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Osteoporosis

Terms in this set (83)

Osteoporosis is a disease characterized by....
Low bone mass
Structural deterioration of bone tissue leading to bone fragility and an increased susceptibility to fractures
Osteoblasts vs Osteoclasts
Osteoblasts: make new bone, produce bone matrix, and control its mineralization.
Osteoclasts: break down bone and remove bone matrix.
Risk Factors for Primary Osteoporosis
Low calcium intake
Sedentary lifestyle
Smoking
Alcohol
Age
Small, thin frame
Caucasian, Asian
Early menopause
Risk Factors for Secondary Osteoporosis
Hypogonadism
Androgen insensitivity
Growth hormone deficiency
Drugs
Drugs that cause osteoporosis
Thyroid supplements
Glucocorticoids
Heparin
Chemotherapy
Anticonvulsants
Aluminum-containing antacids
Chronic lithium therapy
MOA of Glucocorticoid Induced Osteoporosis
Decrease activity of osteoblasts and speeds up their death
Cause bone resorption
Change absorption of calcium
Modify hormone levels
What time/dose are glucocorticoids given at to induce osteoporosis?
>5mg/day for >3 months
Prevention of Glucocorticoid Induced Osteoporosis
Lowest possible dose and shortest duration
Alternative routes of admin (topical)
Manage risk factors
Management of Glucocorticoid Induced Osteoporosis
Bone Mineral Density (monitor)
Increase dietary calcium & vit D
Meds for prevention/management
Diagnosis of Osteoporosis
Symptoms
Fracture
T-Score (<-2.5 SD)
Radiological studies (spine, neck, heels)
Z-Score
Tells the # of standard deviations the patient is compared to the normal value for someone of the SAME AGE and sex
T-Score
Tells the # of standard deviations the patient is compared to a NORMAL YOUNG adult person
-Preferred-
What does a T-Score > -1 SD mean?
Normal
What does a T-Score -1 to -2.5 SD mean?
Osteopenia
What does a T-Score < -2.5 SD mean?
Osteoporosis
Prevention of Osteoporosis
Adequate calcium intake
Weight-bearing exercise
Modification of risk factors
Prevent falls (look @ meds)
What is the recommended calcium intake?
1000-1500mg of elemental calcium per day (usually 1200mg)
What is the maximum amount of elemental calcium that can be absorbed in a single dose?
600mg (give pts 600mg BID)
What is the recommended supplement dose of Vitamin D? What is the role of Vitamin D?
~800IU/day
Helps w/ calcium absorption
What are examples of dietary calcium?
Milk
Yogurt
Cheese
Kale
Spinach
Broccoli
Which has better absorption: Calcium Citrate or Calcium Carbonate?
Calcium Citrate
What is the treatment recommendation for patients with T-Score > -1 SD?
Calcium & Vit D supplement
Exercise
What is the treatment recommendation for patients with T-Score -1 to -2.5 SD?
Pharmacologic therapy to prevent osteoporosis
Calcium & Vit D supplement
Exercise
What is the treatment recommendation for patients with T-Score < -2.5 SD?
Pharmacologic treatment of osteoporosis
Calcium & Vit D supplement
Exercise
What are the types of treatment for osteoporosis?
Calcium / Vit D supplements
Hormone Replacement Therapy
Bisphosphonates
Polypeptide
Parathyroid hormone
SERMs
How do bisphosphonates work?
Stop activity of osteoclasts
Oral Bisphosphonates
Alendronate (Fosamax)
Ibandronate (Boniva)
Actonel
Dose of Alendronate (Fosamax)
70mg PO once weekly
Dose of Ibandronate (Boniva)
150mg PO once monthly
Dose of Actonel
35mg PO once weekly
ADRs of Oral Bisphosphonates
Severe muscle and bone pain
NV
Dysphagia
Inflammation/irritation of esophagus
Osteonecrosis of jaw (ONJ)
If patients have a CrCl <30mL/min, what bisphosphonates should not be used?
Boniva or Actonel
If patients have a CrCl <35mL/min, what bisphosphonates should not be used?
Fosamax
What are contraindications of oral bisphosphonates?
Hypocalcemia
Inability to remain upright for 0.5-1 hour after each dose
Esophageal / GI problems
Monitoring of Oral Bisphosphonates
Dental exam @ baseline (periodically thereafter)
S&S of esophageal problems or ONJ
Muscle pains/weakness
Calcium levels
Renal function
Decreased absorption of bisphosphonates can occur with....
Food, Aluminum, Magnesium, or Calcium containing products
Separate by 3 hours
What bisphosphonates are available IV?
Boniva
Zoledronic acid (Reclast)
Dose of Boniva
3mg IV every 3 months
Dose of Zoledronic acid (Reclast)
5mg IV every 12 months
ADRs of IV Bisphosphonates
Hypersensitivity reactions
Myalgias
Osteonecrosis
Considerations for IV Bisphosphonates
Only used for patients who cannot tolerate PO bisphosphonates
Do not use in pts with uncorrected hypocalcemia
CrCl <30mL/min
Risk factors of ONJ
Patients with cancer (throat, neck, mouth)
Head/neck irradiation
Chemotherapy
Use of glucocorticoids
Previous trauma to jaw
How do you educate your patient about ONJ?
Baseline dental exam
Report S&S of jaw pain
Avoid major dental work if possible
When/how do patients take bisphosphonates?
Swallow tablet whole when you get out of bed in the AM with a large glass of WATER before you eat.
Do not take the medicine while you are still in bed or before you go to bed.
Wait at least 30 minutes after taking the medications before eating/drinking any other medicines in order for best absorption.
What is a counseling point specifically for Alendronate?
Do not lie down for at least 30 minutes after taking Alendronate and do not lie down until you've eaten some food.
Effects of Bisphosphonates
Decrease vertebral and hip fractures
What is the only FDA approved SERM for osteoporosis prevention?
Raloxifene
Dose of Raloxifene
60mg PO QD
ADRs of Raloxifene
Stroke
Clots
Menopause symptoms
Raloxifene can only be used in....
females (not going through menopause)
Effects of Raloxifene
Decrease vertebral and hip fractures
Increase Bone Mineral Density (BMD)
Hormone Replacement Therapy w/ Osteoporosis
Decrease risk of fractures
Should NOT use as primary prevention in postmenopausal women
Not used long term
MOA of Polypeptide Hormone
Increase osteoblast activity
Inhibit osteoclast activity and resorption
Available Polypeptide Hormones
Calcitonin (Miacalcin - nasal & inj, Fortical, nasal)
Approved use / dose of Calcitonin
200 IU (1 spray) intranasally, alternating nostrils
100 IU SQ/IM QOD (Miacalcin only)
Calcitonin is an alternative drug in patients with....
bone pain
ADRs of Calcitonin
Nasal irritation
Dry/bloody nose
Rhinitis
HA
Back pain
Flushing
Storage of Calcitonin
Keep intranasal formulation in the fridge
Contraindication of Calcitonin
Hypersensitivity
Monitoring of Calcitonin
S&S of nasal irritation
Periodic nasal exam
Effects of Calcitonin
Decrease risk of vertebral fractures
What is the available parathyroid hormone?
Teriparatide (Forteo)
SQ injection -- @ home
MOA of Parathyroid Hormone
Stimulate parathyroid glands to release parathyroid hormone, which increases blood calcium levels
ADRs of Teriparatide (Forteo)
Transient rise in calcium
Dizziness
Muscle pain/weakness
NV
Orthostatic hypotension
Gout
What is the Black Box Warning of Teriparatide (Forteo)?
Increased risk of osteosarcoma
Use of Teriparatide (Forteo) should be limited to....
Less than 2 years
Storage / Stability of Teriparatide (Forteo)
Keep refrigerated
Expires 28 days from the first use
Contraindications of Teriparatide (Forteo)
Paget's disease
Hyperparathyroidism
History of irradiation
Elevation of alkaline phosphatase
Open epiphyses
Monitoring of Teriparatide (Forteo)
Compare to Baseline
Serum calcium & albumin
24 hour urine calcium
PTH
Creatinine
Alkaline phosphatase
Uric acid
Effect of Teriparatide (Forteo)
Decreased risk of vertebral fractures
Brand name of Denosumab
Prolia
MOA of Denosumab (Prolia)
Binds osteoclasts and decreases activity
How is Denosumab (Prolia) administered?
60mg SQ every 6 months (in hospital)
Effects of Denosumab (Prolia)
Decreased risk of fractures
ADRs of Denosumab (Prolia)
Dermatologic reaction
Increased risk of infection
REMS program
Brand name of Abaloparatide
Tymlos
MOA of Abaloparatide (Tymlos)
Anabolic medication that increases osteoblasts
Indication for Abaloparatide (Tymlos)
Post-menopausal women at high risk of fracture or intolerant to other therapies
Dose of Abaloparatide (Tymlos)
80mcg SQ QD (pen)
ADR of Abaloparatide (Tymlos)
Osteosarcoma (max 2 years use)
Effect of Abaloparatide (Tymlos)
Decreased risk of vertebral fractures (more than bisphosphonates)
Consequences of Osteoporosis
Fracture
High cost
Pain
Structural deterioration
Decreased quality of life
Mortality
Follow Up Time for Patients based on BMD (T-Score)
> -1 : repeat in 5 years
-1 to -1.5: repeat in 2-3 years
-1.5 to -2: repeat in 2 years
-2 to -2.5: repeat in 1-2 years
< -2.5: repeat in 2 years
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