Pharm - Osteoporosis
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Questions and Answers

Glucocorticoids, phenytoin, carbamazepine, Depo-medroxyprogesterone, PPI are all associated with bone (growth/loss).

loss

What is a major lifestyle modification that is recommended for patients for the prevention of osteoporosis?

  • Decrease of Vitamin D intake
  • Increased Alcohol Use
  • Smoking Cessation (correct)
  • Limiting weight-bearing exercise

    • What are adverse effects associated with calcium?

  • Kidney stones (correct)
  • Gallstones
  • Headaches
  • Gatroparesis

    • Citrate is the preferred calcium supplement over Carbonate when taking with a PPI.

    <p>True</p> Signup and view all the answers

    What vitamin is needed to be able to absorb calcium?

    <p>Vitamin D</p> Signup and view all the answers

    The recommended daily intake of Vitamin D intake (in international units) is _______________ for prevention.

    <p>800-1,000</p> Signup and view all the answers

    Vitamin D3 (cholecalciferol) is the most commonly recommended source of Vitamin D and it is source from animal product and available OTC.

    <p>True</p> Signup and view all the answers

    What is the dosing for Vitamin D for a patient that is DEFICIENT or INSUFFICIENT in vitamin D? This patient's baseline labs showed vitamin D levels less than 29 ng/mL.

    <p>5,000 IU daily x 8-12 weeks</p> Signup and view all the answers

    Who qualifies for pharmaceutical treatment of osteoporosis?

    <p>Patient with a history of hip / vertebral fracture = YES Patient with a T-score ≤ -2.5 at femoral neck or spine = YES Patient with a Z-score ≤ -2.5 at femoral neck or spine = NO Patient's T score shows osteopenia (-1.0 to -2.5) and FRAX ≥ 3% hip fracture or FRAX ≥ 20% major osteoporosis-related fracture = YES</p> Signup and view all the answers

    What are contraindications for Bisphosphonates (alendronate, risendronate, zolendronic acid)

    <p>Hypocalcemia; Esophageal stricture or inability to sit/ stand upright x30mins (PO formulations); eGFR &lt; 30-35</p> Signup and view all the answers

    Bisphosphonate MUST be taken first thing in the morning, on an empty stomach, while sitting upright.

    <p>True</p> Signup and view all the answers

    What are rare adverse reactions related to Bisphosphonate administration?

    <p>Osteonecrosis of the jaw and atypical fractures</p> Signup and view all the answers

    When should a patient take a holiday from Bisphosphonate when they are at moderated or high risk based on their T-score (FRAX)? Note: Moderate risk is defined as a patient with a T-score >-2.5 that remained free of fractures.

    <p>moderate-risk patient that is taking PO bisphosphonate = Holiday after 5 years moderate-risk patient using IV bisphosphonate = Holiday after 3 years In high-risk patient that is taking PO bisphosphonate = Holiday after 6-10 years In high-risk patient using IV bisphosphonate = Holiday after 6 years</p> Signup and view all the answers

    What is NOT a contraindication for Prolia (denosumab)? This is also a good reason to use this medication!

    <p>Renal insufficiency</p> Signup and view all the answers

    What is the MOST common adverse effect of Prolia (denosumab)?

    <p>Dermatologic (rash/dermatitis, eczema)</p> Signup and view all the answers

    Compare the Bisphosphonates options for your patient.

    <p>IV given annually to target mostly spine and hip fracture prevention = Zoledronic acid Tablets given weekly to decrease mostly spine risk of fracture = Risendronate ablets, Effervescent, Solution given weekly to decrease risk of fracture in all risk areas = Alendronate NOT a first line = Ibandronate</p> Signup and view all the answers

    What are the second line options for osteoporosis?

    <p>PTH analogs (teriparatide and abaloparatide) = Stimulates osteoblasts for anabolic bone building, but only indicated for very high-risk fracture (T-score &lt; -3 or fracture while on tx) Estrogen agonist/antagonist (Envista/raloxifene) = Selectively activates estrogenic pathways in some tissues (e.g., bone) and antagonizes in other tissues; Useful for those with osteoporosis AND history/high risk of breast CA Estrogens = Relief of vasomotor sx associated with menopause and maintenance of BMD post-menopause; Limit to those recently postmenopausal and should be used at lowest effective dose for shortest duration possible Miacalcin(calcitonin) intranasal = Antagonizes effects of parathyroid hormone and Inhibits osteoclast bone resorption; Useful for osteoporotic vertebral fracture pain relief</p> Signup and view all the answers

    What adjunct medication can be administered subQ to maintain BMD gains followed by denosumab or bisphosphonate by inhibits regulatory factor in bone metabolism?

    <p>Evenity(romosozumab)</p> Signup and view all the answers

    Alternative agents matching PROS

    <p>Good for high risk (hx fx on tx) Reduces fractures = PTH analogs (e.g., Forteo, teriparatide) Good for osteoporosis + breast CA = Estrogren agonist/antagonists (e.g., Evista/raloxefine) Good for recently post-menopausal = Estrogens Good for reducing pain associated with vertebral fractures = Calcitonin</p> Signup and view all the answers

    Alternative agents CONS

    <p>Osteosarcoma Black box warning; Max 2 years lifetime use = PTH analogs (e.g., Forteo, teriparatide) Women only; Caution: Hot flashes, VTE = Estrogren agonist/antagonists (e.g., Evista/raloxefine) Caution: Breast cancer, VTE, stroke = Estrogens Nasal spray (irritating) and no fracture data = Calcitonin</p> Signup and view all the answers

    Alternative therapies reserved for high-risk patients unresponsive to first-line treatments or those with concomitant indications

    <p>True</p> Signup and view all the answers

    MOA - Alternative therapies

    <p>Estrogen agonist/antagonist = Inhibits osteoClasts Estrogens = Inhibits osteoClasts Calcitonin = Inhibits osteoClasts PTH analogues = Stimulates osteoBlasts</p> Signup and view all the answers

    Bisphosphonates can have acute phase IV reactions in the first hour. What should you pre-treat with?

    <p>Acetaminophen</p> Signup and view all the answers

    Prolia (denosumab) is a first line treatment option given as a subq injection every ___ months.

    <p>6</p> Signup and view all the answers

    Adults ≥ 50 years should intake _____ mg (elemental) calcium daily. This should be spread into two or three doses.

    <p>1200 mg</p> Signup and view all the answers

    Study Notes

    Medications affecting Bone Health

    • Glucocorticoids, phenytoin, carbamazepine, Depo-medroxyprogesterone, and PPI are associated with bone loss.

    Osteoporosis Prevention

    • Major lifestyle modification for osteoporosis prevention: regular exercise and adequate calcium intake.
    • Calcium intake recommendation for adults ≥ 50 years: 500-700 mg (elemental) daily, divided into 2-3 doses.

    Calcium Supplements

    • Citrate is the preferred calcium supplement over Carbonate when taking with a PPI.
    • Vitamin D is necessary for calcium absorption.

    Vitamin D

    • Recommended daily intake of Vitamin D: 600-800 IU for prevention.
    • Vitamin D3 (cholecalciferol) is the most commonly recommended source, available OTC, and sourced from animal products.

    Vitamin D Deficiency Treatment

    • Dosing for Vitamin D deficiency: individualized based on baseline labs; deficient patients have levels < 29 ng/mL.

    Pharmaceutical Treatment of Osteoporosis

    • Qualifications for pharmaceutical treatment: high-risk patients, those with a T-score ≤ -2.5, or those who have experienced a fracture.
    • Contraindications for Bisphosphonates: hypocalcemia, abnormal renal function, esophageal achalasia, and inability to sit upright.

    Bisphosphonates Administration

    • Bisphosphonates must be taken first thing in the morning, on an empty stomach, while sitting upright.
    • Rare adverse reactions: esophageal ulcers, osteonecrosis of the jaw, and atrial fibrillation.

    Bisphosphonate Holiday

    • Patients with moderate risk (T-score > -2.5, no fractures) should take a Bisphosphonate holiday after 5 years of treatment.

    Prolia (Denosumab)

    • Not a contraindication: hypocalcemia.
    • Most common adverse effect: skin reactions.
    • Administered as a subQ injection every 6 months.

    Alternative Agents

    • Second-line options for osteoporosis: teriparatide, romosozumab, and abaloparatide.
    • Adjunct medication for maintaining BMD gains: teriparatide (subQ).
    • Alternative therapies for high-risk patients: romosozumab, abaloparatide, and hormone therapy.

    Bisphosphonate Acute Phase Reactions

    • Pre-treat with acetaminophen or corticosteroids to prevent acute phase IV reactions.

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    Description

    Test your knowledge on medications that are linked to bone loss including Glucocorticoids, phenytoin, carbamazepine, Depo-medroxyprogesterone, and PPI. See how well you understand the impact of these medications on bone health.

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