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Pharm Unit 5 > Parathyroid drugs > Flashcards

Parathyroid drugs Flashcards

1
Q

Alendronate (Fosamax), Risedronate (Actonel)

A

Class: Bisphosphonate
Mech: Reduce osteoclastic bone resorption
Thera: Hypercalcemia; osteoporosis; Paget’s disease of bone; prevention of fractures in osteogenesis imperfecta
Other SE’s: Esophageal irritation
Misc: Oral formulation; patient must be sitting upright, fasting, for 30 minutes; takes several days to see effect

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2
Q

Ibandronate (Boniva)

A

Class: Bisphosphonate
Mech: Reduce osteoclastic bone resorption
Thera: Hypercalcemia; osteoporosis; Paget’s disease of bone; prevention of fractures in osteogenesis imperfecta
Other SE’s: Esophageal irritation
Misc: Oral and IV formulations; patient must be sitting upright, fasting, for 30 minutes; takes several days to see effect

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3
Q

Pamidronate (Aredia)

A

Class: Bisphosphonate
Mech: Reduce osteoclastic bone resorption
Thera: Hypercalcemia of malignancy; Paget’s disease of bone; prevention of fractures in osteogenesis imperfecta
Important SE’s: Serum creatinine elevation
Other SE’s: Fever, flu-like symptoms
Misc: Bypasses GI tract (given IV); takes several days to see effect for lowering calcium

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4
Q

Zoledronic acid (Reclast)

A

Class: Bisphosphonate
Mech: Reduce osteoclastic bone resorption
Thera: Hypercalcemia of malignancy; Paget’s disease of bone; prevention of fractures in osteogenesis imperfecta
Important SE’s: Serum creatinine elevation
Other SE’s: Fever, flu-like symptoms
Misc: Bypasses GI tract (given IV); takes several days to see effect for lowering calcium

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5
Q

Cinacalcet (Sensipar)

A

Class: Calcimimetic
Mech: Reduces PTH and serum calcium levels
Thera: Secondary hyperparathyroidism from renal disease; parathyroid carcinoma; hypercalcemia in primary hyperparathyroidism not treatable by surgery

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6
Q

Calcitonin (Miacalcin)

A

Class: Amino acid peptide
Mech: Increases urinary calcium excretion, inhibits bone reabsorption (modest effect)
Thera: Short-term relief of hypercalcemia; osteoporosis (reduce vertebral fractures); Paget’s disease of bone
Other SE’s: Minimal (e.g., rhinitis)
Misc; No longer recommended for use in nasal spray form because of increased cancer risk. Can still use SQ or IM. Tachyphylaxis in 2-3 days; often used to bridge treatment for other medication

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7
Q

Teriparatide (Forteo)

A

Class: PTH analog
Mech: Short bursts given SQ, stimulating bone resorption and bone formation via osteoblasts
Thera: Osteoporosis (high risk patients who have failed other treatments)
Other SE’s: Transient mild hypercalcemia
Misc: Contraindicated in those with increased chance of osteosarcoma (e.g., Paget’s disease of the bone, radiation exposure)

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8
Q

Raloxifene (Evista)

A

Class: Selective estrogen receptor modulator
Mech: Selectively activates certain estrogen receptors, but blocks others
Thera: Osteoporosis
Important SE’s: Increase risk of hot flashes, DVT

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9
Q

Corticosteroids

A

Mech: Decreases production of 1,25 vitamin D; may inhibit growth of neoplastic lymphoid tissue
Thera: Hypercalcemia from vitamin D intoxication, granulomatous diseases, hematologic malignancies

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10
Q

Denosumab (Prolia)

A

Class: Monoclonal antibody
Mech: RANK ligand inhibitor (targets early effect of osteoclasts on bone)
Thera: Osteoporosis
Misc: can give at any GFR but need to exclude other causes of renal osteodystrophy

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11
Q

Calcium carbonate, Calcium acetate, Sevelamer (Renvela)

A

Mech: Binds phosphate
Thera: Secondary hyperparathyroidism from renal disease

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12
Q

Cortical bone predominates in the _____; trabecular bone predominates in the _____

A

shafts of the long bones;

vertebral bodies, ribs, pelvis, ends of long bones

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13
Q

The inorganic matrix of bone is largely composed of _____, a mineral composed of

A

hydroxyapatite;

Ca and P

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14
Q

Biologic activity of PTH resides in _____; it is secreted by what? Its secretion is controlled by what?

A

first 34 residues; the four parathyroid glands;

serum IONIZED Ca, such that if Ca is low, PTH is stimulated, but if Ca is high, PTH suppressed

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15
Q

Discuss percentages regarding Ca in the body:

A 
99% in skeleton, 1% in ECF;
3 forms:
1. ionized Ca (50%)
2. protein bound Ca (40%)
3. Complexed to bicarb, citrate, phos (10%)
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16
Q

What is physiologically the most important Ca? What accounts for most of its protein binding?

A

Free/ionized;

albumin!!

17
Q

P levels influenced by ____ and _____; what promotes its reabsorption in the ____ and what promotes excretion?

A

vit D3 and PTH;
phosphate deletion, hypoparathyroidism, hypocalcemia increase reabsorption;
PTH, PTHrP, hypercalcemia, hypokalemia, hypomanesemia, calcitonin, glucocorticoids, and diuretics promote excretion

18
Q

For Mg, what is it necessary for? Where is it excreted and what can interfere with its reabsorption at loop of Henle?

A

Release of PTH and action of hormone on its target tissues;
primarily renally excreted;
drugs like furosemide and cisplatin inhibit

19
Q

Renal production of Vit D3 is tightly regulated by _____ through

A

Ca levels; PTH and phosphorus

20
Q

In cases of hypercalcemia, most common causes and what should be ordered? What is PTH levels in either of these causes?

A

Think malignancy or hyperparathyroidism;
if primary, PTH high or normal;
if PTH is low, think about PTHrP, vit D levels, and 24 hr urine Ca

21
Q

Some major causes of hypercalcemia?

A
  1. Primary hyperparathyroidism
  2. malignant disease (osteolytic metastases with breast cancer and MM)
  3. Sarcoid, TB, granulomatous diseases
  4. Milk-alkali syndrome (Tums)
  5. FHH
  6. Vit D or A intoxication
22
Q

Usually, what leads to primary hyperparathyroidism? How can you diagnose it?

A

think benign, solitary adenoma usually, if not hyperplasia of all four glands;
see elevated Ca, elevated or normal PTH, low P maybe, and elevated urine Ca

23
Q

Treatment of primary hyperparathyroidism? Who is recommended for treatment?

A

Remove abnormal parathyroid tissue, especially with overt bone disease, kidney stones, or life threatening hypercalcemia;
think 1.0 mg/dL higher than normal, T score < -2.5, vertebral fracture on X-ray, creatinine clearance < 60, 24 hr urine for Ca > 400 mg/day, if you have nephrolithiasis or nephrocalcinosis, and if LESS THAN 50

24
Q

Treatment of primary hyperpara:

A
  1. adequate hydration and ambulation
  2. still need moderate Ca intake
  3. bisphosphonates for low bone density in those w/o surgery
  4. Calcimimetics: reduce PTH and serum Ca levels (alter function of Ca sensing receptor)
  5. Sensipar: for hyperpara in renal disease and parathyroid carcinoma, and also primary HPT who won’t have/refuse surgery
25
Q

Causes of hypercalcemia:

A
  1. PTHrP, MM (local osteolytic factor)
  2. FHH: AD, PTH normal or only slightly high, urine Ca low
  3. Milk alkali syndrome: excess OTC Ca use
  4. Granulomatous diseases: Increased Vit D3 levels
  5. Meds: think thiazides or Li
26
Q

Treating HYPERCALCEMIA:

A
  1. if mild (Ca < 12): could be asymp, need to increase fluid intake, moderate Ca diet, avoid certain meds
  2. if moderate (12-14): probably need intervention
  3. if severe (greater than 14): could be life-threatening, needs immediate treatment
27
Q

Fluids for hypercalcemia:

A
  1. IV saline (4-6 L)

2. could use loop diuretic but make sure there’s adequate volume replacement

28
Q

Secondary hyperparathyroidism: Facts and how to treat?

A
  1. PTH secreted in response to perceived low Ca concentration; might have renal disease and phosphate retention (high P stimulates directly PTH secretion)
  2. Vit D deficiency maybe
  3. Replace with ergo/cholecalciferol
  4. Could treat with low P diet, phosphate binders, replacement with Vit D2 and dialysis
29
Q

Tertiary HPT:

A
  1. PT glands autonomous after prolonged secondary HPT
  2. Ca here is elevated (low/normal in secondary)
  3. Diagnosis/therapeutic same as for primary HPT
30
Q

Causes of hypocalcemia:

A
  1. PT destruction (surgery or radiation)
  2. autoimmune
  3. reduced PT function (hypomagnesemia)
  4. Vit D deficiency (lack of sunlight, malabsorption, liver or renal failure)
  5. PTH resistance
  6. Others like pancreatitis, rhabdo, massive tumor lysis, etc.
31
Q

Symptoms of hypocalcemia:

A
  1. Parasthesias of finers, toes, and circumoral areas
  2. Tetany
  3. muscle cramps
  4. Chvostek’s sign
  5. Trousseau’s sign
  6. Prolonged QT on EKG
  7. Laryngospasm;
    long term: cataracts, papilledema, calcifications in basal ganglia
32
Q

Labs of hypocaclemia:

A

look at albumin to see if hypoalbuminemia is present; look at PTH again and Mg; also maybe P and creatinine levels

33
Q

Treatment of chronic renal failure and hypocalcemia:

A
  1. Calcitriol or other vit D analogs
  2. Phosphate binders can reduce P levels
  3. Calcimimetics an option
34
Q

HypoPTism is; what is seen in labs? PseudohypoPTism?

Treat hypoPTism?

A

PTH insufficiently made or can’t function properly at tissues;
see low Ca, high P, low PTH;
with pseudohypoPTism, PTH will be elevated;
need to restore Ca and P as close to normal as possible: think calcitriol, or ergo/cholecalciferol; limit P in diet

35
Q

Aggressive repletion is necessary in patients with vit D deficiency

A

secondary to dietary insufficiency, malabsorption, or other diseases

36
Q

For acute hypocalcemia, give

A

Ca gluconate 10 ml diluted in 50 ml of D5W or NS IV over 5 minutes; watch Ca levels and could need vit D orally if low Ca persists

37
Q

Treatment of hypophosphatemia consists of

A

replacing P and calcitriol

Pharm Unit 5 (9 decks)

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