Osteperosis √ Flashcards
How long does it take for osteoblast and osteoclast to reform
Blast 3-4 months
Clast 3-4 weeks
2 types of fractures
Fragility and atraumatic
When do you start losing bone mass and at what rate
After 30
.4% per year
Why do we worry about osteoporosis for women
Menopause early years osteoclast reabsorb too much and later years osteoblast does activity decreased
what are the 6 long term meds associated with osteoporosis
- Chronic glucocorticoid use (≥ 5 mg prednisone or equivalent for ≥ 3 months)
- Gonadotropin-releasing hormone agonists
- Cancer chemotherapy drugs
- Aromatase inhibitors (anastrozole, exemestane, letrozole)
- Anticonvulsant therapy > 2 years and age > 40 years old
- Anticoagulants (> 6 months UFH/LMWH)
What does the T score mean for DEXA OP
> -1 normal
-1 to -2.4 osteoporosis
≤ -2.5 osteoporosis
≤ -2.5 with one or more fracture - severe
what are the 4 patients we recommend screening for
When your T score is -1 to -2.4, when would we consider treatment
A FRAX ≥20 % major risk or hip fracture score of ≥ 3%
what are the Goals of therapy for OP
What are some 3 non pharm treatments for OP
- achieve peak bone mass from childhood to adolescence age
- lifestyle (sun, smoking, limit alch, and diet)
- Weight-bearing exercises ≥ 30 for children, ≥60 for adults
name 3 fall prevention stratagies
Name 3 food that inhibits dietary calcium
Spinach, rhubarb, sweet potatoes, beans, collard greens, nuts, whole-grain and wheat brand
What amount of calcium do you want your pt taking
1000mg men
1200mg women
How do I determine Calcium dosing?
RDI - dietary intake
if dose 500-600 give BID to TID
What are some Calicum ADR
Flatulence and constipation
DNE 1200-1500 due to kidney stones
does Calcium reduce fractures?
No so needs to be paired with vita D
What form of calcium is the best
Chewable or liquid
2 Pros for calcium carbonate
Prefers salt and the highest and cheapest of all the elemental CA
Can act like an ant-acids
2 Cons for calcium carbonate
Must be taken with meals or citrus juices
Rebound acids if taken on an empty
What would calcium would i give a patient with heartburn
Caltrate
Pro of Citracal
Preferred for elderly
Don’t need to take it with food
Less constipating
includes vitamin D3
If I am having issues with Caltrate what should I switch to
Citracal
Cons for calcium citrate
Only 21% e Ca
What can decrease calcium absorption
Fiber laxatives
What can cause hypercalcemia with calcium
Thiazide
What age can you not convert Vita D properly via the skin
> 70 year
What Vita D do we have
Ergocalciferol D2 - high dose RX
Cholecalciferol D3 - OTC
What is the dose for vita D
1000-2000 IU 25-50 mcg
Why do I avoid D2 in older adults
bc the metabolism is impaired
Which is better D2 or D3
D3 because of the meta pathways
What is the goal vita D level
≥ 30 or 30-50 (preferred)
Recheck after 3 months bc HL is 1 month
Vita D DDI
Increase metabolism
Phenytoin
Barbiturates
CBZ
Rifampin
Decrease absorption
Cholestryramine
Colestipol
Orlistat
Mineral oil
What values raise alarms with Vita D
20-30 is low <20 is deficient
How do we treat low vita D labs
50K IU qwK for 8-12 weeks
Then once monthly or 1000-2000 IU PO after
AD for vita D
hypercalemia
hypercalciuria
What is the typical regiment for calcium and D3
1000-1200mg daily for calcium
600-1000 IU for D3
How do we RX treat pts with OP
1st bisphosphonates
2nd denosumab ( only if can tolerate above med)
What RX do we give to post meno OP with high risk fracture
Sclerosis inhibitor (romosozumab, Envity)
PTH (teriparatide, Forteo) + bisphosphonate
What 3 patients do we consider RX treatment
- Post meno women or men ≥50 that have low trauma hip or vertebra fracture
- T score ≤ -2.5 at neck hip or spine
- T score -1 - -2.5 that have a FRAX ≥20% frac or hip ≥3%
Alendronate treatment dosing
70 mg qwK
10 mg QD
Fosomax prevent dosing
35mg PO weekly or 5mg QD
What do we give if pt can’t swallow bisphosphonates
Binosto
Oral alendronate (same dosing)
When can’t we use alendronate
CrCL ≤35
Risedronate dosing women OP
150 mg monthly (75mg taking 2 days in a row )
35mg qwK
5mg QD (RARE)
Risedronate men OP
35mg qwK
Treatment of GIO w/ alendronate (glucocorticoids induce OP)
5mg QD
What is the Crcl cut off for risendronate
CrCl ≤ 30
What is 2 special things about Ibandronate
Boniva can only treat women and veterbral
3 months IV option at providers office
Ibrandonate dosing
150mg qmonth
Crcl cut off for Boniva
Ibandronate
Crcl ≤30
What is special about Zoledronic acid
IV only
5mg once yearly
Or 5mg every 2 years for prevention
Considerations for Reclast
zolendric acid
need to be admin in 15 mins and pt needs to be well hydrates
CrCl for Zolendric acid
≤35
Major Barriers for bisphosphonates
GI (oral only) for 3 months
Bone pain for 3 months
IV ibandonate ADR
Myalgia, cramps and limb pain
Zoledronic acid ADR
HYPOCALCEMIA absolute CI
Flu like sysmtoms
A fib
Arthritis, arthralgias and headaches
DDI for bisphosphonates
Aminoglycoside
Loops
NSAIDs
what is the 2 very rare ADR for bisphosphonates
ONJ
Mouth necrosis
Risk with any immune suppression
Prevent with oral hygiene and see dentist
Femur fractures with use for 5+ years
How to reduce ADR and improve adherence with bisphosphonates
take ≥30 mins (≥60 for ibandroate) before first food
Or take with a full glass of water
Remain up right for ≥ 30mins (60 for ibandroate )
patient education point for Atelvia?
Risedronate
Take right after breakfast
Patient education for Binosto
dissolve in 4 oz of warm water
3 Patent education for bisphosphonates
Space calcium 30-60 mins
X NSAIDs except for aspirin
Dental exam 2x a year
Weekly
Missed dose
Take the next day and if more take at the next weekly dose
Monthly
Take up to 7 days before next month dose
How long should you use bisphosphonates
What cant denosumab (prolia be used for)
Prevention
except
1. Women receiving adjuvant aromatase inhibitor therapy for breast cancer at high risk
2. Men receiving androgen-deprivation therapy for non- metastatic prostate cancer at high risk
who should usually get prolia
high risk patients
What is the dose for prolia
60mg subq every 6 months
Pros of denosumab
Improved adherence
No drug holidays
Can be used with any renal function
Cons of prolia
Expensive
If poor adherence wears off quick
ADR with denosumab
Farting, skin rashes, increased cholesterol
Rare but need to know
UTI increased
Hypocalcemia
ONJ - more than bisphosphonates
Less femur fracture than bisphosphonates
What to monitor for Prolia
Serious infections
Skin reactions
Can not be Hypocalcemic
Dose cant bel delayed for more than one month
When do we use teriparatide
Treatment of OP with high risk (excluding hip)
Treatment of GIO
What is the doses of Teriparatide
20 mcg sq QD
ADR for teriparatide
Well tolerated
Hypercalcemia
ORTHOSTATIC HYPOTENSION - important
what is the max treatment duration
2 years
what is the monitoring for teriparatide
BBW for osteosarcoma
Beware
Kidney stones
Renal failure
Hypotension
Pagers disease
Monitor calcium level
And new fractures
When do we use abaloparatide
Salvage therapy
No GIO or hip
Ad and monitoring for Abaloparatide
same as teriparatide
When do we use Romosozumab
Women and vertebral
Not as recommended as teriparatide
BBW for romosozumab
BBW for MACE - can not start if MI/CVA within one year and dc if you do get one
When do we use Raloxifene
Women and spine
Reduce breast cancer
High breast cancer risk
What is kept if we stop raloxifene
Breast cancer reduction
When do we use bazedoxifene (Duavee)
Veterbral/ prevention with intact uterus
X in hepatic impairment and kind of in renal
Estrogen/progestin when we use
Younger age or <10 year past menopause
Low risk DVT, breast cancer
How do we treat GIO
Try bisphosphonates
Then teriparatide
what patients are at risk for GIO
≥ 5 mg/day (or equivalent) for ≥ 3 months
Calcium and D3 dosing for GIO
Calcium 1200-1500 mg daily + vitamin D3 800-1200 IU daily
Ca levels
8.5-10.2 mg/dL
