Osteoporosis

Front 1

Calcitonin is secreted by ____.

It's function is to ___ (3)

Back 1

parafollicular cells (C cells) in the thyroid gland

Lower serum Ca++ and Phosphate by:
increase calcium excretion in the urine
inhibit the activity of the osteoclasts in bone tissue
decrease phosphate resorption (enhance elimination) in kidneys

Front 2

Parathyroid hormone is secreted by ___.

It's function is to ___ (4)

Back 2

regulate calcium levels by:
*Low doses: increase bone formation w/o stim bone resorption
*high doses: ^ osteoclast activity --> ^ bone resorption
increase Ca++ absorption (small intestine)
increase phosphate absorption in intestine
increase Ca++ resorption from kidneys
decrease phosphate resorption (increase elimination) by kidneys

Front 3

Calcitriol is ___ and its job is to ___.

Back 3

- activated vitamin D

- enhances intestinal absorption of calcium and phosphorus
- calcium mobilization in bone (with PTH)
- renal tubular reabsorption of calcium (with PTH)
-renal tubular resorption of phosphorus
- other physiological actions such as activating fast twitch muscle fibers (eg. in fall prevention)

Front 4

Osteoporosis - Following a hip fragility fracture, ___ % of women and ___ % of men die within 1 year.

Back 4

- 28%
- 37%

Front 5

Osteoporosis - Prevalence over 50 years old is 1 in ___ for women and 1 in ___ for men.

Back 5

- 4
- 8

Front 6

Osteoporosis - Both women and men begin to lose bone in their ___

Back 6

- mid 30s

Front 7

Osteoporosis - Pattern of bone loss is ____.

Back 7

- Biphasic (first phase is age dependent, second phase is post menopausal)

Front 8

Osteoporosis - Initial bone density is influenced by ___ (4).

Back 8

1. Race
2. Heredity (big vs small, heavy vs light)
3. Gender
4. Calcium intake during growth

Front 9

Osteoporosis - Races such as ___ (2) have thinner bones while ___ have thicker bones.

Back 9

- Caucasians and Asians

- Blacks

Front 10

Osteoporosis - Early menopause is before age ___

Back 10

45

Front 11

Osteoporosis - Secondary causes can be ___ (5)

Back 11

- primary hyperparathyroidism
- hyperthroidism
- Cushing's syndrome
- malabsorption syndrome
- chronic inflammatory diseases (eg RA)

Front 12

Osteoporosis - Drugs that can cause it are ___ (10)

Back 12

- glucocorticoids (~12% bone loss/yr on prednisone)
- anticonvulsants (AC affect vit D metabolism)
- thyroid hormone
- anticoagulants
- antineoplastics
- thiazolidinediones (glitazones)
- proton pump inhibitors (changes in gut function)
- vitamin D toxicity
- vitamin A excess
- aromatase inhibitors, androgen deprivation therapy

Front 13

Osteoporosis - When seeing synthroid ___ mcg, one should be concerned about osteoporosis in elderly.

Back 13

-100mcg

Front 14

Osteoporosis - Risk factors for low BMD, fractures and falls (8):

Back 14

- Prior fragility fractures
- High alcohol intake (≥3 units per day)
- Parental hip fracture
- Rheumatoid arthritis
- Glucocorticoid use
- Falls in the previous 12 months
- Current smoking
- Gait and balance

Front 15

Osteoporosis - Recommended lab tests (7)

Back 15

All should be normal:
Calcium, corrected for albumin
Thyroid stimulating hormone (TSH)- if clinical suspicion of thyroid disease
Complete blood count
Serum Creatinine Sr Cr
Alkaline phosphatase (may be elevated if acute recovery from fracture)
Serum protein electrophoresis- if suspicious of secondary causes of osteoporosis
25-hydroxy vitamin D (25-OH-D)- if pt at increased risk of deficiency (housebound,established osteoporosis)

Front 16

Osteoporosis - Optimum level of 25-OH Vit D is ___.

Back 16

75 nmol/L

Front 17

Osteoporosis - Prolonged glucocorticoid use for anyone is considered to be ____(amount) for over ____(time) in prior year.

Back 17

7.5mg prednisone equivalent daily

3 months (cumulative)

Front 18

Osteoporosis - The way to measure BMD is through ___. If that is not available another option is ___.

Back 18

- Dual x-ray absorptiometry (DXA) -spine and hip
(also for monitoring response to therapy)

- Heel ultrasound

Front 19

Osteoporosis - ___ or ___after age 50 will move an individual to the High risk category of CAROC automatically, IRRESPECTIVE of BMD: IT IS DIAGNOSTIC OF OSTEOPOROSIS. A single fragility fracture (eg wrist) in this age group is considered a sign of osteoporosis until proven otherwise.

Back 19

-Hip or Vertebral hip fracture. (unless high trauma incident) or
-more than 1 fragility fracture

Front 20

Osteoporosis - ___ will move an individual to one higher up category of CAROC: HIGHER RISK CATEGORY (Than simply indicated by BMD and age)

Back 20

Glucocorticoid therapy or NON-hip/vertebra FRAGILITY fracture

Front 21

Osteoporosis - An alternative to CAROC designed by the WHO is ___. It involves BMD measurement at the ___.

Back 21

FRAX 10 year risk.

femoral neck

Front 22

Osteoporosis - Screening tool used for osteoporosis, it cannot be used for diagnosis: ___.

Back 22

Quantitative ultrasound

Front 23

Osteoporosis - Non pharmacologic choices (4)

Back 23

- Regular weight bearing exercise
- Reduce risk of falling: minimize hazards: remove throw rugs, grab bars in bathroom, adequate lighting, assess drugs such as BZD and other psychotropics
- Smoking cessation
- Adequate vit D 800-2000iu/d, calcium 1200 mg/d AND PROTEIN
- Stop excessive alcohol (>2 drinks/day) and caffeine (>4 cups/day)

Front 24

Osteoporosis - Recommended calcium per day is ___.

Back 24

1200mg

Front 25

Osteoporosis - Recommended Vit D per day is ___.

Back 25

800-2000 IU.

Front 26

Osteoporosis - Bisphosphonates (RAZE) belong to ____ class.

Back 26

Anticatabolic

Front 27

Osteoporosis - Oral bisphosphanates are (3)

Back 27

RA(z)E:
Alendronate
Risedronate
Cyclical Etidronate

Front 28

All oral bisphosphonates have _____ intestinal absorption. Must be taken on ____ stomach with only ______, as other medications will ______ absorption.

Back 28

poor
empty
water (6-8 oz)
prevent

Front 29

Osteoporosis - IV bisphosphanate is ___

Back 29

raZe:
Zoledronic acid

Front 30

Osteoporosis - If one eats any kind of food during the day, intake of calcium is estimated to be ___ mg.

Back 30

300

Front 31

Osteoporosis - A cup of milk or yogurt, and a chunk of cheese has approximately ___ mg of calcium. Ice cream a cup has about ___ mg.

Back 31

300

160

Front 32

Osteoporosis - Instructions how to take oral bisphosphonates

Back 32

- Due to low absorption in GI, must be taken on empty stomach and only with water 30 minutes before 1st food of the day.
- Do not lie down or recline within 30 minutes of taking the medication.
- Do not take other vitamins or medications within half hour of taking bisphosphonate.

Front 33

Osteoporosis - Dose schedule of cyclical etidronate. (Etidronate evidence for fracture prevention is less robust than RAZ). 1st lines are R and A.

Back 33

- 2 weeks every 3 months = etidronate
- The other 76 days is elemental calcium 500mg.
(14 days + 76 days = 3months)-packaged together

Front 34

Osteoporosis - Zoledronate is administered once every ___ by IV infusion to those who can't tolerate G/I s/e's of oral agents or not responting to oral agents.

counselling pts?

Back 34

Year

HYDRATE well: 500 ml before and 500 ml after infusion
Acute phase rxn (witing 24-72 hrs and lasts 3-4 days): fever, joint and msl pain, skin rxns, ocular effects - these acute rnxs are rarely seen with ALL bisphosphonates (RAZE), but occurs more frequently when (10-20% pts) given Z.

Front 35

Osteoporosis - RISKS/SERIOUS ADVERSE EFFECTS of bisphosphonate therapy? (but normally only mild s/e's are seen: GI IRRITAT AND HYPERSENSITIVITY - very well tolerated.)

Back 35

NEATO:
- Nighttime leg cramps
- Esophageal ulceration (aminobisphosphonates only -R&A)
- Atypical fractures: stop b/phos (mainly seen with alendronate), consider anabolic agent FORTEO (teriparatide)
- Taste is altered
- ONJ - osteonecrosis of the jaw (1-3% with IV use for CANCER-absolute risk for osteoporosis veryyy low)

Front 36

Osteoporosis - Calcium carbonate is ___ % elemental calcium. (Should/Should not) take with food.

Back 36

40%

With food, as food will increase stomach acid (concern for ppi users).

Front 37

Osteoporosis - Calcium citrate is ___ % elemental calcium. (Should/Should not) take with food.

Back 37

21%

Doesn't matter because citrate is so soluble.

Front 38

Osteoporosis - Calcium side effects

Back 38

Constipation more of an issue with carbonate (brand specific)
Upset stomach

(brand specific)

Front 39

Osteoporosis - Calcium interaction with iron? (Yes/No).

Back 39

Yes. Calcium reduces iron absorption. Should space calcium apart from iron by 2 hours.

Front 40

Osteoporosis - Caclium interaction with levothyroxine? (Yes/No)

Back 40

Yes. Calcium reduces bioavailability of synthroid by one third. Space them out by 4 hours.

Front 41

Osteoporosis - Calcium DI with ___ (5)

Back 41

BC LIT:
- Bisphosphonates
- Ciprofloxacin
- Levothyroxine
- Iron
- Tetracycline

Front 42

Osteoporosis - first biologic agent approved for treatment of osteoporosis. What is it's category?

Back 42

Denosumab.

RANK ligand inhibitor. Blocks osteoclast activity: diminished formation, structure and survival

Front 43

Who can receive denosumab?
1______________ with a previous ___________,or
2_______________ risk factors for fracture, or
3_______________ other therapies

Back 43

postmenopausal women, fracture
multiple
failed/intolerant to

Front 44

Osteoporosis - SERM example

Back 44

Raloxifine. (Evista) 60mg/d

Estrogen antagonist in breast and uterine tissue but estrogen like activity in bone/lipid metabolism.
#Prevents post-menopausal bone loss,
#increases bone density by 3%,
#reduces new vertebral fractures by 30-40%

Front 45

S/e Raloxifene EVISTA (3) to tell patient

Back 45

Hot flushes (don't start until menopause established)
leg cramps
VTE/PE risk similar to estrogen

Front 46

Good things about raloxifene?
1,unlike estroge, it significantly REDUCES risk of _______________ by 76%
2more Good news! also Unlike estrogen, it is NOT associated with increased__________.

Back 46

estrogen receptor-positive BRCA

CV risk

Front 47

Osteoporosis - Anabolic agents (2, only one is used in canada)

Back 47

- Teriparatide (PTH analog) FORTEO: causes steady gain in bone density and 50% reduction in osteoporotic fractures
- Recombinant human PTH (EUROPE, not in north america)

Front 48

s/e of teriparatide FORTEO
-nausea
-dizziness
-leg cramps
-hypercalcemia
-_______________ > counsel to _____________
-_______________ > don't give to ppl with elevated baseline risk of this.. also the reason why max use of forteo(lifetime exposure) should NOT be > ____ months

Back 48

orthostatic hypotension: be in supine/sitting position for administration

osteogenic sarcoma, 24 months

Front 49

After 24 months of FORTEO, whats the plan?

Back 49

Give bisphosphonate or other anticatabolic to consolidate gains achieved with anabolic agent.
Think : COMBINATION THERAPY

Front 50

what to use to PREVENT osteoporosis?
1. in EARLY POSTMENOPAUSE, when estrogen deficiency symptoms also require tx, give ___________
2. if menopausal symptoms OVER, give ____________

Back 50

HRT (estrogen or estrogen/progesterone)

raloxifen (EVISTA)

Front 51

Osteoporosis - First line treatment for ESTABLISHED osteoporosis (ie. fragility FRACTURE and BMD in osteoporosis range)

Back 51

- Bisphosphonates
- Denosumab
- Estrogen
- Teriparatide FORTEO (SEVERE cases:>1 fragility fracture and VERY LOW BMD)

-EVISTA is also 1st line BUT only after other 1st lines REJECTED for high risk grp (>70y + prior hx of fragility fracture)

Front 52

2nd line tx for osteoporosis is_________ because of weaker ___________ (for prevention of vertebral fractures)
However,interestingly, it reduces _________ associated with _________
s/es: local: rhinitis/dryness w crusting, sinusitis
RARE systemic: NV ,dizziness, FLUSHING with HEAT

Back 52

-salmon calcitonin NASAL spray (MIACALCIN NS)
weaker clinical trial data

pain, ACUTE VERTEBRAL FRACTURES

Front 53

Who can take HRT for osteoporosis? SELECTED people only! HRT is NOT recommended for osteoporosis prevention unless.....
(3)

Back 53

#EARLY menopause <45 yrs old: take until 45 yrs old
#ALREADY menopausal BUT still has menopausal SYMPTOMS (and they want osteoporosis prevention)
***IF given to women > 60 with established osteoporosis: increased risk of BRCA and heart disease (balance risk vs benefit) - i personally don't like this idea...

Front 54

Who can have a drug holiday and for how long can the holiday be?
#People on ________ for (how long?) __________yr

#and people prescribed _________ because of low_______ alone for (how long?) ___________yrs.

#However, people with a previous __________ CANNOT have a holiday because they are at higher risk for ___________.

Back 54

Risedronate, < 1 year
Alendronate,low BMD, 1-3 years
osteoporotic fracture
reccurence