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117 Cards in this Set
- Front
- Back
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How is BMD monitored? |
DEXA scan: BMD in spine, hip(most reliable), wrist expressed as amount of mineralized tissue in area scanned (g/cm2) difference between patient's score and normal, as SD± mean HIGH value is LOW fracture risk |
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Osteopenia (low bone mass) is diagnosed as BMD= ________ |
1-2.5 SD of normal adult |
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Osteoporosis is defined as___ |
systemic disease characterized by low bone mass and microarchitecture deterioration with consequent increase in bone fragility and susceptibility to fracture |
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Osteoporosis is diagnosed as BMD ___ |
≥ 2.5 SD below a normal adult (mean) |
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what are osteoblasts |
bone- forming cells that promote bone matrix (Ca++, PO4, hydroxyapatite) |
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what are osteocytes |
mature bone cells in the matrix |
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what are osteoclasts |
bone- degrading cells that promote bone resorption- breaking down bone and releasing ions(mainly Calcium) into the blood stream |
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Calcitonin is made in the ___ cells of the ___ |
parafollicular thyroid |
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Calcitonins function is__ |
inhibition of OC activity ( inhibition of bone resorption) promotes HoCalcemia |
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Parathyroid hormone increases Ca++ by: |
1) stim Ca++ resorption from bones 2)stim Ca++ reabsorption in kidneys 3) stimulates Vit D synthesis |
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Vitamin D___ |
increases Ca++ absorption in intestines |
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The active form of vitamin D is___ |
1, 25 dihydroxyvitamin D |
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What three hormones are responsible for controlling calcium homeostasis. |
Calcitonin Parathyroid Hormone Vitamin D |
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What are secondary causes of OP |
Corticosteroid Use/ Cushing's syndrome Hyperparathyroidism Hyperthyroidism Hypogonadism (T/E deficiency) Renal Failure Paget's disease (abnormal bone growth and destruction) GI dysfuntion(dec Ca absorption) RA Eating disorders, Vit D deficiency, Ca deficiency |
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what risk factors are associated with OP |
Increased Age caucasian or asian ancestry early menopause (<45 yrs) or post menopausal( early or surgery induced) late menarchy (> 16)/ amenorrhea/ irregular menses Thin body frame Family history Ca and Vit D deficient diet sedentary lifestyle/ immobilization T1DM Cigarette smoking Heavy OH use |
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what are some pharmalogical agents associated with OP |
Glucocorticoids anticonvulsants (phenytoin, phenobarbitol,carbamazepine) Lithium Phosphate binding antacids (chronic use) Methotrexate Loops Excess thyroid supplementation |
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Pre menopausal women lose ____ of their skeleton per year with a Ca++ deficiency
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0.3% |
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Post menopausal women lose ___ of ther skeleton each year . This is believed to be due to protective role of ______
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2% estrogen |
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Women lose a total of ____-____ % of their peak bone mass in their lifetime |
40-50% |
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men lose a total of ____-____% of their peak bone mass in their lifetime |
20-30% |
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Hip fracture rates are ___ times higher in women |
2-3 |
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____ % of caucasian women can expect a hip, forearm or spine fracture after age 50. |
50 |
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1 in ____ postmenopausal women with vertebral fracture refracture within a year. |
5 |
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The one year mortality rate after a fracture is two times higher in _______ |
males |
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_____ % of hip fracture patients over the age of 50 die in the year following the fracture |
24 |
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_____% of hip fracture patients over the age of 50 who were ambulatory prior to the fracture require long term care. |
25 |
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only ___ % of hip fracture patients will regain the same level ofindependence |
50 |
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Women ≥ _____ should get annual DEXA scans |
65 |
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Men ≥ ____ should get annual DEXA scans |
70 |
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ANYONE ≥ ____ should get annual DEXA scans if they have risk factors |
60 |
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Glucocorticoids can accelerate or cause OP because they: |
1) stimulate OCs and inhibit OBs 2) Disrupt Ca++ homeostasis 3) reduce sex hormone levels |
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Methotrexate can accelerate or cause OP because ____ |
Increase OC activity and decrease OB activity |
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Loop diuretics can cause osteoporosis because they ___ |
inc Ca++ renal excretion |
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People who qualify for BMD testing are chosen based on ____ |
- age - risk factors -pharmacologic agents |
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List ways to prevent bone loss |
1) Adequate Ca, Vit D in diet 2) smoking cessation 3) limiting alcohol consumption 4)Weight bearing, muscle strengthening exercise 5)Avoid falls |
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What are the goals for pharmacologic OP treatment? |
PREVENT or slow existing bone loss, building up existing bone |
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What are current FDA approved pharmacologic options for prevention and/or treatment of OP |
bisphosphonates calcitonin teriparatide denosumab estrogen, selective estrogen receptor modulators (SERMs), testosterone |
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a normal recommended daily amount of Ca for men 19- 70 is ____ |
1 g/d |
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a normal recommended daily amount of Ca for men >70 is ___ |
1.2 g/d |
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a normal recommended daily amount of Ca for females 19-50 is ____ |
1 g/d |
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a normal recommended daily amount of Ca for females > 50 is ___
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1.2 g/d |
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the MAXIMUM single dose of calcium is ___ |
600 mg |
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a safe upper limit for total daily calcium is ___ |
2.5 g/d |
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The primary side effects of excess calcium are___ |
constipation and kidney stones |
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the best absorbed calcium supplement is ___ |
Calcium Triphosphate ( posture 1565.2) |
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how many mg of elemental Ca are in each dose of calcium triphosphate |
600 mg |
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_____ MUST be taken with calcium and vitamin D supplements |
Antiresorptive agents (bisphosphonates) |
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Hypocalcemia is a contraindication for ___ |
bisphosphonates and denosumab |
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precaution should be taken when prescribing ___ to patients with hypocalcemia |
calcitonin |
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what is the MOA for bisphosphonates? |
inhibition of OC activity by binding to sites of active resorption, inhibiting further bone loss |
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Bisphosphates are available in what different formulations |
IV and oral |
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what are common side effects associated with bisphosphonates |
flatulence, abdominal distension esophageal ulcers/ esophagitis (esp oral) dysphagia severe bone, joint, and/or muscle pain HA |
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what are rare side effects of bisphosphonates to monitor for in patients? |
osteoporosis of the jaw due to antiangiogenesis effects of BPs that cause dec nutrients and blood flow(?) 95% high dose, 5% low dose atypical fractures typically occuring in femur and caused by minimal trauma due to long term reduced bone turnover |
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what are contraindications for bisphosphonate use? |
1) hypocalcemia 2) severe renal insufficiency 3) Upper GI/ esophageal problems (oral agents) 4)inability to stand or sit upright for 30 min (oral) |
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How are bisphosphonates excreted? |
they are excreted unchanged |
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are dosing adjustments needed for elderly patients on bisphosphonates? |
no, even with decreased renal function (with the exception of reclast) |
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What drugs interact with bisphosphonates |
multivalent cations can interfere with bisphosphonate absorption |
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Name different bisphosphonate agents |
alendronate( Fosomax) alendronate + Vit D (Fosomax D) risedronate (Actonel) Actonel + Ca delayed release risedronate (Atelvia) ibadronate(Boniva) zoledronate(Reclast) |
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What are specific oral administration considerations for bisphosphonates |
take on an empty stomach with a full glass of water fast overnight take 30 min prior to eating remain upright for 30 min after taking |
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oral bisphosphonate therapy provides no added benefit for prevention of fractures beyond ____ |
3-5 years |
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High risk patients can be on BPs for |
10 years |
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Lower risk patients can be on BPs for |
5 years, then take 5 years off, then 5 years on again if needed |
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What is the typical prevention dose for alendronate? |
35 mg/ week |
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what is the typical treatment dose for alendronate |
70 mg/ week |
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what is the typical alendronate dose for Paget's disease |
40 mg QD for 6 mths |
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what are the typical doses for fosamax D |
70 mg alendronate + 70/140 ug (2800IU/5600IU) vit D/ wk |
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what is the typical prevention/treatment dose for risedronate? |
35 mg/ wk or 150 mg/ mth |
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what is the typical dose of risedronate for Paget's disease? |
30 mg QD x 2 months |
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what is the typical dose for Actonel with Calcium? |
35 mg risedronate + 1.250 mg Ca carbonate/ week |
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What is the brand name for delayed release risedronate |
Atelvia |
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What is EDTA and what does it do in Atelvia |
a chelating agent that binds divalent cations |
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what advantage does delayed release risedronate have over immediate release? |
it can be taken with food (usually after breakfast with a fatty meal) |
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What is a disadvantage of delayed release risedronate |
increased incidence of diarrhea? |
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how long should a patient wait before taking oral calcium supplements, antacids, iron preparations,magnesium supplements/ laxatives ? |
at least 30 minutes |
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what doseage forms does ibandronate come in? |
150 mg tabs 3mg/ mL IV |
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what is the typical dose for prevention/ treatment with ibandronate |
150 mg/ mth or 3 mg/mL IV q3mth |
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what is the typical prevention/ treatment dose for zoledronate(Reclast) |
5 mg/ 100 mL IV once a year |
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What are additional side effects unique to zoledronate |
HoCa Fever Flu like symptoms Redness/swelling at infusion site |
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What is the MOA of SERMs |
It is an estrogen agonist at the bone and an estrogen antagonist elsewhere |
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What special considerations should be taken into account when a patient is on Reclast |
Patient must be properly hydrated Dose should be adjusted for renal dysfunction |
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Reclast should be adjusted with a CrCl <______ |
35mL/min |
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What pregnancy category is risedronate in? |
D |
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What is the MOA for calcitonin |
Inhibition of OC and decreases bone resorption as well as analgesic properties that reduce bone pain due to acute fractures |
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What are the different calcitonin agents available |
Calcitonin- salmon injection(sq, im) and nasal spray |
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What are the side effects of calcitonin |
Antibody generation after 2-18 months of use N/v Skin/nasal irritation Allergic reactions(salmon) |
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What is the direct mechanism of action for estrogens |
They directly inhibit osteoclast activity and stimulate osteoblast activity. |
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What is the indirect MOA of estrogens in calcium homeostasis |
by antagonizing bone-resorbing action of PTH and by affecting Ca absorption and excretion |
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Estrogens are only for use by ____ |
Postmenopausal women at significant risk for op or patients who can't tolerate non E treatments |
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What are the side effects of SERMs and estrogens |
1) hot flashes 2) breast tendernessSERM 3) ha 4)nausea 5) diarrhea 6) weight gain |
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What is denosumab |
Human immunoglobulin G2 mAb |
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What is denosumab's MOA |
Binds to receptor activator of nuclear factor kappa b ligand (RANKL)- a protein essential for the formation and function of OCs- preventing it from binding to its receptor -RANK- on the surface of OCs and its precursors, inhibiting OC formation, function, and survival(dec resorption and inc bone mass) |
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What is denosumab indicated for |
-Postmenopausal women with OP at high risk for fractures -Patients who have failed or are intolerant to other therapies -chemo induced bone loss |
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How is denosumab administered |
SQ q6mths in combination with 1000 mg Ca and min 400 IU vit D daily |
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What are the SE of denosumab |
Back pain Pain in extremities Musculoskeletal pain Hypercholesterolemia Cystitis Pancreatitis |
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What is a contraindication for denosumab |
HoCa |
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What are patients with crcl <30 or those on dialysis at risk for after denosumab administration |
HoCa |
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What are precautions patients on denosumab should be aware of |
-- |
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What are general adverse effects of estrogens, SERMs |
1) blood clots 2) uterine and breast cancer |
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Anabolic therapy is for patients that___ |
Are at high risk for osteoporotic fractures |
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What things put a patient at high risk for OP fractures |
H/O op fractures Multiple fracture risk factors Failed other therapies Intolerant to other therapies |
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What are the different anabolic therapy agents |
Teriparatide injection Denosumab |
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What is the pharmacology of teriparatide |
Recombinant human PTH binds PTH1R, stimulating OB activity over OC activity when given in a cyclical, pulsed manner. It activates vitamin D,inc Ca absorption and inc tubular reabsorption of Ca and PO4 |
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What is teriparatide indicated for |
-Treatment of menopausal women with osteoporosis who are at high risk for fractures -Men with primary or hypogonadal osteoporosis who are at high risk for fractures |
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How is teriparatide administered |
Disposable pen for once daily SQ injection |
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How long should patients be on teriparatide (max) |
2 years |
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What are precautions patients on denosumab should be aware of |
Potential exacerbation of HoCa Severe infection Osteonecrosis of jaw Atypical fractures |
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Aledronate |
Fosomax |
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Denosumab |
Prolia |
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Aledronate plus vit D |
Fosomax plus D |
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Risedronate |
Actonel |
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Delayed release risedronate |
Atelvia |
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Ibadronate |
Boniva |
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Zoledronate |
Reclast |
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Calcitonin injection |
Miacalcin |
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Calcitonin nasal spray |
Fortical |
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Raloxifene |
Evista |
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Teriparatide |
Forteo |
