Osteoporosis & Osteoarthritis & Ra

Front 1

Osteoporosis

Back 1

1. low bone mass and structural deterioration of bone tissue
2. leads to bone fragility
3. leads to increased fractures ( spine, hip, wrist)

Front 2

Function of the Skeleton (Bone Physio)

Back 2

1. structural support
2. protect organs
3. contains calcium and phosphorus stores

Front 3

Types of Bone (Bone Physio)

Back 3

1. Trabecular/cancellous (metabolic) - supplies minerals when deficient
2. Cortical (structural) - outer part of bone

Front 4

Osteoblasts

Back 4

responsible of bone formation

Front 5

Osteoclasts

Back 5

responsible for bone resorption

Front 6

Types of Osteoporosis

Back 6

1. Postmenopausal - decline in estrogen production
2. Age-Related(senile) - hormone, calcium and Vit D deficiencies
3. Secondary (drugs, diseases, other)

Front 7

Clinical Presentation of Osteoporosis

Back 7

SIGNS: shortened stature, fracture, humpback (kyphosis) or hollow back/saddle back (lordosis)

SYMPTOMS: pain, immobility

Front 8

Non-modifiable Risk Factors for Osteoporosis

Back 8

1. Family history of disease in 1st degree relative
2. Family history of fracture in 1st degree relative
3. age at menarch and menopause

Front 9

Lifestyle Risk Factors for Osteoporosis

Back 9

1. low calcium intake
2. inadequate physical activity
3. thinness
4. vitamin D deficiency
5. smoking
6. high caffeine intake
7. alcohol (>3 drinks/day)
8. falling
9. high salt intake

Front 10

Diseases that are Risk Factors for Osteoporosis

Back 10

1. rheumatoid arthritis
2. prior fracture
3. hyperparathyroidism
4. hypogonadism
5. inflammatory bowel disease
6. epilepsy
7. alcoholism
8. diabetes

Front 11

Medications that are Risk Factors for Osteoporosis

Back 11

1. glucocorticoids (>5mg/d of prednisone for >3 months)
2. cyclosporine
3. chemo
4. anticonvulsants
5. depo-medroxy
6. drugs that alter calcium absorption or elimination

Front 12

Bone Mineral Density Test (BMD)

Back 12

The LOWER the BMD, the HIGHER the fracture risk

Front 13

Gold standard for measuring BMD for diagnosis and monitoring

Back 13

Central Dual X-Ray Absorptiometry (DXA)

Front 14

Bone Density Value is measured as

Back 14

g/cm^2

Front 15

T-score

Back 15

value that represents the patient's BMD compared to the peak/optimal bone density for a young adult of the same sex

Front 16

Normal T-score

Back 16

at -1 or above

Front 17

T-score for osteopenia (low bone mass)

Back 17

-2.5 to -1

Front 18

T-score for osteoporosis

Back 18

-2.5 or below

Front 19

Severe or established osteoporosis

Back 19

<-2.5 and a history of fracture

Front 20

Z-Score

Back 20

value that represents the patients BMD compared to what is expected for someone with the same age and sex

Front 21

Deficient in Vitamin D

Back 21

<20 ng/ml

Front 22

Insufficient in Vitamin D

Back 22

21-29 ng/ml

Front 23

Normal Vitamin D

Back 23

>30 ng/ml

Front 24

if you are given multiple T-scores (1 from spine, L & R hip, L & R femoral neck), which one do you take

Back 24

take the worst score (the most negative)

Front 25

Goals of Treatment for Osteoporosis

Back 25

1. Birth - 30yrs = obtain highest bone bass possible and optimize bone quality
2. >30 yrs - maintain BMD, minimize bone loss, prevent falls/fractures
3. with fractures = control pain, restore independence and quality of life, prevent further fractures

Front 26

Non-Pharm Treatment for Osteoporosis

Back 26

1. Adequate Calcium and Vitamine D Intake
2. Exercise - weight bearing and muscle strengthening
3. Fall prevention (exercise, cane, walker, meds)
4. Good Habits - smoking cessation, limit alcohol, reduce caffeine/soda intake

Front 27

Daily requirements for adults over 50 years old

Back 27

CALCIUM: 1200mg

VITAMIN D: 800-1000 IU

Front 28

Foods that contain calcium

Back 28

1. milk (x300)
2. yogurt (x300)
3. cheese (x200)
4. collard greens (178)
5. broccoli (100-180)
6. soy beans (88-130)
7. tofu (253)

Front 29

Pharmacological Treatment Options for Osteoporosis

Back 29

1. Calcium/Vitamin D
2. Bisphosphonates
3. Estrogen agonists/antagonists
4. Calcitonin
5. Denosumab
6. Hormone Therapy
7. Parathyroid Hormone

Front 30

Calcium Carbonate

Back 30

MOA: increase/maintain BMD

1. limit single dose to 600mg elemental Ca
2.Take with food
3. preferred form of calcium - least expensive, fewest number of tablets

Front 31

Calcium Citrate

Back 31

MOA: increase/maintain BMD

1. take with or without food

Front 32

Drug Interactions with Calcium Supplements

Back 32

1. Iron
2. Quinolone
3. Tetracycline
4. Levothyroxine

Front 33

Side Effects of Calcium Supplements

Back 33

constipation, gas, stomach upset

Front 34

Vitamin D Supplement

Back 34

MOA: maximizes Ca absorption

1. Cholecalciferol (D3) - preferred - OTC
2. Ergocalciferol (D2) - OTC and RX

Front 35

MOA of Bisphosphonates

Back 35

1. decrease osteoclast activity
2. increase/maintain BMD
3. reduce fracture risks

Front 36

Bisphosphonates

Back 36

1. Alendronate (Fosamax)
2. Risedronate (Actonel)
3. Ibandronate (Boniva)
4. Zoledronic Acid (Reclast)

Front 37

Gold Standard for treating Osteoporosis

Back 37

Bisphosphonates

Front 38

Which bisphos doesn't decrease his fractures

Back 38

ibandronate (boniva)

Front 39

Administration of Alendronate and Risedronate

Back 39

1. take 1st thing in morning, at least 30 minutes prior to food, drink, or other meds
2. take tablet with at least 8oz of plain water
3. remain sitting or standing for at least 30 minutes

Front 40

Common ADRs of Bisphosphonates

Back 40

1. abdominal pain, dyspepsia, nausea (ORAL)
2. fever, flu-like symptoms, injection site reactions (IV)

Front 41

Alendronate (Fosamax)

Back 41

1. 10mg PO daily
2. 70mg PO weekly

Front 42

Risedronate (Actonel)

Back 42

1. 5mg PO daily
2. 35mg PO weekly
3. 35mg PO weekly EC
4. 75mg PO x2 consecutive days per month
5. 150mg PO monthly

Front 43

Ibandronate (Boniva)

Back 43

1. 150mg PO monthly
2. 2.5mg PO daily
3. 3mg IV push q3months

**must check before each dose: serum Ca, SCr, Vit D

Front 44

Administration of Oral Ibandronate

Back 44

1. separate from food, drink, other meds by at least 60 minutes
2. remain sitting or standing for at least 60 minutes

Front 45

Missed a dose of oral bisphosphonates

Back 45

DAILY: take next thing, 1st thing in morning

WEEKLY: take next day - >1day elapsed, skip week

MONTHLY: same date each month

Front 46

Zoledronic Acid (Reclast)

Back 46

1. 5mg IV once a year
2. check creatinine before each dose
3. SIDE EFFECTS: fever, headache, muscle/joint pain, flu-like symptoms, fatigue
*pretreat with APAP*

Front 47

Advantages of IV bisphos treatment

Back 47

1. less risk of GI ADRs
2. improved bioavailability
3. increased adherence
4. good if patient cant stay sitting or standing for 30-60 minutes

Front 48

Reasons to not use Bisphosphonates

Back 48

1. hypocalcemia
2. CrCl < 35
3. upcoming dental work
4. risk of atypical fractures
5. severe GERD

Front 49

Mixed Estrogen Agonists/Antagonists

Back 49

1. Raloxifene (Evista)
2. Calcitonin (Fortical, Miacalcin)

Front 50

Raloxifene (Evista)

Back 50

MOA: estrogen agonist on bone, but antagonist on breast/uterus, decreases vertebral fractures, increases spine/hip BMD

DOSE: 60mg PO daily

ADRs: hot flashes, flu-like symptoms, peripheral edema, leg cramps

Front 51

Major ADR for Raloxifene

Back 51

Increased risk of Thromboembolic Disease (3-fold)
*do not take if immobilized

Front 52

Clinical Pearls of Raloxifene (Evista)

Back 52

1. less potent than bisphosphonates
2. decreases LDL and total cholesterol levels
3. no increased risk of breast or endometrial cancer

Front 53

Calcitonin (Fortical, Miacalcin)

Back 53

MOA: decreases vertebral fractures (intranasal form)

DOSE: 200mcg intranasally daily or 50-100mcg SC or IM daily

*Intranasal- last line

Front 54

Denosumab (Prolia)

Back 54

MOA: inhibits osteoclastogenesis and increases osteoclast apoptosis

IND: postmenopausal osteoporosis &osteoporosis in men with high risk of fractures

DOSE: 60mg SUBQ once every 6 months plus calcium and Vit D

ADRs: eczema and cellulitis

Front 55

Clinical Pearls of Denosumab (Prolia)

Back 55

1. correct hypocalcemia first
2. monitor Ca levels
3. no dosage adjustment in renal impairment

Front 56

Teriparatide (Forteo)

Back 56

*Recombinant Parathyroid Hormone*

MOA: increases bone formation and osteoblast activity

IND: treat osteoporosis for up to 2 years, reserved for patients with severe osteoporosis at highest risk of fractures who cant take bisphos

DOSE: 20mcg SC daily into thigh or abdomen

Front 57

Contraindications for Teriparatide (Forteo)

Back 57

1. hypercalcemia
2. history of bone cancer
3. history of cancer that has metastasized to the bone
4. Radiation to skeleton

Front 58

Clinical Pearls for Teriparatide (Forteo)

Back 58

1. most expensive
2. decreases vertebral fractures by up to 65%
3. caused osteosarcoma in rats when given high doses
4. don't know what happens after 2 years of therapy

Front 59

Glucocorticoid-Induced Osteoporosis

Back 59

1. drug class most commonly associated with secondary osteoporosis
2. greatest bone loss occurs in first 6-12 months of steroid therapy

Front 60

MOA of Glucocorticoid-Induced Osteoporosis

Back 60

decreased bone formation, increased bone resorption, decreased calcium absorption, increased calcium excretion, decreased estrogen and testosterone

Front 61

Who is at risk for Glucocorticoid-Induced Osteoporosis

Back 61

1. oral doses of prednisone >5mg (or equivalent)
2. Long term, high dose inhaled steroids

Front 62

Management of Glucocorticoid-Induced Osteoporosis

Back 62

1. Discontinue glucocorticoid
2. use lowest dose and shortest duration
3. check baseline BMD
4.ensure adequate daily Calcium and Vitamin D
5. Bisphosphonates are drug of choice!!!!

Front 63

osteoarthritis

Back 63

disease of localized joints associated with deterioration of cartilage and secondary changes in underlying bone

Front 64

Pathophysiology for Osteoarthritis

Back 64

1. cartilage water content increases
2. loss of proteoglycan
3. increase levels of protease enzymes
4. destruction of cartilage, structural changes in bone
CONSEQUENCES: pain, decreased functioning and mobility

Front 65

Clinical Presentation of Osteoarthritis

Back 65

1. PAIN - dull, aching
2. join stiffness (morning)
3. Inflammation
4. bony enlargements on fingers
5. loss of range of motion
6. joint tenderness
7. grating or crackling sound heard with joint movement

Front 66

Risk factors for Osteoarthritis

Back 66

1. obesity
2. repetitive joint stress, over use of joint
3. age (>50)
4. family history
5. Gender

Front 67

Diagnosis of Osteoarthritis

Back 67

1. Lab Findings (synovial fluid - clear/viscous, WBC and ESR - normal, RF negative)

Front 68

Goals of Treatment for Osteoarthritis

Back 68

1. relieve pain and joint stiffness
2. maintain &/or improve joint mobility
3. limit functional impairment
4. minimize ADRs
5. maintain or improve patient's QOL
6. educate

Front 69

Non-Pharm Treatment of Osteoarthritis

Back 69

1. Social Support services
2. weight loss
3. aerobic and muscle strengthening exercises
4. heat/cold therapy
5. PT or OT
6. surgery
7. assistive devices

Front 70

Pharmalogical treatment of osteoarthritis

Back 70

1. APAP
2. NSAIDS
3. COX-2 inhibitor

Front 71

Tylenol for Osteoarthritis

Back 71

1st line agent for mild-moderate pain due to safety profile and cost

Front 72

Dosing for Tylenol

Back 72

325-650mg q4-6h or 1000mg 3-4x/day

MAX: 4g/day

Front 73

NSAIDS for Osteoporosis

Back 73

used for moderate to severe pain

ADRs: GI effects

INTERACTIONS: anticoagulant, ASA, ACE-I, ARBs

Front 74

Risk Factors for GI events

Back 74

1. >65
2. lots of comorbidities
3. history of PUD
4. history of upper GI bleeding
5. on anticoagulants
6. high dose and long use of NSAIDS

Front 75

Celecoxib (Celebrex)

Back 75

for moderate to severe pain, possibly less GI toxicity

Front 76

Capsaicin

Back 76

*Topical Prep for Osteoarthritis*

MOA: inhibits release of Substance P in the peripheral nerves

ADRs: burning, stinging, erythema

Front 77

Intra-articular Injections

Back 77

1. glucocorticoids
2. hyaluronic acid

Front 78

Glucocorticoid

Back 78

1. effective knee for local inflammation
2. short term use
3. 4-6 month intervals (no more than 3-4 injections/year)

Front 79

Hyaluronic Acid

Back 79

1. for moderate to severe pain with ADR or contraindication to APAP, NSAIDs, or COX2
2. provides lubrication and shock absorbency
3. for knee only
4. pain relief occurs slowly, can last up to 6 months

Front 80

Tramadol

Back 80

for moderate to severe pain if no response or ADR or C/I to APAP, NSAIDs, COX-2

Dosing: 50-100mg q4-6h

ADRs: sedation, confusion, urinary incontinence, constipation

Front 81

Narcotic and Analgesic Combos

Back 81

for moderate to severe pain if no response or ADR or C/I to APAP, NSAIDs, COX-2 inhibits and tramadol

AVOID IN ELDERLY DUE TO FALL RISK

Front 82

Glucosamine Sulfate

Back 82

1. rebuild cartilage, decrease cartilage loss
2. ADRs - may increase INR, may cause GI upset and nausea
3. not FDA regulated

Front 83

Rheumatoid Arthritis

Back 83

chronic, systemic, inflammatory disease characterized by symmetrical joint involvement and a wide spectrum of other signs (rheumatoid nodules, vasculitis, ocular inflamation)

Front 84

Risk Factors for RA

Back 84

1. Genetics
2. increasing age (35-60yrs)
3. females
4. positive RF
5. maybe smoking?

Front 85

Pathophysiology of RA

Back 85

1. immune system cant distinguish between normal and foreign tissues - attacks normal synovial and connective tissues
2. Inflammation of synovial tissue - proliferation of synovial tissue (Pannus)
3. Pannus invades cartilage - erosion of bone

Front 86

Signs and Symptoms of RA

Back 86

PRODROME - weak, low fever, loss of appetite, join pain, fatigue

JOINT PAIN (hands, feet, wrists) - swelling(soft and spongy), read, warm, swan neck, grip problems,

1. fatigue, morning stiffness
2. Rheumatoid Nodules
3. Vasculitis

Front 87

Lab and Radiology Tests for RA

Back 87

1. CBC
2. Inflammatory markers
3. Radiologic Findings

Front 88

Inflammatory Markers

Back 88

1. Erythrocyte Sedimentation Rate - increased
2. C-Reactive protein - Elevated
3. Rheumatoid Factor - Positive
4. Anticyclic Citrullinated Peptide - present = aggressive

Front 89

ACR/EULER 2010 classification criteria for RA

Back 89

1. helps identify patients with undifferentiated inflammatory synovitis
2. uses a scoring system to help predict the severity
3. 4 categories
4. score of 6 out of 10 = definite RA

Front 90

4 Categories of ACR/EULER classification criteria for RA

Back 90

1. Joint Involvement
2. Serology
3. Acute-Phase reactants
4. Duration of Symptoms

Front 91

Gols of Treatment for RA

Back 91

1. improve QOL and improve/maintain functional status
2. control disease activity
3. decrease joint pain
4. improve ability to perform ADL
5. disease remission

Front 92

Non-Pharm Treatments of RA

Back 92

1. Rest - relieves stress
2. Physical Activity - range of motion and strengthening
3. OT/PT
4. Weight loss
5. Assistive devices - canes, walkers
6. Surgery

Front 93

Immunizations all patients with RA should get

Back 93

1. annual flu vaccine
2. Pneumococcal Vaccine
3. Hep B (with risk factors)

Front 94

Symptomatic Relief for RA

Back 94

1. Salicylates, NSAIDS, COX2 inhibitors
2. Corticosteroids - intra-articular or PO - must do DEXA scan

Front 95

Initiation of Therapy with a DMARD

Back 95

should not be delayed beyond 3 months for patient with established diagnosis of RA

Front 96

Non-Biologic DMARDS

Back 96

1. Methotrexate (Rheumatrex)
2. Leflunomide (Arava)
3. Hydroxychloroquine (Plaquenil)
4. Sulfasalazine (Azulfidine)

Front 97

Methotrexate

Back 97

*1st Line for mild-moderate-severe active disease

MOA: dihydrofolate reductase inhibitor

ONSET: 4-8 weeks

*should also take a folate supplement

Front 98

Toxicities and Monitoring for Methotrexate

Back 98

1. Pregnancy Category X
2. myelosuppression, hepatic fibrosis, cirrhosis

MONITOR: CBC, LFTs

Front 99

Leflunomide (Arava)

Back 99

*Used alone or in combo with MTX*

MOA: inhibits pyrimidine synthesis

ONSET: 4-12 weeks

Front 100

Toxicities and Monitory for Leflunomide

Back 100

1. Pregnancy Category X
2. diarrhea, rash, hepatotoxicity

MONITOR: CBCs and LFTs, may increase INR

Front 101

Hydroxychloroquine (Paquenil)

Back 101

*first line choice for early or mild disease*

MOA: antimalarial, inhibits T-cell and B-cells

ONSET: 8-24 weeks

Front 102

Toxicities and Monitory for Hydroxychloroquine

Back 102

1. nausea, diarrhea, macular damage
2. Retinal toxicity

MONITOR: eyes

Front 103

Sulfasalazine (Azulfidine)

Back 103

*1st line for mild-moderate disease*

MOA: suppression of pro-inflammatory cytokines

ONSET: 8-12 weeks

*alternative agent for pregnant patients (Cat B)

Front 104

Toxicities and Monitoring for Sulfasalazine

Back 104

1. n/v/d, rash, photosensitivity, yellow-orange urine
2. sulfa allergy
3. myelosuppression, leukopenia, LFT elevation

MONITOR: CBC, LFTs

Front 105

Biologic DMARDS

Back 105

*1st line Moderate - Severe RA*
1. genetically engineered protein molecules that target and block pro-inflammatory cytokines such as TNF-a and IL-1
2. No lab monitoring required
3. risk of serious infection

Front 106

TNF Antagonist

Back 106

**1st Line Biologic DMARD**

ONSET: 1-4 weeks
BLACK BOX: infection risk

MUST HAVE TB screening prior to starting treatment

Front 107

TNF Antagonists

Back 107

1. Etanercept (Enbrel)
2. Infliximab (Remicade)
3. Adalimumab (Humira)
4. Golimumab (Simponi)
5. Certolizumab (Cimzia)

Front 108

Etanercept (Enbrel)

Back 108

*TNF ANTAGONIST*

1. administered SUBQ at home
2. 25mg twice weekly or 50mg once weekly

Front 109

Infliximab (Remicade)

Back 109

*TNF Antagonist*

1. administered in doctor's office
2. IV infusion over 2hrs at 0,2,6 weeks then q8 weeks
3. usually given with MTX

Front 110

Adalimumab (Humira)

Back 110

*TNF Antagonist*

1. administered SUBQ at home
2. 40mg every other week

Front 111

Golimumab (Simponi)

Back 111

*TNF Antagonist*

1. administered SUBQ at home
2. once monthly in combo with MTX

Front 112

Certolizumab pegol (Cimzia)

Back 112

*TNF Antagonist*

1. administered at home
2. at weeks 2 & 4, then either every other week or every 4 weeks

Front 113

Anakinra (Kineret)

Back 113

*IL-1 Antagonist*

1. self-administered at home
2. daily SUBQ injection
**LAST LINE**

Front 114

Rituximab

Back 114

*Anti-CD20 monoclonal antibody*

1. Used in combo with MTX (moderate-severe RA)
2. administered IV, then a second dose 2 weeks later

Front 115

Abatacept (Orencia)

Back 115

*Selectie Co-Stimulation Modulator*

1. targets T lymphocytes
2. administered in doctor's office
3. IV infusion over 30 minutes
4. usually give steroid to pretreat

Front 116

Tocilizumab (Actemra)

Back 116

*Humanized monoclonal antibody to IL-6 Receptor*

1. used after failure of TNF antagonist and/or DMARD
2. used in combo with MTX
3. IV infusion every 4 weeks

Front 117

Tofactinib (Xeljanz)

Back 117

*Janus Kinase Inhibitor*

1. inhibits intracellular signaling mediated by JAK-STAT pathway
2. taken orally BID
3. newest agent for moderate to severe RA who have problems with MTX