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57 Cards in this Set
- Front
- Back
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Bone Remodeling steps (4)
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1)resorption
2)reversal 3)formation 4)quiesence |
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Resorption (remodeling)
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bone breakdown facilitated by osteoclast cells that resorb (dissolve) bone
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Reversal (remodeling) (2)
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1)occurs when evacuation is complete
2)and is the process of osteoclast undergoing apoptosis or moving to a new section |
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Formation (remodeling) (2)
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1)Bone building process facilitated by osteoblast cells
2)osteolbast ultimately become lining cells or become part of bone as osteocytes |
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Quiescence (remodeling)
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rest period following bone formation (mineralization)
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Ca in bone health (3)
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1)chief mineral component of skeletion
2)essential to development and fxn of bone 3)99% of body's Ca is in skeleton; so when serum Ca in body is low--bone is resorbed to incr serum Ca |
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Vitamin D in bone health (4)
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1)sources are sun, diet, supplements
2)undergoes hepatic conversion then PTH stims its renal conversion to calcitriol 3)role of calcitriol is promo of intestinal Ca absorption 4)calcitriol also works w/ PTH to release Ca from bone |
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Parathyroid hormone (PTH) in bone health (3)
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1)release is stimulated by decr Ca []s
2)PTH then stim production of calcitriol 3)PTH works w/ calcitriol to release Ca from bone to restore levels |
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Calcitonin in bone health (3)
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1)high []s inhibits bone resorption by acting on osteoclast
2)NOT sig in normal physiology as these high levels are NOT achieved 3)principle interest of calcitonin is as a pharmaceutical product |
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Bone function (4)
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provides structural fxn giving:
a)mobility b)support c)protection Provides reservoir fxn as a storehouse for minerals |
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WHO classification of:
a)Osteopenia b)Osteoporosis c)Severe Osteoporosis |
a)T score b/w -1 to -2.5
b)T-score b/w -2.5 or lower c)T-score b/w -2.5 or lower AND history of fragility fracture NORMAL IS -1 OR HIGHER |
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LOOK AT CHART FOR CLINICAL CLASSIFICATION OF POSTMENOPAUSAL, AGE-RELATED, SECONDARY OSTEO (P. 5)
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now
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Risk factors for fractures (5)
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1)advanced age
2)falls 3)prior fragility fracture 4)low BMD 5)FH of osteoporosis |
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Risk factors associated w/ falls (6)
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1)prior fall
2)impaired vision/hearing 3)physical disability 4)environmental obstacles or hazards 5)orthostatic hypotension 6)cognitive impairment |
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MEDS associated w/ falls (4)
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1)antidepressants
2)antiHTN 3)BZD's 4)diuretics |
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S/sx associated w/ osteoporosis and fragility fractures (7)
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1)deformity (dowagers/hump)
2)shortened stature (over 1.5" loss) 3)fracture 4)pain 5)immobility 6)depression 7)low self-esteem |
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ENDOgenous risk factors of Osteoporosis (6)
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1)incr age
2)female 3)white/asian 4)positive FH 5)small stature 6)postmenopausal |
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EXOgenous risk factors of Osteoporosis (9)
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1)prior fragility fracture
2)sedentary lifestyle 3)decr mobility 4)low Ca intake 5)over 7 drinks per week 6)smoker 7)malnutrition 8)under 127 pounds 9)never had a kid |
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Medical conditions predisposing to osteoporosis (5)
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1)chronic renal failure
2)hyperparathyroidism 3)hyperthyroidism 4)Cushing's syndrome 5)GI disorders |
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Predisposing meds (w/ long term use) to Osteoporosis (10)
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1)glucocorticoids (prednisone)
2)anticonvulsants 3)herapin 4)loop diuretics 5)thyroid supplements 6)Lithium 7)Al-containing antacids 8)chemo 9immunosuppresants 10)medroxyprogesterone injexn |
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When to undergo BMD testing (4)
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1)all women over 65
2)all men over 70 3)postmenopausal women under 65 w/ 1 additional risk for fracture 4)women/men w/ fragility fracture or who have diseases or meds that incr risk (main prednisone over 3 months) |
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When to evaulate a patient for secondary causes of osteoporosis (5)
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1)premenopausal women
2)men under 70yo 3)pts w/ no risk factors 4)pts w/ multiple low trauma fractures 5)pts w/ bone loss despite adequate drug tx |
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Use of CENTRAL skeletal DXA (2) and what it assesses
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1)gold-standard
2)has greatest precision and uses minimal radiation 1)BMD of hip, spine, wrist |
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Use of PERIPHERAL skeletal DXA (3) and what it assesses
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1)screening test to determine need for further testing (ie central DXA)
2)portable units available 3)threshold for further testing is T-score of -1 or less BMD of forearm, heel, phalanges |
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Goals and desired outcomes of treatment of osteoporosis (5)
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1)From birth up to 30yo achieve highest peak bone mass possible
2)From 30+ maintain BMD and minimize bone loss 3)in pts w/ osteopenia prevent progression to osteoporosis 4)incr BMD, decr bone loss and prevent falls/fractures in pts w/ osteoporosis and high risk for osteoporosis related fractures 5)in pts w/ osteoporosis fractures (control pain, max rehab to restore QoL and prevent more fracture/death) |
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Nonpharma therapy options for Osteoporosis (4)
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1)Diet
2)decr smoking/alcohol 3)exercise 4)fall prevention |
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Diet used for Osteoporosis (3) and place in therapy
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1)adults under 50 get 1000mg/d Ca; 400-800IU/d Vit D
2)adults over 50 get 1200mg/d Ca; 800-1000IU/d Vit D 3)adults taking prednisone (over 7.5mg/d for over 3months) 1500mg/d Ca; 800-1000IU/d Vit D ALL should have well-balanced diet w/ adequate Ca/Vit D |
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Exercise and Osteoporosis (4) and place in therapy
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1)while young this increases your peak bone mass; later in life it increases BMD and slows decline of BMD
2)reduced fall risk (incr muscle) 3)mod intensity wt-bearing activity (walk/jog) at least 30min most days of the week 4)resistance activity (weights) at least 2x/wk for 20-30min Recommended for everyone who is fit to participate in a long term exercise program |
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Fall Prevention and Osteoporosis (4)
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1)cane/walker
2)visual correction 3)modifications for improved safety in living environment 4)review/eliminate problematic meds that incr fall risk |
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What to use to PREVENT osteoporosis (4)
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1)Ca/Vit D supplements (FIRST LINE)
2)Calcitonin salmon (used in prevention in postmenopausal women; but lacks FDA indications) 4)Estrogen agonist/antagonist is option in postmenopausal 3)biphosphanates are an option |
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What to use to tx Osteoporosis (5)
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1)Ca/Vit D supplements also FIRST LINE for tx of osteoporosis
3)Bisphonates FIRST LINE for tx in postmenopause women, men, pts w/ prednisone-induced disease 2)Calcitonin salmon SECOND line tx for tx b/c less fracture reduction 4)Teriparatide used for male/female pts w/ severe disease or those who've failed other therapies or cost/ADR considerations 5)Estrogen agonist/antagonist 2nd line option in postmenopausal |
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Ca/Vit D supplements EFFICACY (3)
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1)incr BMD and decr fractures
2)clinical trials studying other drugs all required concurrent Ca/Vit D 3)Vit D3 is the best and the one in OTC products |
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Calcitonin salmon EFFICACY (2)
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1)incr BMD
2)decr in new vertebral fractures by 35% |
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Bisphosphanates EFFICACY (5)
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1)incr BMD
2)decr fractures by 45-60% at all skeletal sites 3)benefits shown in men/women 4)alendronate in men have equal efficacy to postmenopausal women 5)oral weekly and monthly and IV have shown similar efficacy to oral daily dosing (w/ better compliance) |
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HT EFFICACY
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doesn't matter; not used any more due to risks w/ long-term use
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Estrogen Agonist/Antagonist Place in therapy (3)
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1)option for prevention of osteoporosis in postmenopausal women
2)2nd line in tx of osteoporosis in postmenopausal women 3)not for men w/ prednisone induced osteoporosis |
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Estrogen Agonist/Antagonist EFFICACY (2)
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1)decr vertebral fractures by 30-50%
2)incr BMD but less than bisphosphanates and teriparatide |
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Estrogen Agonist/Antagonist ADDITIONAL BENEFITS (3)
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1)doesn't cause endometrial cancer
2)lowers serum []s of total and LDL 3)55-70% decr in breast cancer |
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Teriparatide EFFICACY (2)
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1)decr risk of vertrebral and nonvertrebral fractures in postmenopause by 65% and 55%
2)incr BMD in men/women |
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Calcitonin Salmon
a)brand name b)dosing c)ROA d)FDA indication |
a)Miacalcin
Fortical b)200U (1spray) daily c)IN d)tx of PM OP (in women 5yrs past menopause) |
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Alendronate
a)brand name b)dosing (2) c)FDA indications (3) |
a)fosamax
b)5mg qd or 35mg weekly FOR PREVENTION 10mg qd or 70mg weekly FOR TX c1)tx/prevent OP in PM c2)glucocorticoid induced OP c3)tx of OP in men |
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Risedronate
a)brand name b)dosing (2) c)FDA indications (3) |
a)Actonel
b)5mg qd or 35mg weekly PREVENTION AND TX 75mg for 2 consecutive days every month or 150mg monthly for TX c1)prevention/tx of PM OP c2)glucocorticoid-induced OP c3)tx of OP in men |
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Ibandronate
a)brand name b)dosing (2) c)ROA d)FDA indications |
a)Boniva
b)2.5mg qd or 150mg monthly for PREVENTION/TX 3mg IV every 3months FOR TX c)PO/IV d)prevention/tx of PM OP |
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Raloxifene
a)brand name b)dosing c)FDA indications |
a)Evista
b)60mg qd c)prevention/tx of PM OP |
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Teriparatide
a)brand name b)dosing c)ROA d)FDA indications (2) |
a)Forteo
b)20mcg qd c)SC d1)tx of PM OP in those at high-risk for fractures d2)tx of OP in men @ high risk for fractures |
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Teriparatide (Forteo)
a)ADRs (4) b)black box warning (2) |
a1)nausea
a2)dizziness a3)leg cramps a4)orthostasis b1)not used in pts @ high risk of osteosarcoma (dose and duration effect) b2)risks for osteosarcoma include Paget's disease, elevations in alkaline phosphatase, prior radiation therapy involving skeleton |
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Bisphosphonates common ADR's (oral-3; IV-2)
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oral1)ab pain
oral2)dyspepsia oral3)n/v/d IV1)injexn site redness/swelling IV2)flu like symptoms |
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Bisphosphonates SEVERE ADR's (oral-1; oral AND IV--2)
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a1)GI perforation/ulceration/bleed
b1)severe bone/joint/muscle pain b2)jaw osteonecrosis |
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Jaw Osteonecrosis (4)
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1)death of bone causing collapse of bone's structure and pain and loss of jaw bone fxn
2)commonly follows tooth extraction (so make sure they tell their dentist) 3)make sure they practice good dental hygiene and have regular dental exams 4)95% of cases are associated w/ IV bisphosphonates in cancer tx |
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Precautions w/ Bisphosphanates (2)
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1)renal dysfxn
2)GI interferences and adverse effects |
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Renal dysfxn and bisphosphanates (2)
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1)not for pts w/ CrCl under 35
2)IV ibandronate and zoledronic acid recommend SCr measurement prior to each dosing |
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GI interferences and adverse effects and bisphosphonates (2)
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1)avoid in pts w/ GI intolerance b/c of stricture, ulceration or severe sx
2)adherence w/ administration recommendations maximizes absorption and minimizes GI effects |
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Bisphosphonates and what to do when a dose is missed (5)
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WEEKLY REGIMEN
a)if missed pt can take morning after they remember b)do NOT take 2 doses on same day c)return to originally scheduled day for weekly dosing MONTHLY DOSING a)if missed dose pt can take it morning after you remember up to 7d before the next scheduled dose b)if it is within 7d of next dose; forgotten dose should be skipped |
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Bisphosphanates and oral dosing recommendations (3)
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1)take on empty stomach immediately after getting up in the morning
2)take w/ full 6-8oz glass of plain water 3)do NOT lie down, take other meds, eat or drink for atleast 30min (w/ alendronate/risedronate) or 60min w/ ibandronate |
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Calcium Carbonate
a)% elemental Ca b)comments (2) c)brand name (4) |
a)40%
b1)take w/ meals for optimal absorption b2)preferred b/c least expensive and highest elemental Ca c)Os-Cal c)Caltrate c)Viactiv c)Tums |
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Tricalcium Phosphate
a)% elemental Ca b)comments (2) c)brand name |
a)39%
b1)preferred if concurrent hypophosphatemia b2)take w/ food for optimal absorption c)Posture |
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Calcium Citrate
a)% elemental Ca b)comments (3) c)brand name |
a)24%
b1)fewer GI ADR's b2)acid-independent (so take w/ or w/o food) b3)good choice for pt w/ low gastric acidity or on acid reducing meds c)Citracal |
