nurse exam - bone and joint disorders

calcium is what % of our body weight

2

Calcium has essential functions in the

nervous, muscular, andcardiovascular systems

Homeostasis of calcium is maintained by the

thyroid (via calcitonin) and parathyroid glands

Osteoclasts cells are stimulated by

parathyroid hormone (PTH)

osteoclast function

demineralize bone (resorption)

osteoblast cells are stimulated by

calcitonin

osteoblast function

serum calcium is used to build bones (deposition)

Vitamin D

promotes absorption of calcium

Cholecalciferol (inactive) is produced in

the skin from cholesterol and sunlight or is ingested through calcium containing foods.

what converts cholecalciferol to calcifediol

liver

what converts calcifediol to calcitriol (active) via the influence of PTH

kidneys

Active vitamin D and PTH stimulate

calcium absorption through the GI tract

Normal serum levels of calcium are

~8-10 mg/dL

Hypocalcemia (< 8 mg/dL) maybe caused by:

1.Lack of calcium in the diet.
2. Excessive vomiting/malabsorption GI disorders.
3. Chronic kidney disease
4. Decreased secretion of PTH.
5. Blood transfusion/use of anticonvulsants (phenytoin) or overtreatment with drugs which
decrease serum calcium (furosemide, phosphates, bisphosphonates, and corticosteroids

what causes muscle and nerve excitability

hypocalcemia

what exists in oral and intravenous forms as either acetate, carbonate, chloride, gluconate, lactate, and phosphate

calcium

Common Side Effects of hypocalcemia

N&V, constipation, metallic taste

Serious Adverse Events of hypocalcemia

hypercalcemia, cardiac dysrhythmia, renal stones, confusion, coma-
occurs with IV calcium preparations.

what exists in oral and intravenous forms as well as calcitriol and ergocalciferol

vitamin D

overdoses are associated with?

HYPERcalcemia

Metabolic Bone Diseases

These disorders are caused by abnormal amounts of minerals or hormones needed for calcium homeostasis.

metabolic bone disorders include

osteomalacia, Paget’s disease, and osteoporosis

what disorders may have a genetic etiology but are more commonly associated with certain medications.

metabolic bone diseases

Osteomalacia

softening of the bones due to inadequate dietary vitamin D and calcium

In children, osteomalacia is called

rickets

treatments for osteomalacia

supplements

Paget’s disease

chronic disorder which leads to softening of bones.

what is characterized by accelerated and simultaneous bone resorption and deposition

pagets diseases

what is the most common metabolic bone disorder.

osteoporosis

Risk factors for osteoporosis include

1.Menopause
2. Increasing age
3. Family history of osteoporosis or personal history of fracture
4. Alcohol-> 2 drinks/day women; > 4 drinks/day men
5. Caucasian or Asian race
6. Smoking
7. Sedentary lifestyle/immobility
8. Estrogen/androgen deficiency
9. Low intake vitamin D and calcium
10. Medications

what medications cause risk factors for osteoporosis

corticosteroids, seizure medications, immunosuppressants

DEXA scans are used to diagnose

osteoporosis

DEXA

This exam uses traditional x-ray technology. Dual Energy X-ray Absorptiometry

Central DEXA measures

BMD in the spine or hip.

Quantification of osteoporosis by

measurement of bone mineral density (BMD)

how are DEXA results reported

as T and X score

T - DEXA score

score shows the amount of bone compared with that of a young adult of the same sex with peak bone mass.

DEXA score about -1 is

normal

DEXA score of -1 to -2.5 indicates

osteopenia

Z - DEXA score

reflects the amount of bone compared with an age-matched group.

The underlying mechanism of osteoporosis

bone resorption > bone deposition

Medications for osteoporosis include

1. Bisphosphonates
2. Hormone replacement therapy for menopausal women
3. Calcitonin
4. Others include denosumab (Prolia), raloxifene (Evista), teriparatide (Forteo)

any patient with osteoporosis needs to supplement calcium with

vitamin D

drugs in bisphosphonate class

lendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and
zoledronic acid (Reclast/Zometa).

-dronate drugs are apart of which drug class

bisphosphonates

Common Side Effects of bisphosphonates

nausea, heartburn, diarrhea, bone, and back pain

Severe Adverse Events of bisphosphonates include

atypical bone fractures, nephrotoxicity, hypocalcemia, UGI
ulceration/perforation, osteonecrosis of the jaw, cardiac dysrhythmia

bisphosphonates are used for what condition

osteoporosis & Paget’s disease

calcitonin andminisered how

commonly prescribed as a nasal spray

common side effects of calcitonin

include runny nose, flushing face/hands

serious adverse events for calcitonin

only anaphylaxis

Nasal septal perforation can occur with improper administration of what

calcitonin

what drug is an analog of the thyroid hormone.

calcitonin

Denosumab (Prolia) administered how

given as a SQ injection

common side effects of denosumab

include fatigue, elevated cholesterol, hypophosphatemia, MUSCOSKELETAL PAIN

serious adverse events of denosumab

hypocalcemia, increased risk of infection, osteonecrosis of the jaw

Raloxifene

selective estrogen receptor modulator for osteoporosis

raloxifene function

blocks estrogen receptors in the breast and uterus but decreases bone resorption

common side effects of raloxifene

hot flashes

serious adverse events of raloxifene

breast pain and vaginal bleeding.

Teriparatide (Forteo)

a PTH analog; given as a SQ injection for osteoporosis

common side effects of teriparatide

dizziness, depression, insomnia, arthralgias

Serious adverse events of teriparatide

syncope, increased risk osteosarcoma (Black Box Warning).

what osteoporosis drug has a black box warning

teriparatide

what osteoporosis drug is a monoclonal antibody

denosumab

common joint disorder

osteoarthritis

rheumatoid arthritis

gout

Osteoarthritis

the progressive breakdown of articular cartilage

Rheumatoid arthritis

a chronic, progressive inflammatory disorder (autoimmune). Usually
involves multiple joints and produces systemic manifestations

Gout

an arthritis caused by the accumulation of uric acid in the joints.

increased uric acid occurs with

increased metabolism of nucleic acids or decreased renal excretion.

which type of gout is hereditary

primary gout

which gout is due to medications (thiazide diuretics, ASA, cyclosporine, chronic alcohol) or other underlying disorders (DKA, renal failure, leukemias, hemolytic anemia)

secondary gout

First-line treatments for osteoarthritis

exercise, acetaminophen, NSAIDs (topical/oral), heat/ice

moderate to severe symptoms of osteoarthritis are treated with

joint injections of sodium hyaluronate or corticosteroids

severe symptoms of osteoarthritis are treated with

joint replacement surgery

Rheumatoid Arthritis is frequently treated with which medication

Anti-inflammatory medications (NSAIDs, corticosteroids)

other rheumatoid arthritis medications

nonbiological DMARDs

Biologic DMARDs (TNF antagonist)

biologic DMARDs (non-TNF antagonist)

Nonbiologic DMARDs for rheumatoid arthritis

azathioprine, hydroxychloroquine, Methotrexate, Sulfasalazine

Biologic DMARDs (TNF antagonists) for rheumatoid arthritis

adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade)

Biologic DMARDs (non-TNF antagonist) for rheumatoid arthritis

abatacept (Orencia), rituximab (Rituxan), tofacitinib (Xeljanz)

Gout what is the preferred drugs for the treatment of gout

NSAIDS (indomethacin, naproxen), corticosteroids may also be used

what drugs also used for GOUT but due to GI side effects and the potential for serious adverse events they aren’t used as much

colchicine

probenecid drug for chronic gout and prophylaxis function

increase the renal excretion of uric acid (uricosuric)

drugs for chronic gout and prophylaxis

allopurinol and febuxostat (uloric)

probenecid

allopurinol and febuxostat drugs for chronic gout and prophylaxis function

inhibit the formation of uric acid

function of enzymes created with recombinant DNA technology (to treat chronic gout and prophylaxis)

convert uric acid to a less toxic form

what is recommended for patients with gout

Avoidance of gout inducing drugs, control of blood sugar, and a low purine diet