=50 with adult age fracture

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8
Q
A
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9
Q

Describe the DXA

A

measures bone mineral density (BMD)
-should not be used in premenopausal women, only postmenopausal women and men > 50
SCORES:
-normal = -1 or above
-low bone density= -1 - -2.4
-osteoporosis: -2.5 or below

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10
Q

How can a patient prevent osteoporosis?

A

-adequate calcium and vitamin D intake
-avoid smoking, falling
-limit alcohol and caffeine intake
-weight-bearing exercise for at least 30 minutes a day

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11
Q

What is the recommended calcium and vitamin D3 intake?

A

calcium= 1,200 mg/day >50 yo, vitamin D3= 800-1000 IU/day >50 yo

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12
Q

How much elemental calcium is in calcium carbonate (TUMS)?

A

40%

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13
Q

How much elemental calcium is in calcium citrate?

A

21%

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14
Q

What is the max amount of elemental calcium that may be ingested in 1 dose?

A

500mg

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15
Q

What can be given to patient as a vitamin D supplement?

A

cholecalciferol (D3) 1000-2000 IU/daily

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16
Q

What is the target lab value of vitamin D?

A

30ng/mL +

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17
Q

When do you treat osteoporosis?

A

-osteoporotic vertebral or hip fracture
-T-score of -2.5 or below at the spine, femoral neck, or total hip
-T-score from -1 to -2.4 and a 10-year risk >20% for major osteoporotic fracture or hip fracture risk >3%

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18
Q

Mechanism of Action: Bisphosphonates

A

antiresorptive agents
inhibits resorption by inhibiting osteoclasts from binding to bone, bone mineral density increases can be sustained for up to a year after discontinuation

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19
Q

Side Effects: Bisphosphonates

A

-Oral preparations= GI symptoms (gastric ulcerations, abdominal pain, constipation, diarrhea, nausea)
-IV preparations (zoledronic acid)= flu-like symptoms

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20
Q

What are the rare, but serious side effects of Bisphosphonates?

A

-atypical femur fractures
-osteonecrosis of the jaw (ONJ)

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21
Q

What are the contraindications and cautions when a patient is taking bisphosphonates?

A

avoid use in patients with renal insufficiency (see product- specific cut-offs for CrCl)

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22
Q

Why should patients on bisphosphonates consider a drug holiday?

A

to reduce the risk of atypical femur fracture

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23
Q

When should a drug holiday be considered for patients on bisphosphonates?

A

5 years on oral preparations and 3 years on IV preparations

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24
Q

What should vitamin D levels be at to begin bisphosphonate therapy?

A

> 20 ng/mL

25
Q

What monitor parameters are in place while a patient is on bisphosphonates?

A

calcium, phosphorus, SCr

26
Q

Indication: Alendronate

A

men and postmenopausal women to reduce the incidence of vertebral, nonvertebral, and hip fractures

27
Q

Instructions for Use: Alendronate

A

70mg/weekly, take on an empty stomach with a full glass of water, remain upright for 30 minutes after ingestion, no food or meds for 30 minutes

28
Q

What is the CrCl cut-off for Alendronate?

A

<35mL/min

29
Q

Indication: Risedronate

A

approved for men and postmenopausal women to reduce the incidence of vertebral, nonvertebral, hip fractures

30
Q

Instructions for Use: Risedronate

A

5mg/daily, 35mg/weekly take on empty stomach with water, remain upright for 30 minutes after ingestion, no food or other meds for 30 minutes

31
Q

What is the CrCl cut-off for Risedronate?

A

< 30 mL/min

32
Q

Indication: Ibandronate

A

postmenopausal women only to reduce incidence of vertebral fractures

33
Q

What is the CrCl cut-off for Ibandronate?

A

<30 mL/min

34
Q

Indication: Zoledronic acid

A

men, postmenopausal women, GIOP to reduce the risk of vertebral, nonvertebral, hip fractures- IV infusion so first choice for patient who cannot take oral bisphosphonates

35
Q

MOA: Denosumab

A

human monoclonal antibody that binds to RANKL

36
Q

Indication: Denosumab

A

men, postmenopausal women, GIOP, and patients on hormone-deprivation therapy for cancer to reduce risk of vertebral, nonvertebral, and hip fractures- may be preferred agent for patients with renal impairment

37
Q

Why is there a REMS program for Desnosumab?

A

to inform healthcare professional about hypocalcemia, ONJ, AFF, serious infection, dermatologic reactions and a MedGuide must be dispensed

38
Q

Dosing: Denosumab

A

60mg every 6 months via subcutaneous injection that must be administered by a healthcare professional

39
Q

Contraindications: Denosumab

A

hypocalcemia- must be checked prior to therapy initiation, and rechecked 2 weeks after starting therapy in patients with CrCl < 30 mL/min

40
Q

Adverse Effects: Denosumab

A

pain (back, extremities, musculoskeletal), hypercholesterolemia, cystitis
-uncommon, but serious= ONJ, AFF

41
Q

MOA: Raloxifene (Evista)

A

SERM, mixed estrogen agonist and antagonist activity- agonist for bone and lipids, antagonist in breast and endometrial tissue

42
Q

Indication: Raloxifene

A

postmenopausal women to reduces the risk of vertebral fractures

43
Q

Adverse effects: Raloxifene

A

vasomotor symptoms (hot flashes), thromboembolism

44
Q

Contraindications: Raloxifene

A

-active thromboembolism
-hypersensitivity
-pregnancy/lactation

45
Q

Black Box Warning: Raloxifene

A

thromboembolic events, cardiovascular disease

46
Q

Describe Hormone Therapy use in osteoporosis

A

-estrogen binds on osteoblasts, which may increase activity and can suppress cytokine-activating factors that stimulate osteoclast activity
-approved for prevention of osteoporosis in women but do not use for this sole purpose
-safety concerns

47
Q

MOA: Teriparatide (Forteo)

A

daily subq injection
recombinant form of endogenous parathyroid hormone which stimulates osteoblast activity and increase calcium absorption

48
Q

Indication: Teriparatide

A

men, postmenopausal women, GIOP for vertebral and non-vertebral fractures- may hip?
*usually reserved for T scores worse than -3 or those with refractory to antiresorptive therapy

49
Q

MOA: Abaloparatide

A

injection
analog of human parathyroid hormone related peptide= stimulates osteoblast activity

50
Q

Indication: Abaloparatide

A

men and postmenopausal women for vertebral and non-vertebral fractures

51
Q

What is the max time that a pt may take Abaloparatide?

A

2 years, then must switch to antiresorptive agent

52
Q

Black Box Warning: Abaloparatide

A

increased risk of osteosarcoma

53
Q

Adverse effects: Abaloparatide

A

uric acid increase, orthostatic hypotension, injection site rxn, hypercalcemia

54
Q

MOA: Romosozumab (Evenity)

A

monoclonal antibody, inhibits sclerotin

55
Q

Indication: Romosozumab

A

post menopausal women with high risk of fracture or previous history for vertebral and nonvertebral fractures- possibly hip

56
Q

Black Box Warning: Romosozumab

A

increased risk of MI, stroke, and cardiovascular disease

57
Q

What is the max time a pt can take Romosozumab?

A

12 months, switch to antiresorptive agent after

58
Q

What monitoring parameters are suggested when treating osteoporosis?

A

-annual height measurements
-DEXA every 2 years
-adverse effects
-adherence
-falls
-calciums and vitamin D intake
-calcium, vitamin D labs, SCr
-oral hygiene and reg exams

Therapeutics 1 (16 decks)

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