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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
What monitor parameters are in place while a patient is on bisphosphonates?
calcium, phosphorus, SCr
26
Indication: Alendronate
men and postmenopausal women to reduce the incidence of vertebral, nonvertebral, and hip fractures
27
Instructions for Use: Alendronate
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
What is the CrCl cut-off for Alendronate?
<35mL/min
29
Indication: Risedronate
approved for men and postmenopausal women to reduce the incidence of vertebral, nonvertebral, hip fractures
30
Instructions for Use: Risedronate
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
What is the CrCl cut-off for Risedronate?
< 30 mL/min
32
Indication: Ibandronate
postmenopausal women only to reduce incidence of vertebral fractures
33
What is the CrCl cut-off for Ibandronate?
<30 mL/min
34
Indication: Zoledronic acid
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
MOA: Denosumab
human monoclonal antibody that binds to RANKL
36
Indication: Denosumab
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
Why is there a REMS program for Desnosumab?
to inform healthcare professional about hypocalcemia, ONJ, AFF, serious infection, dermatologic reactions and a MedGuide must be dispensed
38
Dosing: Denosumab
60mg every 6 months via subcutaneous injection that must be administered by a healthcare professional
39
Contraindications: Denosumab
hypocalcemia- must be checked prior to therapy initiation, and rechecked 2 weeks after starting therapy in patients with CrCl < 30 mL/min
40
Adverse Effects: Denosumab
pain (back, extremities, musculoskeletal), hypercholesterolemia, cystitis -uncommon, but serious= ONJ, AFF
41
MOA: Raloxifene (Evista)
SERM, mixed estrogen agonist and antagonist activity- agonist for bone and lipids, antagonist in breast and endometrial tissue
42
Indication: Raloxifene
postmenopausal women to reduces the risk of vertebral fractures
43
Adverse effects: Raloxifene
vasomotor symptoms (hot flashes), thromboembolism
44
Contraindications: Raloxifene
-active thromboembolism -hypersensitivity -pregnancy/lactation
45
Black Box Warning: Raloxifene
thromboembolic events, cardiovascular disease
46
Describe Hormone Therapy use in osteoporosis
-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
MOA: Teriparatide (Forteo)
*daily subq injection* recombinant form of endogenous parathyroid hormone which stimulates osteoblast activity and increase calcium absorption
48
Indication: Teriparatide
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
MOA: Abaloparatide
*injection* analog of human parathyroid hormone related peptide= stimulates osteoblast activity
50
Indication: Abaloparatide
men and postmenopausal women for vertebral and non-vertebral fractures
51
What is the max time that a pt may take Abaloparatide?
2 years, then must switch to antiresorptive agent
52
Black Box Warning: Abaloparatide
increased risk of osteosarcoma
53
Adverse effects: Abaloparatide
uric acid increase, orthostatic hypotension, injection site rxn, hypercalcemia
54
MOA: Romosozumab (Evenity)
monoclonal antibody, inhibits sclerotin
55
Indication: Romosozumab
post menopausal women with high risk of fracture or previous history for vertebral and nonvertebral fractures- possibly hip
56
Black Box Warning: Romosozumab
increased risk of MI, stroke, and cardiovascular disease
57
What is the max time a pt can take Romosozumab?
12 months, switch to antiresorptive agent after
58
What monitoring parameters are suggested when treating osteoporosis?
-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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