Osteoprosis Flashcards
Secondary Osteoporosis
- Oral Glucocorticoid induced
FRAX
- online fracture risk calculator
- Treat if osteopenic pts with 10 yr hip fracture risk > 3% or major osteoporotic fracture risk >20%
- Only for treatment naive pts
Medication Management
- Calcium and Vit D
- Bisphosphonates (most common)
- HRT (horomone replacement therapy)
- Raloxifene
- Calcitonin
- N 1-34 PTH (teriparatide)
- Denosumab
Calcium/Vit D
- Adjuvant therapy for all individuals (esp >65 yrs old)
- Statistically significant only with FULL doses and in older population
- Otherwise: small increase in bone density with small decrease in hip fractures
Ca and Vit D requirements
Children
- Age 4-8: 1000mg/day Ca; 600IU/day Vit D
- Age 9-18: 1300mg/day Ca; 600IU/day Vit D
Adult
- Women 50 and men>70: 1200mg/day Ca
- 70: 800IU/day Vit D
Cacium carbonate vs calcium citrate
- Take both with food, then doesn’t matter if pt taking carbonate or citrate
- calcium citrate better absorption
- calcium carbonate better absorption with food
- Need to split the dose, 500-600 each dose
Treatment
FIRST LINE: Alendronate, Risedronate, Zoledronic acid, Denosumab
SECOND LINE: Ibandronate
SECOND-THIRD LINE: Raloxifene
LAST LINE: Calcitonin
Very high fracture risk/Bisphosphonate failed: Teriparatide
Advise against the use of combination therapy
Bisphosphonates
Alendronate (Fosamax) Risedronate (Actonel) Ibandronate (Moniva) Zoledronate (Reclast) Zoledronic acid Pamidronate (Aredia)
- MOA: Increase bone mass, reduce incidence of fractures by inhibiting osteoclast activity (slower breakdown, but does not build bone)
- USE: Effective for treatment and prevention of osteoporosis
- ADR: GI, infusion rxn, Osteonecrosis of the jaw, arrhythmia, bone quality, Uveitis/scleritis
- COMPLICATION: osteonecrosis of the jaw (seen mostly in cancer pts getting IV bisphosphonates)
- PRECAUTIONS: can induce esophagitis (reflux, FERD, other esophageal abnomalities); Uveitis/scleritis in first time users
- MUST be taken on empty stomach and remain upright for 30-60 mins
- Preg category X
Bisphosphonate monitoring
- DXA
- Bone turnover markers: Formation (Alk phos), Resorption (urine NTX, urine CTX)
Alendronate (Fosamax)
- Also indicated for treatment of Paget’s Dz
- More GI ADRs than other bisphosphonates: DYSPEPSIA, abd pain, acid reflux, C/D/N, musculoskeletal pain
- OTHER ADR: hypoCa, thigh or goin pain (requires eval for atypical trochanteric fracture)
Osteonecrosis of the jaw
- Usually after dental extraction
- More common with IV bisphosphonates
- Need regular dental checkups
Risedronate (Actonel, Atelvia)
- Wait/sit up for 30 mins
Ibandronate (Boniva)
- IV or PO
- Pts must wait/sit up 60mins before eating or drinking
Zoledronate (Reclast)
- IV annually
- Reduced spine fractures/hip fractures
- ADR: flu like infusion rxn
Zoledronic Acid (Zometa)
- Indicated for hyperCa of malignancy, multiple myeloma and bone mets (ONJ incidence higher)
Pamidronate (Aredia)
- IV
Hormones
- NOT first line for pt in postmenopause (due to risk of breast cancer, stroke, VTEs, CAD)
- Estrogen + Medroxyprogesterone
- Reduces hop and vertebral fractures, overall fractures
- INDICATIONS: persistent menopausal sx, inability to tolerate other options, failure to response to other options
SERMs
- Raloxifene (Evista)
- NOT good for hip fractures, FOR vertebral fractures
- Mixed estrogenic and antiestrogen properties depending on tissue
- Lowers risk of breask Ca w/o stimulating endometrial hyperplasia
- Increased risks of DVTs and increased vasomotor sx (hot flashes)
- Black box for DVT, stroke risk
Calcitonin (Miacalcin, Fortical)
- Inhibits bone resorption
- Indicated for women > 5yrs post menopause who cannot take estrogen
- Not effective for osteoporosis: increases vertebral BMD modestly, not really for fractures risk
Teriparatide–N 1-34 PTH (Forteo)
- Decreased spine fractures and non spine fractures
- Not first line normally, But might be first line if very high fracture risk
- MOA: Helps build bone by stimulating osteoblast activity
- Female: postmenopausal OP with high fracture risk
- Male: primary or hypogonadal OP with high fracture risk
- ADR: transient/persistent hyperCa, HA, transient myalgia/arthralgia
- CONTRAINDICATIONS: Paget’s dz, pregnant/nursing, pediatrics/young adults, PRIOR RADIATION THERAPY, BONE METS, SKELETAL MALIGNANCIES, hyperCa
- WARNING: potential risk of osteosarcoma
- 2 yrs only
- Effects blunted in pts on bisphosphonates (start with teriparatide x2yrs, then start on bisphosphonates)
- IV
Denosumab (Prolia, Xgeva)
- Monoclonal antibody that blocks RANK ligand which stimulates osteoclasts
- ADR: cellulitis, eczema, flatulence, fatigue, asthenia, hypophosphatemia, N, dyspnea, arthralia, HA
- WARNING: hypocalcemia, ONJ, rash, infection, atypical fractures
- Preg category D
Prolia
- INDICATION: postmenopausal women with osteoporosis at high risk for fracture
- Reduces non-vertebral fractures, vertebral fractures
- SubQ injections
- Take with Ca and Vit D
Xgeva
- INDICATION: cancer
- giant cell tumor of bone, androgen deprivation therapy for prostate cancer, bone metastases from solid tumors
Osteoporosis treatment
- Postmenopausal women and men > 50 yrs old
- Bone mineral density T score of
Monitoring
- Obtain baseline DXA, repeat every 1-2yrs until findings are stable
- follow up DXA every 2 yrs
- Monitor changes in spine or total hip bone mineral density
- Follow up of pts should be in the same facility, with the same machine, and if possible, with the same technologist
- Bone turnover markers may be used at baseline to identify pts with high bone turnover and can be used to follow the response to therapy
