Pregnancy & Osteoporosis Flashcards
Acne Teratogenic Drugs
-Isotretinoin
-Topical Retinoids
Antibiotic Teratogenic Drugs
-Quinolones
-Tetracyclines
Anticoagulant Teratogenic Drugs
-Warfarin
CV Teratogenic Drugs
-Statins
-ACE/ARB
-Aliskiren
-Entresto (Sacubitril/Valsartan)
Hormone Teratogenic Drugs
-Progesterone
-Estradiol
-Raloxifene
-Testosterone
-Contraceptives
Migraine Teratogenic Drugs
-Dihydroergotamine
-Ergotamine
Other important Teratogens
-Hydroxyurea
-Lithium
-Methotrexate
-Misoprostol
-NSAID
-Paroxetine
-Thalidomide
-Topiramate
-Weight loss drugs
-Valproic Acid
Risk Factors of Osteoporosis
-Age
-Ethnicity
-Family History
-Sex (females > males)
-Low body weight
-Smoking
-Excessive alcohol intake
-Low calcium intake
-Low vitamin D intake
-Physical inactivity
Medications which may cause Osteoporosis
-Anticonvulsants (Carbamazepine, Phenytoin, Phenobarbital)
-Depo-medroxyprogesterone
-GnRH agonists
-Lithium
-PPI
-Steroids
-Thyroid hormones (in excess)
-Loop diuretics
-SSRI
-TZDs
Osteoclasts vs Osteoblasts
1) Osteoclasts - bone resorption: they breakdown tissue in the bone.
2) Osteoblasts - bone formation
When should a BMD be measured?
BMD: Bone Mineral Density
Men: >= 70
Women: >= 65
What is FRAX?
The FRAX tool is a computer-based algorithm developed by WHO, that estimates the risk of osteoporotic fracture in the next 10 years.
Clinical Risk Factors include:
-Age, Sex, Weight, Height
-Previous Fracture
-Parental Hip Fracture
-Femoral Neck BMD
-Smoking Status
-Steroid Use
-Alcohol Intake
-Rheumatoid Arthritis
T-Score Interpretation
Normal: >= -1
Osteopenia (low bone mass): -1 to -2.4
Osteoporosis: <= -2.5
Calcium Requirement
Adults: 1000-1200 mg Elemental Calcium per day
Calcium Carbonate: 40% elemental calcium
Calcium Citrate: 21% elemental calcium
Vitamin D Requirement
-Required for Calcium Absorption
Deficiency: < 30 mg/mL
-Treat with Cholecalciferol (D3) or Ergocalciferol (D2)
-Cholecalciferol (D3): 125-175 mcg (5000-7000 IU) daily
-Ergocalciferol (D2): 1250 mcg (50,000 IU) weekly
When to initiate treatment for Osteoporosis?
1) T-score <= -2.5 at the femoral neck, total hip or lumbar spine or 1/3 radius
OR
2) Presence of a fragility fracture, regardless of BMD
When to initiate treatment of Osteopenia (if high risk)?
1) Low bone density (T-score between -1 and -2.5)
AND
2) FRAX score of >=20% of a major osteoporosis-related fracture or >= 3% hip fracture probability
Medications for Prevention of Osteoporosis
1) Bisphosphonates
2) Estrogen-based therapies
3) Raloxifene
4) Bazedoxifene+Estrogens (Duavee)
Medications for the TREATMENT of Osteoporosis
1) Bisphosphonates
2) Denosumab
3) Parathyroid hormone analogs (Teriparatide, Abaloparatide)
4) Calcitonin
Bisphosphonates
MOA: Increases bone density by inhibiting osteoclast activity and bone resorption.
-They reduce vertebral and hip fracture risk. (Ibandronate only reduces vertebral fractures)
-First-line therapy for BOTH prevention and treatment
-Drug holiday for low-risk patients after 3-5 years of treatment
DRUGS:
1) Alendronate (FOSAMAX) - PO
2) Risendronate - PO
3) Ibandronate - PO & IV-q3mths
4) Zoledronic Acid (Reclast) - IV
Contraindications:
1) Hypocalcemia
2) Inability to stand upright for atleast 30 minutes
Warnings:
1) Osteonecrosis of the jaw
2) Do not eat or drink 30 mins before or after medication. Except for water
Raloxifene
MOA: SERM which decreases bone resorption
-Used for BOTH prevention and treatment (postmenopausal women)
-Second line to Bisphosphonates if there is a high risk of vertebral fractures
-Use if there is a low VTE risk or high breast cancer risk
-Contraindication: History of DVT/PE, Pregnancy
BOXED WARNING:
- Increased risk for DVT/PE
- Increased risk of death in women with CHD
Conjugated Estrogens+Bazedoxifene (Duavee)
MOA: Horse (Equine)/SERM combination indicated for osteoporosis prevention in postmoenpausal women with a UTERUS.
BOXED WARNING:
-Endometrial Cancer
-Increased risk of DVT and Stroke
-Dementia
CONTRAINDICATION:
-Breast Cancer (or history of)
-Pregnancy
-Undiagnosed uterine bleeding
-VTE (or history of)
-MI or Stroke
Calcitonin
MOA: Inhibits bone resorption by osteoclasts
-Not as effective as bisphosphonates and estrogen products
Parathyroid Hormone 1-34
MOA: Analogs of human parathyroid hormone, which stimulates osteoblast activity and increases bone formation.
-Used to treat osteoporosis when there is a very high risk of fracture
-Cumulative lifetime treatment duration: 2 years or less
-Daily SQ injections
-Recommended for very high risk patients only
DRUGS:
1) Teriparatide
2) Abaloparatide
Denosumab (Prolia)
MOA: -mab which binds to RANKL and blocks its interaction with RANK (a receptor on osteoclasts) to prevent osteoclast formation. This leads to decreased bone resorption and increased bone mass.
-SQ every 6 months
-Alternative to bisphosphonates
-Used to treat osteoporosis when there is a high risk of fracture.
-Contraindication: Pregnancy, hypocalcemia
-If dc, bone loss can be rapid. Consider alternative agents to maintain BMD
Romosozumab
MOA: Inhibits sclerostin, a protein that blocks bone formation
-Treatment limit: 1 year
-Indicated for postmenopausal women with a history of an osteoporotic fracture or multiple risk factors
Which osteoporosis drug can males use?
-No med is used for the prevention of osteoporosis in MALES <—Treatment only!
1) Alendronate, Risendronate, Zoledronic Acid
2) Parathyroid hormone 1-35
3) Denosumab and Romososumab
-All are indicated for females
