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Anatomy > Pharm Exam 2 > Flashcards

Pharm Exam 2 Flashcards

1
Q

How long can bone remodeling take?

A

3-4 months

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2
Q

What reabsorbs (removes) bone?

A

osteoclasts

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3
Q

What forms (synthesizes) bone?

A

osteoblasts

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4
Q

What do osteoblasts secrete?

A

alkaline phosphatase (ALP)

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5
Q

When is secretion of alkaline phosphatase increased?

A

In bone growth (children & adolescents)

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6
Q

What causes the loss of bone mass after 30?

A

Reabsorption > Formation

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7
Q

Name of vitamin D2?

A

Ergocalciferol

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8
Q

Name of Vitamin D3?

A

Cholecalciferol

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9
Q

“Vitamin D”

A

D2 & D3 (both act similarly)

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10
Q

Where is vitamin D converted into 25-hydroxyvitamin D?

A

Liver

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11
Q

Where is 25-hydroxyvitamin D converted to 1-25 dihydroxyvit D (calitriol;D3)

A

Kidneys

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12
Q

What is the result of:
Low serum Ca 2+ and
Increases in PTH

A

Increased bone resorption AND Increased Ca2+ resorption from the gut

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13
Q

What is the precursor condition of osteoporosis?

A

osteopenia

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14
Q

What is the bone density of osteopenia?

A

1 to <2.5 SD below average bone mass

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15
Q

What is the bone density of osteoporosis?

A

> or = to 2.5 SD below average bone mass

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16
Q

What are the 3 categories of osteoporosis?

A

Post menopausal
Age-related
Secondary: medications

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17
Q

What causes postmenopausal osteoporosis?

A 
Decreased estrogen (E2),
Increased bone resorption WITHOUT increased formation
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18
Q

What are the 2 cytokines that are stimulated and released by decreases in estrogen?

A

IL-1

TNF-alpha

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19
Q

What does IL-1 do?

A

potent inducer of resorption

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20
Q

What does TNF-alpha do?

A

induces osteoclast maturation

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21
Q

When does peak bone density occur?

A

2nd- 4th decades

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22
Q

Why are females more likely to have fractures compared to men with age related osteoporosis?

A

females have smaller mass and therefore a smaller loss results in fracture

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23
Q

What are the causes of age related osteoporosis? (6)

A
  1. Decreased osteoblast function
  2. Decreased Ca2+ and Vitamin D intake and absorption
  3. Decreased sex hormone levels
  4. Increased mechanical bone stress
  5. Decreased physical activity
  6. Decreased sun exposure (Decreased formation of DHVitD)
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24
Q

What is secondary osteoporosis associated with in men?

A

risk factors

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25
Q

What are the drug-induced medications of secondary osteoporosis?

A

Steroids, heparin, thyroid hormone replacement & anticonvulsants are most common
Prednisone >7.5mg/d (decreased bone formation; increased bone resorption)
Heparin greater than 15K-30K units/day for > 3-6 months :MOA unknown
T3 & T4 increase osteoclast activity
anticonvulsants increase vitamin D metabolism (osteomalacia & OP)

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26
Q

Osteoporosis Risk Factors (5)

A 
Lifestyle
Diet
Chronic Illness
Medications
Fall-related conditions ( meds: anxiolytics &amp; benzodiazepines)
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27
Q

Dietary changes for Osteoporosis therapy? (3)

A

Increase Ca2+ to 1200-1500mg/d
Increase Vet D to 200-600 units/daily
Dairy products; oily fishies; fortified milk; 15-20 mins sun 2-3x/week

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28
Q

What are the nonpharmacologic therapies for osteoporosis? (3)

A

Dietary changes
social habit changes
exercise

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29
Q

Why should calcium supplements be taken with meals?

A

best absorbed in acid pH

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30
Q

What type of calcium is pH independent?

A

calcium citrate (24% Ca, $$$)

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31
Q

Why is calcium citrate beneficial in elderly?

A

elderly may have decreased gastric acid output

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32
Q

What is a common SE of calcium supplements for osteoporosis?

A

constipation

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33
Q

Calcium cannot be taken within 1-2 hours of : (5)

A 
iron
tetracycline
quinolones
bisphosphonates
phenytoin
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34
Q

What is first line therapy for osteoporosis in men and women?

A

Bisphosphonates

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35
Q

How do bisphosphonates work?

A

they are absorbed to the bone later becoming permanent

inhibit action of osteoclasts

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36
Q

How are bisphosohonates taken?

A

take with water and don’t lie down for half an hour

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37
Q

What are a SE of oral bisphosphonates?

A

esophagitis may occur

Osteonecrosis of bone!!! (esp jaw)

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38
Q

What are bisphosphonate medications? (6)

A 
alendronate (fosamax)
Etidronate (Didronel)
Ibanronate (Boniva)
Pamidronate (Aredia)
Risedronate (actonel)
zoledronic acid (Reclast)
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39
Q

How is alendronate (fosamax) taken for OP prevention and treatment?

A

prevention: 5mg daily/ 35mg weekly

TreatmentL 10mg daily/ 70 mg weekly

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40
Q

What is etidronate (didronel) used for?

A

Paget’s disease

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41
Q

What is the indication for pamdronate (aredia)?

A

hypercalcemia of malignancy

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42
Q

What is a monoclonal antibodies (MAb) for osteoporosis?

A

denosumab (prolia)

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43
Q

What is the method of action of denosumab (prolia)?

A

inhibition of osteoclast formation, function & survival

NOT FIRST LINE

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44
Q

What is denosumab (prolia) different compared to bisphosphonates?

A

unlike bisphosphonates, effects of osteoclasts are reversible

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45
Q

What medication is a recombinant human parathyroid hormone PTH for osteoporosis?

A

Teriparatide (forteto)

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46
Q

Why is teriparatide (forteo) only reserved for pts with very high risk of fracture?

A

$$$$$

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47
Q

What is a common SE of teriparatide (forteo)?

A

orthostatic hypotension may occur early in therapy

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48
Q

What is the blackbox warning associated with teriparatide (forteo)?

A

induces osteosarcoma in animals (no cases reported in humans)

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49
Q

What is the line of therapy for osteoporosis AFTER bisphosphonates, denosumab or terparatide?

A

selective estrogen receptor modulators (SERMs)

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50
Q

What is the MOA of SERMs?

A

estrogen- like activity on bone

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51
Q

What are the types of selective estrogen receptors modulators (SERMS)? (2)

A

Raloxifene (Evista)

Bazedoxifene (Duavee)

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52
Q

What SERM is used in combination with conjugated estrogen and only for shoe term use?

A

Bazedoxifene (Duavee)

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53
Q

What medication for OP opposes action fo PTH?

A

calcitonin

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54
Q

What medication decreases osteoclast activity and resorption but is not as effective as other OP meds?

A

calcitonin

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55
Q

What medication is reserved for acute fractures or chronic osteoporosis pain?

A

calcitonin

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56
Q

What medications should be given with calcitonin?

A

concurrent Ca 2+ and Vit D should be given

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57
Q

Pharmacologic doses decrease bone resorption and are less effective than bisphosphonates?

A

calcitonin

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58
Q

What is the more potent type of calcitonin compared to mammalian?

A

salmon calcitonin

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59
Q

What form is calcitonin given?

A

nasal spray

60
Q

Osteonecrosis or aseptic necrosis is associated with what?

A

steroid therapy

61
Q

When will you see the greatest bone loss with steroid therapy?

A

1st 6-12 months of therapy

62
Q

What does of prednisone is usually required for steroid induced osteoporosis (SIO)?

A

> 7.5mg/ daily

therefore important to use lower dose for shortest duration

63
Q

What are the 3 main types of arthritic conditions?

A
  1. osteoarthritis: “wear and tear”; obesity
  2. Rheumatoid Arthritis: autoimmune
  3. Gouty Arthritis: elevated uric acid
64
Q

What is the most common of the joint diseases that affects nearly 50% of adults over 65 years of age?

A

Osteoarthritis

65
Q

What joint disease affects mainly all the weight bearing joints and hands?

A

osteoarthritis

66
Q

What type of joint disease is often unilateral and early in the disease the pain decreases with rest; however morning stiffness usually lasts less than 30 mins

A

osteoarthritis

67
Q

How many people in the US are affected by OA?

A

15.8 million

68
Q

What are the risk factors of OA?

A

obesity

repetitive use injury

69
Q

What are the categories of OA?

A

Primary (idiopathic): no known cause
Secondary: known abnormalities or trauma
Erosive: reflects changes to underlying bone

70
Q

What are the treatment options for OA?

A

diet
physical & occupational therapy
surgery

71
Q

What are the diet treatments for OA?

A

weight reduction
glucosamine supplements
chondrotin sulfate
Neither are PDA approved!

72
Q

What are the physical and occupational therapy treatments for OA?

A

heat treatments, exercise- reduce pain, decrease stiffness

caution against heat >30 mins (burns)

73
Q

What is OA drug therapy target at?

A

pain relief

74
Q

What is the oral analgesic of choice for OA?

A

acetaminophen

75
Q

What is the second choice oral agents for OA?

A

NSAIDs

76
Q

What medicine for OA is better for significant inflammation?

A

NSAIDs

77
Q

What other two medications besides NSAIDs and Acetaminophen may help with OA?

A 
topical analgesics (Cepsaicin)
COX-2 inhibitors
78
Q

What medication is a COX-2 Inhibitor?

A

Celecoxin (Celebrex) 100-200mg BID or 200mg QD

79
Q

What is chronic inflammation of synovial lining with proliferation = pannus

A

Rheaumatoid arthritis

80
Q

What does pannus do to the joint?

A

erodes cartilage and bone surface

81
Q

RA causes erosions that ultimately destroy the joint resulting in what?

A

immobility

82
Q

What joints are usually affected with RA?

A

small joints of hands
wrists
feet

83
Q

How long does morning stiffness usually last with RA?

A

> 30 minutes or ALL DAY

84
Q

What are the non-pharmacologic therapies for RA? (5)

A 
rest
occupational therapy
physical therapy
use of assistive devices
weight reduction
85
Q

What are the recent changes in approach to therapy for RA? (4)

A
  1. early diagnosis and treatment
  2. combination of DMARDs
  3. agents that target cytokines (anti tif alpha & interleukin-1 receptor antagonists)
  4. recognizing coexisting illnesses (infection, OP, cardiovascular dz)
86
Q

What are the 2 classifications for ‘length of disease’ for RA?

A

early : less than 6 months

established: greater than 6 months

87
Q

What is the ‘extent of disease activity’ for RA?

A

low
moderate
high

88
Q

what is the ‘presence of poor prognostic factors’ for RA?

A

functional limitation
extra-articular disease (nodes, RA vasculitis)
Positive Rheumatoid factor
bony erosions by X-ray

89
Q

What are the pharmacologic agents for RA?

A

NSAIDs
Corticosteroids
DEMARDS

90
Q

When are NSAIDs especially helpful with RA?

A

early disease to provide pain relief pending diagnosis. they DO NOT slow progression of the disease

91
Q

What are potent suppressors of inflammatory response that decrease the progression of RA on X-ray?

A

corticosteroids (CS)

92
Q

Over 1/2 patients will receive what LOW dose of CS therapy?

A

less than or equal to 10mg prednisone daily

93
Q

What high dose CS therapy is used for RA?

A

greater than 10mg- 60mg daily of prednisone

used less than 3 months followed by a taper over 7-10 days

94
Q

What is a predictable side effects of corticosteroids for RA?

A

adrenal cortex suppression

95
Q

What are common csDMARDS(Conventional synthetic Disease modifying anti rheumatic drugs) medications?

A

methotrexate (MTX)
Leflunomide (LEF)
Hydroxychloroquine (HCQ)
Sulfasalazine(SSZ)

96
Q

What is the csMARD of choice for RA that is most often selected for initial therapy?

A

methotrexate (MTX)

97
Q

What is the RA low dose for methotrexate?

A

less than 30mg weekly; start at 7.5mg weekly and increase by 5mg a week

98
Q

What is the standard of care for RA patients without contraindications?

A

methotrexate

99
Q

Methotrexate oral absorption is variable therefore if poor PO response what do you do?

A

try IV / Sub Q

100
Q

What mediation can be taken with methotrexate on skip days to minimize toxicity?

A

folic acid 1-3mg/daily

101
Q

What pregnancy category is methotrexate?

A

Category X

102
Q

What mediation used with methotrexate is potentially complimentary (additive toxicity)?

A

leflunomide (LEF)

103
Q

What csMARD has a long half life of 15-18 days and can take 2 years for complete elimination?

A

leflunomide (LEF)

104
Q

Since leflunomide is a category X what is important in females?

A

females need reliable birth control during use and verify non detectable blood level prior to pregnancy

105
Q

What is a rare complication of leflunomide?

A

hepatic necrosis (0.02-0.04%)

106
Q

What is the least potent but best tolerated csDMARD and commonly combined with methotrexate?

A

hydroxychloroquine (HCG)

107
Q

What was the first DMARD that was developed specifically for RA and is most commonly used in combination therapy?

A

sulfasalazine (SSZ)

108
Q

What are the dual therapy combinations of csDMARDS for RA? (4)

A

MTX + SSZ
MTX + HCQ
SSZ + HCG
combos with LEF

109
Q

What is the triple therapy csDMARD combination for RA?

A

MTX + SSZ + HCQ

110
Q

What is the anti- TNFbiologic for RA?

A

Infliximab (Remicade)

111
Q

What is the non TNF RA biologic?

A

Tofacitinib (Xeljanz)

112
Q

What was the first biologic agent available for RA?

A

Infliximab (Remicade)

113
Q

What medication is chimeric (human/mouse) monoclonal antibody?

A

Infliximab (Remicade)

114
Q

What mediations may reactivate latent TB and other infections.

A

Infliximab (Remicade) & Tofacitinib (Xeljanz)

115
Q

What testing should be done prior to starting Infliximab (Remicade) & Tofacitinib (Xeljanz)?

A

TB skin test & CXR

116
Q

What medications may minimize anaphylactoid reactions of Infliximab (Remicade)?

A

antihistamines
APAP
steroids

117
Q

In feb 2016 the FDA approved the first BIOSIMILAR product in the US, which is a “generic” of what medication for RA?

A

Infliximab (Remicade)

118
Q

What is the only FDA approved oral non DMARD for RA?

A

Tofacitinib (Xeljanz)

119
Q

What medications for RA has a MOA to inhibit janus kinase (JAK)

A

Tofacitinib (Xeljanz)

120
Q

What is gout characterized by? (3)

A

Hyperuricemia (greater than 7mg/dL)
Recurrent attacks of gouty arthritis
Caused by precipitated monosodium rate crystals in joints (decreased pH)

121
Q

Gout is the result of what 2 things?

A

uric acid overproduction (increase PRPP synthetase and decreased HGPRT enzyme)
uric acid under excretion (100% filtered, 90% reabsorbed)

122
Q

What are the risk factors for gout?

A 
obesity
male (10x)
increased age
alcohol intake 
protein/purine rich diet
htn
123
Q

IN gout what suggests increased synthesis?

A

greater than 1 g uric acid/ 24 hour urine

124
Q

What are chronic uric acid deposits?

A

tophi

125
Q

What are the gout treatments? (5)

A 
patient education (diet)
analgesics for gout: NSAIDs
Mediations for acute attacks: colchicine high dose
Corticosteroids
Prevention of future attacks
126
Q

What medication is given in gout for prevention of future attacks? (4)

A

colchicine (low dose)
Xanthine oxidase inhibitor (first line)
Uricoseuric agents (add on)
recombinant urate oxidase

127
Q

When should NSAIDs be taken for Gout?

A

Around the clock-NOT PRN

128
Q

What is a common analgesic agent for gout?

A

celecoxib (Celebrex)

129
Q

What mediation is used for acute attacks (flares), max is 3 tabs in an hour, 75-95% of patients respond

A

colchicine

130
Q

What percentage of people taking colchicine experience GI side effects(diarrhea) before relief of gout?

A

50-80%

131
Q

How is colchicine prescribed prophylactic ?

A

0.6 mg QD or BID

stop when symptom free for 1 year

132
Q

When are corticosteroids used for gout?

A

reserved for patients with contraindications to NSAIDs or colchicine

133
Q

How are the corticosteroids given for gout?

A

oral
IM
intraarticular injection

134
Q

What is the adult doing for allopurinol with mild gout?

A

200-300mg po daily

135
Q

What is the adult dose for moderate- severe gout for allopurinol?

A

400-600mg po daily

136
Q

When do you increase the dose of allopurinol

A

increase over 3-4 weeks

137
Q

When do you decrease dose of allopurinol?

A

with increased age or decreased renal function

138
Q

What is an adverse effect of allopurinol?

A

agranulocytosis <1%

139
Q

Why is allopurinol given with colchicine prophylaxis?

A

may predicate gout

140
Q

what mediation has no advantage over allopurinol but is more expensive. May predicate gout with initial use

A

Febuxostat (Uloric)

141
Q

what agents promote urinary UA elimination inhibiting UA resorption?

A

uricosuric agents for gout

142
Q

What are the uricosuric agents? (2)

A

probenecid

sulfinpyrazone

143
Q

what is the first in new class-urate oxidase (uricase) enzymes?

A

pegloticase (krystexxa)

144
Q

What medication is a pegylated recombinant (procine) enzyme?

A

pegloticase (krystexxa)

145
Q

What medication may produce anaphylaxis (<7%) and is suggesting to premeditate with antihistamine AND steroids?

A

pegloticase (krystexxa)

146
Q

What medication is used ONLY for severe gout refractory to or intolerant of approximately dosed oral ULT?

A

pegloticase (krystexxa)

Anatomy (13 decks)

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