Pharmaceutical Care of Osteoporosis Flashcards
What is osteoporosis?
Progressive, systemic skeletal disorder characterised by loss of bone tissue + disruption of bone micro architecture
= increased fragility + fracture
What are the stages of osteoporosis?
Normal bone density
Osteopenia
Osteoporosis
Severe osteoporosis
What is osteopenia?
Loss of bone mass + density BUT bone loss is not yet severe
What builds bones?
Osteoblasts
What crushes bones?
Osteoclasts
What are osteocytes?
Former osteoblasts that lie in the matrix they form
What are the non-modifiable risk factors?
Previous fractures
Parental history
Early menopause
What are the modifiable risk factors?
Low BMI
Smoking
Low BMD
Alcohol intake
What are the coexisting diseases that contribute?
Diabetes
RA
IBD/malabsorption
Moderate-severe CKD
What drug therapies contribute?
Long-term antidepressants
Antiepileptics
Aromatase inhibitors
PPIs
Oral corticosteroids
What are the complications?
Fractures
= often result from low-level trauma
Where are fractures most common?
Spine (vertebral)
Hip
Wrist
What are the causes?
Primary = multifactorial = idiopathic
Secondary = conditions
What is the initial investigations for diagnosis?
Blood tests = vitD, thyroid test, U+Es
DXA scan
X-ray = suspect fracture
How do you assess fracture risk?
QFracture
FRAX score
When do you consider a fracture assessment?
In all women aged 65 years + over + in all men aged 75 years + over
In all women under 65 + men under 75 with risk factors
When do you warrant for investigation for QFracture + FRAX?
When score is over 10%
What is DXA scan?
Dual x-ray
Measures bone mineral density
When does the DXA scan warrant for investigation?
T Score
Osteopenia =-1-2.5
Osteoporosis = less than -2.5
Severe = Less than -2.5 + fracture
How do you target reversible risk factors?
Exercise = outdoors, strength training, balance of exercises
Diet
Smoking cessation
Alcohol intake limited
If calcium + VitD inadequate what is given?
Ca = 1000mg
VitD = 800 units
BUT double if house bound or in nursing home
What do bisphosphonates do?
Bind to, + stabilise bone by inhibiting osteoclast activity
What needs to be monitoring with bisphosphonates?
Kidney function = renally excreted
What are the drug choices for bisphosphonates?
Alendronic acid
Risedronate
What are the counselling points for bisphosphonates?
Take once weekly
Take with plenty of H2O
Take whilst standing up
Take on empty stomach
Remain upright for 30mins after taking
Do not take at night
Do not crush
What are the side effects of bisphosphonates?
Oesophageal reactions = counselling points
Atypical fractures
Osteonecrosis
How do you manage osteonecrosis of the jaw?
Report any oral symptoms
Encourage good oral hygiene
Increased risk with IV formulations + malignancies
How do you manage osteonecrosis of the ear?
Report any ear pain, discharge or infections
Associated with long term use
What is denosumab?
Monoclonal Ab
S/C injection given for 6 months
When is denosumab given?
When patient cannot tolerate bisphosphonate therapy
What must be ensured before starting denosumab?
Ca + VitD levels are adequate
What are the side effects of denosumab?
Osteonecrosis jaw + ear
Atypical fractures
Increased risk of infections at injection site
Hypocalcaemia
What is Raloxifene?
Selective oestrogen receptor modulator (SERM)
What does Raloxifene do?
Partial agonists of oestrogen receptors within bone tissue = induce osteoblast activity
What is Raloxifene licensed for?
Postmenopausal osteoporosis
What is an example of a parathyroid hormone analogue?
Teriparatide
Daily S/C injection
What does Teriparatide do?
Mimic effects of PTH = increase bone formation pathway
What must be ensured first before starting Teriparatide?
Adequate Ca + VitD levels
What are the side effects of Teriparatide?
Post doe orthostatic hypotension
How long is PO bisphosphonate treatment?
5 years
Then assess if improvement if no longer above treatment threshold = “bisphosphonate holiday”
Then review after 2 years
