Pharm: Osteoporosis Flashcards
Define Osteoporosis
- Common disease characterized by low bone mass with microarchitectural disruption and skeletal fragility, resulting in an increased risk of fracture, particularily at the spine, hip, wrist, humerus, and pelvis.
- T-score < -2.5
- Osteoporotic fractures occur fro a fall from standing height or less without major trauma.
Define Osteopenia
- Bone density that is not normal but also not as low as osteoporosis.
- T-score of -1 to -2.5.
Define T-score
- Result of DEXA scan.
- Comparison of a woman’s bone density with that of healthy young women.
- Negative means thinner bones that average; the more negative, the higher the risk of bone fracture.
- Normal value is -1 or above
Define DEXA scane
- MC and accurate way to perform bone density scanning.
- Uses low-dose x-rays
Define fragility fracture
Pathologic fracture that occurs as a result of normal activities. Three sites: vertebral, neck of femur, and wrist.
Define low trauma fx
no definition… I’m thinking this is a fragility fracture…
4 components of a bone healthy lifestyle
- Smoking cessation
- Limit alcohol intake
- Well-balanced diet with adequate calcium and vitamin D
- Weight bearing exercise and fall prevention
9 Risk factors for fx
- Advanced age
- Previous Fx
- Glucocorticoid therapy
- Current smoker
- Low BMI or body weight
- Hx of osteoporosis/low trauma fx in a first degree relative
- Excessive alcohol intake
- Rheumatoid arthritis
- Secondary osteoporosis dt hypogonadism, premature menopause, malabsorption, chronic liver dz, inflammatory bowel dz.
Osteoporosis prevention Goals
- gen pop birth to 30
- gen pop 30+
- osteopenia
- Gen population birth to 30: achieve highest peak bone mass possible
- Gen population 30+: maintain BMD and minimize bone loss
- Osteopenia: prevent progression to osteoporosis
Osteoporosis prevention treatments
Generally a bone healthy lifestyle beginning at birth and continuing throughout life
Treatments:
- Calcium and Vitamin D
- Bisphosphonates
- Raloxifene
- Hormone therapy
Tx goal for pt with osteoporosis AND
- high risk for fx
- with a fracture
- High risk for fx: increase BMD, prevent further bone loss, prevent falls and fx
- With fx: adequate pain control, max rehab to restore independence and QOL, prevent subsequent fx and death
Treatment options for osteoporosis
- Calcium and Vitamin D
- Bisphosphonates
- Raloxifene
- Denosumab or Teriparatide (PTH)→for high risk fracture
4 steps to take to prevent falls
- Ambulation assistance (cane, walker, etc.)
- Vision correction
- Modifications for improved safety in living environment (handles in shower, etc.)
- Review medication list – remove those that increase fall risk (antidepressants, anti-hypertensives, benzos, diuretics, alcohol)
Calcium daily recommendations
- Adults < 50 1000 mg/day elemental calcium
- Adults ≥ 50 1200 mg/day elemental calcium
- Adults on long term glucocorticoids 1500 mg/day
Vitamin D daily recommendations
- Adults < 50 400-800 IU/day
- Adults ≥ 50 800-1000 IU/day
- Adults on long term glucocorticoids 800-1000 IU/day
% elemental calcium in
- calcium carbonate
- calcium citrate
- carbonate: 40%
Tums and Os-cal - citrate: 21%
Citracal
Example how to calculate dose of calcium in a Tums
600 mg calcium carbonate capsule contains 240 mg (40%) elemental calcium
Note about calcium absorption
absorption is dose-related, spread it throughout day into doses ≤ 600 mg
Place in prevention therapy for bisphosphonate
First line for most patients
- High efficacy
- Low cost
- Long-term safety data
4 bisphosphonate options list
- Alendroneate
- Risedronate
- Ibandronate
- Zoledronic acid
Which two bisphosphonate options are first line choice
Alendronaate and risedronate
- generic, cheaper
- reduce both vertebral and hip fractures
- Avail in Q week dose
Prevention dose for
- Alendroneate
- Risedronate
- Zoledronic acid
- Alendronate: 35mg PO/week
- Risedronate: 35mg PO/week
- Zoledronic Acid: 5mg IV every 2 years
How long to use bisphosphonate therapy when using for prevention
3-5 years
Raloxifene dose
60 mg PO daily
Raloxifene
- place in therapy
- what pt is it not suited for
- May be first line therapy for prevention of osteoporosis in women who are high risk for invasive breast cancer (but bisphosphonate has better efficacy)
- women who cannot or want to avoid bisphosphonates
- Not for use in men or pts on long term corticosteroid tx
- Avoid in premenopausal women dt estrogen-blocking action which can reduce bone density.
Hormone therapy
- place in prevention of osteoporosis
- Less efficacy than bisphophonates, similar efficacy to raloxifine
- Not first line, only use in women who need HT for menopausal sx, do not use solely for osteoporosis prevention
- Not for men or glucocorticoid induced osteoporosis
Forms of hormone therapy used for osteoporosis? how to dose?
- patch or tablet (min benefit with vaginal ring and cream)
- use lowest possible dose
Hormone therapy example approved for osteoporosis prevention
Menostar
- ultra-low dose 17β- estradiol
- weekly patch
Bisphosphonate therapy for treatment of osteoporosis dosing for
- Alendronate
- Risedronate
- Zoledronic acid
- Alendronate: 70mg PO/week
- Risedronate: 35mg PO/week or 150mg PO/month
- Zoledronic Acid: 5mg IV once a year
How long to continue Bisphosphonate when used to treat osteoporosis
5+ years as needed
How to use denosumab for osteoporosis treatment
same as prevention (as far as I can tell?!?!)
Denosumab use for treatment of osteoporosis
- indications for use
- not first line for women with uncomplicated osteoporosis
- Postmenopausal osteoporosis esp who have failed or can’t/won’t take bisphosphonates
- Renal insufficiency (can’t use bisphosphonates)
- Prostate cancer, receiving androgen deprivation therapy for prostate cancer (aka good for men)
- Breast cancer receiving aromatase inhibitor
Denosumab
- overview of who should use it
osteoporosis in postmenopausal women
- at high risk of fx
OR
- who do not tolerate or get enough benefit from other osteoporosis medications
Indications for use of teriparatide for treatment of osteoporosis
- Treatment only (only med that increases bone formation)
- for those who have failed other therapies
- Indicated for women, men, and long term glucocorticoid use pts at high-risk for fractures:
- Hx of fragility fracture
- Multiple risk factors for fracture
- Low bone density score (T score < -3.5)
2 cases when teriparatide may be considered initial treatment
- Women with severe osteoporosis (T score < -2.5) AND fragility fracture
- Women with severe osteoporosis (T score < -3.5) WITHOUT fragility fracture
Administration of teriparatide
Prefilled pen (refrigerate), SC 20 mcg daily into thigh or abdomen
Time frame for use of teriparatide
<2 years due to lack of long term safety studies
Bisphosphonate CI
- Cannot remain uprgith for min 30 minutes
- Esophageal or swallowing disorders
- Cr clearance <30 mL/min
- Hypoglycemia
- Pregnancy
Raloxifine CI
- Women with hot flashes
- Hx venous thromboembolism (increases risk)
- Hip fx is primary concern
Denosumab CI
Uncorrected hypocalcemia
Teriparatide CI
- Metabolic bone disease
- Paget’s disease
- Previous skeletal irradiation
- Elevated alk phos of unknown etiology
- Severe renal dysfunction
Patient education for administration of bisphosphonate
- Take with a full 6-8 oz glass of plain water
- Stay upright for min 30-60 minutes to minimize esophageal irritation
3 Patient factors that indicate the need for therapy
- Vertebral or hip fracture
- Hip DXA (femoral neck or total hip) or lumbar spine T-score < -2.5
- Osteopenia and FRAX calculation of 10-year prob of a hip fracture > 3% or the 10-year prob of any major osteoporosis-related fracture is >20%
Calcium & VitD
- for prevention and/or treatment?
- Reduces risk for what type of fx
- prevention and tx
- n/a
Bisphosphonate
- for prevention and/or treatment?
- Reduces risk for what type of fx
- prevention and tx
- Vertebrae and hip: alendronate and risedronate
- Vertebrae: ibandronate
Raloxifene
- for prevention and/or treatment?
- Reduces risk for what type of fx
- prevention and tx
- vertebrae
Hormone therapy
- for prevention and/or treatment?
- Reduces risk for what type of fx
- prevention only
Denosumab (Prolia)
- for prevention and/or treatment?
- Reduces risk for what type of fx
- Treatment only
- vertebrae and hip
Teriparatide (PTH)
- for prevention and/or treatment?
- Reduces risk for what type of fx
- treatment only
- vertebrae and non-vertebral
ADR
- bisphosphonate
- GI (MC): perforation, ulceration, GI bleeding
(Use IV ibandronate and zolendronic acid with GI CI or intolerance) - MSK pain
- Osteonecrosis of the jaw
ADR Denosumab (Prolia)
- Back pain
- MSK pain
- Pain in extremities
- Hyperlipidemia
- Cystitis
- Severe: jaw osteonecrosis and atypical fractures
ADR: Teriparatide (PTH)
- Nausea
- Dizzy
- Leg cramps
- Transient orthostatic hypotension
- Osteosarcoma
ADR
- Raloxifene
Generally well tolerated – possible hot flashes and leg cramps
