PC 1: Osteoporosis Questions

Which of the following statements is correct about the epidemiology of osteoporosis?

a. The disease affects women and men equally.

b. Vertebral fractures are the most prevalent and the largest component of osteoporosis healthcare expenditures.

c. The disease affects all race and ethnic groups equally.

d. Adults with low bone density also experience osteoporotic fractures.

d. Adults with low bone density also experience osteoporotic fractures. - 43 million adults have low bone mass. In one study, 5.3% of adults with low bone mass had osteoporotic fractures, just a bit lower than the percentage of those with osteoporosis having a fracture (6.896). Women have a higher incidence of osteoporosis; however, mortality after a hip fracture is greater in men. Non-Hispanic White and Mexican American women have more osteoporosis and osteoporotic fractures than non-Hispanic Black women. Hip fractures consume the greatest amount of osteoporosis healthcare expenditures.

Which statement is true about bone physiology and pathophysiology?

a. Osteoblasts secrete osteoprotegerin that binds to immature and mature osteoclasts to cause bone resorption.

b. Bone loss due to menopause is predominantly from increasing bone resorption.

c. Parathyroid hormone prevents RANKL from binding to the Wnt signaling pathway.

d. Sclerostin binds to RANKL and thereby stops bone formation.

b. Bone loss due to menopause is predominantly from increasing bone resorption. - Bone loss due to menopause is predominantly due to increased bone resorption from increased RANKL and decreased osteoprotegerin. Osteoblasts control bone resorption by producing RANKL that works to increase maturation of osteoclasts and also increase their actions on bone. They also secrete osteoprotegerin that binds to RANKL to stop bone resorption. Parathyroid hormone stimulates Wnt activity to increase bone formation. Sclerostin inhibits bone formation by binding to LRP 5/6.

Which statement is correct about calcium and vitamin D homeostasis?

a. Calcium undergoes predominantly a passive absorption process from the stomach to achieve the serum calcium concentration.

b. Vitamin D increases calcium absorption from the small intestine.

c. Vitamin D is converted to 25(OH) vitamin D in the kidneys.

d. Guidelines consider 25(OH) vitamin D concentrations less than 50 ng/mL (mcg/L; 125 nmol/L) to be deficient.

b. Vitamin D increases calcium absorption from the small intestine. - Calcium absorption is an active process requiring 1,25(OH) vitamin D, and occurs in the duodenum and jejunum. Vitamin D is converted to25(OH) vitamin D in the liver and to 1,25(OH) vitamin D in the kidneys. 25(OH) vitamin D concentrations greater than 30 ng/mL (mcg/L; 75 nmol/L.)are usually considered in the normal range, insufficiency is usually described as 20 to 30 ng/mL (mcg/L; 50-75 nmol/L), and deficiency is usually described as less than 20 ng/mL (mcg/L; 50 nmol/L). Certain laboratories can have different cut off points, for example, deficiency less than 13 ng/mL (mcg/L; 32 mol/L).

The FRAX tool can be used to calculate fracture risk in which of the below patients to determine whether osteoporosis therapy is needed or should be continued?

a. A 68-year-old postmenopausal woman with a T-score of -2.1 at the femoral neck.

b. A 72-year-old woman currently receiving denosumab.

c. A 70-year-old man with a T-score of -2.7 at the femoral neck.

d. A 58-year-old woman with a 3-year history of osteoporosis secondary to glucocorticoid therapy.

e. A 66-year-old woman with a low-trauma vertebral fracture on abaloparatide.

a. A 68-year-old postmenopausal woman with a T-score of -2.1 at the femoral neck. - Per US guidelines and practices, FRAX should be used to calculate fracture risk in patients with low bone mass (T-score between - 1 and -2.5) to determine if prescription osteoporosis medications are needed. FRAX should not be used for patients on current therapy, who already have osteoporosis diagnosed or if a patient has had a low-trauma fracture.

A 65-year-old woman with osteoporosis has adjusted her diet but cannot achieve the recommended daily calcium intake. She has hypertension and hypercholesteremia. Her daily medications include alendronate, amlodipine, and atorvastatin. Her current dietary calcium intake is approximately 700 mg daily. Which of the following calcium supplement regimens is the BEST recommendation? Note doses listed represent elemental calcium content.

a. Calcium carbonate 500 mg daily

b. Calcium carbonate 1,200 mg daily in divided doses

c. Calcium citrate 250 mg twice daily

d. Calcium citrate 1,200 mg daily in divided doses

a. Calcium carbonate 500 mg daily - The goal for a woman this age is 1,200 mg of calcium per day. She is receiving 700 mg through her diet, which leaves a need for 500 mg daily from supplements. This patient is not taking any acid-suppression therapy where calcium citrate would be the preferred salt since it does not require acid tor absorption. The calcium citrate option here is also twice a day, increasing medication burden. Calcium carbonate is inexpensive and has a higher percentage of elemental calcium.

A 66-year-old woman with osteoporosis asks for recommendations for calcium and vitamin D daily intakes. According to the American Association of Clinical Endocrinology guidelines, which daily calcium and vitamin D intake would you recommend she achieve through diet and/or supplements?

a. Calcium 1,000 mg and vitamin D 600 units

b. Calcium 1,000 mg and vitamin D 800 units

c. Calcium 1,200 mg and vitamin D 600 units

d. Calcium 1,200 mg and vitamin D 1,000 units

e. Calcium 1,500 mg and vitamin D 2,000 units

d. Calcium 1,200 mg and vitamin D 1,000 units - Calcium goals are different between men and women 51 to 70 years old. For this woman, 1,200 mg elemental calcium would be recommended.The American Association of Clinical Endocrinologists recommends 1,000 to 2,000 units of vitamin D for patients with osteoporosis or at high risk for osteoporosis, which would include all older adults. The National Osteoporosis Foundation recommends 800 to 1,000 units of vitamin D daily and the Institute of Medicine recommends 600 units daily for this age group.

In which of the following postmenopausal women should bisphosphonate therapy be recommended? A postmenopausal woman with a

a. T-score lumbar spine -0.9

b. T-score lumbar spine -2.1, T-score femoral neck -1.9, and 10-year probability of major osteoporotic fracture of 12%6

c. T-score lumbar spine of -2.3 and 10-year probability of hip fracture of 3.2%

d. T-score femoral neck of -2.3 and 10-year probability of major osteoporotic fracture of 1896

c. T-score lumbar spine of -2.3 and 10-year probability of hip fracture of 3.2% - Therapy for osteoporosis is indicated for those with a low-trauma fracture, a T-score <-2.5, or low bone mass (T-score between -1 and -2.5) and a 10-year risk of major osteoporotic fracture of greater than or equal to 20% or hip fracture of greater than or equal to 396.

Which oral medication is a first-line therapy option for osteoporosis in a postmenopausal woman with high fracture risk?

a. Romosozumas

b. Alendronate

c. Ibandronate

d. Raloxifene

b. Alendronate - Medications recommended first line for treatment of osteoporosis with high fracture risk are those that reduce the risk of hip fracture. These medications include alendronate, risedronate, zoledronic acid, and denosumab. Alendronate and risedronate are orally available medications.The other medications might be used if high risk for breast cancer (raloxifene) or very high fracture risk (romosozumab). Ibandronate does not have hip fracture prevention data.

A patient with osteoporosis is being treated with alendronate to prevent hip and spine fractures. What is the minimum timeframe alendronate should be continued before considering a drug holiday for a patient with high fracture risk?

a. 1 year

b. 3 years

c. 5 years

d. 6 years

c. 5 years - Drug holidays are used only for bisphosphonate medications because they reside in bone for long durations after discontinuation and have some activity. For the other medication classes, bone effects begin to return to baseline after discontinuation. The minimum time at which a drug holiday from oral bisphosphonates can be considered is after 5 years of therapy. The minimum time at which a drug holiday from zoledronic acid is considered is after 3 years of therapy. The fracture risk of the patient will be considered (longer treatment durations for patients at very high risk of fracture, such as those on zoledronic acid for 6 years).

Which instruction for administration should be given to a patient on delayed release risedronate?

a. Take after breakfast

b. Remain upright for at least 60 minutes after taking

c. Take with at least 4-8 ounces (120-240 mL) of water

d. May take together with your multivitamin tablet

a. Take after breakfast - Delayed-release risedronate is the only oral bisphosphonate that can be taken after food (breakfast). Alendronate, regular release risedronate, and ibandronate need to be taken 30 minutes before breakfast. All oral bisphosphonates should be ingested with 6 to 8 ounces (180-240 mL) of water only (oral delayed-release risedronate can be taken with 4 ounces (120 mL). Patients need to remain upright for at least 30 minutes (60 minutes for ibandronate) to prevent oral bisphosphonate gastrointestinal adverse effects. Oral bisphosphonates have minimal absorption <1%, so they should not be taken with any other medications or supplements nor with any foods or beverages except plain water.

A health professional identifies a 70-year-old postmenopausal woman who has not refilled her risedronate prescription for the last 6 months. The practitioner discusses her adherence with her. She responds that she is concerned about osteonecrosis of the jaw (ONJ). What is the health professional's BEST response?

a. ONJ is only associated with intravenous bisphosphonate medications.

b. ONJ only happens in patients with cancer taking high-dose bisphosphonates.

c. Because of the risk of ONJ, the healthcare team will consider changing your risedronate to denosumab.

d. ONJ is rare with this medication. You are more likely to have a hip fracture.

d. ONJ is rare with this medication. You are more likely to have a hip fracture. - Osteonecrosis of the jaw (ONJ) is a rare adverse effect seen with oral and intravenous bisphosphonates, denosumab, and romosozumab but not with raloxifene and conjugated equine estrogens with bazedoxifene. In osteoporosis, the incidence is 0.0019 to 0.01%. The incidence is higher with larger doses of intravenous bisphosphonates used in cancer patients (also increased from radiation and glucocorticoid therapy use) but can occur with lower oral and injectable doses for osteoporosis. Denosumab can prevent hip fractures but does have ONJ as a rare adverse effect. She might have problems with insurance coverage for denosumab, which could be explored. The magnitude of the risk of ONJ and the benefit of therapy should be conveyed to the patient to determine if it alleviates her concerns. You can use an osteoporosis decision aid to help her understand the risks.

A 53-year-old postmenopausal woman is in the community pharmacy participating in an osteoporosis health fair. The pharmacist calculates her FRAX scores and finds she has a 1.296 risk for hip fracture and a 14% risk for any osteoporotic fracture. She has a strong family history of breast cancer. What should the pharmacist recommend?

a. Practice a bone-healthy lifestyle and get a central DXA when your hip fracture FRAX score is greater than 396 or your major osteoporotic fracture risk is greater than 20%.

b. Since you have osteoporosis, schedule a visit with your healthcare provider to get an osteoporosis prevention medication ordered.

c. Ask your healthcare provider for a central DXA, and if you have only spine but not hip osteoporosis, raloxifene could be a good medication for you.

d. Get a central DXA in 5 years since you don't have osteoporosis.

c. Ask your healthcare provider for a central DXA, and if you have only spine but not hip osteoporosis, raloxifene could be a good medication for you. - C. A FRAX major osteoporotic fracture risk score greater than 8.496 for a postmenopausal woman under 65 years old should get a central DXA.Younger postmenopausal women are at greater risk for a vertebral fracture. With her family history of breast cancer, she could be a candidate for raloxifene as long as she does not have osteoporosis at the hip. Since her FRAX suggests a DXA, she should not wait for 5 years. With normal FRAX scores (<8.496) and no other risks, getting a repeat DXA in 5 years could be acceptable. FRAX scores are screening data. Central DXA would be needed for a diagnosis. Practicing a bone healthy lifestyle is good for everyone including this woman, but she needs to get a DXA now.

A 70-year-old man with symptomatic hypogonadism is diagnosed with osteoporosis. He is at high risk for hip fracture. Which of the following is the BEST initial treatment?

a. Risedronate and testosterone

b. Ibandronate and testosterone

c. Alendronate alone

d. Ibandronate alone

e. Testosterone alone

a. Risedronate and testosterone - If a man has both symptomatic hypogonadism and osteoporosis with a high risk of fracture, he would be prescribed both testosterone and a first line osteoporosis medication, one of the infrequent times combination therapy is advocated. The provider might start one medication first to check for tolerance and then add the next medication. Testosterone has a positive effect on bone but is generally insufficient alone to prevent osteoporosis and osteoporotic fractures. An older man has a high risk for hip fracture, requiring a first-line medication such as alendronate, risedronate, zoledronic acid, and denosumab. Ibandonate does not decrease hip fracture risk.

A 38-year-old premenopausal woman with a 15-year history of inflammatory bowel disease for which she takes prednisone 7.5 mg daily is in clinic today to discuss her DXA results. Her Z-scores are lumbar spine - 2.8 and femoral neck (right) -2.6. Besides a bone health lifestyle, what would you recommend/do today?

a. All osteoporosis medications are contraindicated, so she should add daily running to her bone healthy lifestyle.

b. Data support denosumab but not bisphosphonates to prevent fractures in premenopausal women. Denosumab has no fetal toxicity risks.

c. Add calcium and vitamin D supplements to achieve adequate intakes to prevent bone loss. They are safe during pregnancy.

d. If she uses birth control, she could start a bisphosphonate. No long-term effects exist for a future baby.

c. Add calcium and vitamin D supplements to achieve adequate intakes to prevent bone loss. They are safe during pregnancy. - This woman is categorized as low fracture risk since her Z-scores are above -3.0 and she hasn't had a fragility tracture. The American College of Rheumatology does not recommend any prescription therapy for patients on glucocorticoids with low fracture risk. Due to secondary causes or medications, premenopausal women can develop osteoporosis. Glucocorticoids are the medications that cause the most medication-induced osteoporosis. Bisphosphonates stay in bone for long durations and could have an impact on the fetus during pregnancy, so childbearing status needs to be determined and considered. If a woman does not become pregnant while on therapy and needs bone loss and fracture prevention, the benefit of a bisphosphonate or denosumab could be considered greater than the risk; however, the woman needs to be educated about all benefits, risks, and unknown tetal toxicities to make this decision about a future pregnancy. Data on osteoporosis medications for fracture prevention in children, and premenopausal and pregnant women are limited or nonexistent. Calcium and vitamin D are assumed safe during pregnancy. They have some effects on decreasing bone density. In premenopausal women, only the Z-score is evaluated and if <-2.0 she is labeled as bone mass below the expected range for age, not as having osteoporosis (unless she has had the required number of fragility fractures) per International Society of Bone Densitometry guidelines. The T-scores will be used with FRAX to determine her osteoporosis risk and medication choices. FRAX scores need to be increased by 1.15 for major osteoporotic fracture and by 1.2 for hip fracture for interpretation.

A 60-year-old woman is initiated on alendronate. She has been receiving prednisone for rheumatoid arthritis. She asks the pharmacist why her doctor started this medication. Your BEST answer is?

a. Because of your age but not due to your medications, the doctor prescribed alendronate to prevent postmenopausal osteoporosis.

b. The prednisone you are taking for arthritis causes bone loss and fractures that can be prevented with this medication. Bone loss also decreases with aging.

c. Your doctor should have prescribed romosozumab.

d. The osteoporosis medication is not needed.

b. The prednisone you are taking for arthritis causes bone loss and fractures that can be prevented with this medication. Bone loss also decreases with aging. - Glucacorticoids can cause cone loss, osteoporosis, and osteodorotic tractures and require osteoporosis medications to orevent theseconditions. Bisohosononates are used to orevent @lucocorticoid-induced bone loss. Bisonosphonates are also used to orevent costmenopausa.osteoporosis, so this medication would be used for both indications. lenparatide has evidence to nelo prevent osteoporosis while on glucocorticoids but no data exist yet for romosozumab.