bones

fosamax generic

alendronate

evista gen

Raloxifene

is this calcitonin or calcitriol?

is this calcitonin or calcitriol? lowers blood calcium

calcitonin

• triol increases blood Ca

is this calcitonin or calcitriol? activated in kidneys to increase absorption of Ca; also increases absorption of phosphate

calcitriol

is this calcitonin or calcitriol? released by thyroid; a hormone, stops osteoclasts

calcitonin (“tones down Ca”)

Boniva gen

Ibandronate

Risedronate gen

Actonel

which of the four meds on teh chart is NOT a bisphosphonate

raloxifene (evista)

what are the things people do to prevent osteoporosis

ca2+, vit D supplements, wt bearing exercise

how much of bone is “inorg” and what ions

75%— Ca, PO4

how much of bone is “org” ie cells? what main two cells

osteoblasts, osteoclasts

what can hypocalcemia cause

tetany, weakness

what can hypercalcemia cause

coma, HA, bone pain, muscle cramps

what do osteoclasts do ? what ARE they?

mutlinucleated cells derived from monocytes, help reabsorb material from bones

what do osteoblasts do

bone FORMATION, from mesenchymal stem cells

what is the mature osteoblast in bones that coordinates remodelling

osteocyte

how are kdineys related to ca/po4/vit d

reabsorb or excrete

effect of vit D on calcium

body uses to incream die3tary Ca into bloodstream

what is pth ? + or - feedback

parathyroid hormone

• negative feedback

when Ca is low what happens to PTH

parathyroid releases more PTH

how does PTH raise Ca levels

• bones— release more stores into blood

• kidneys == stop kidneys form losing Ca in urine; activate vit D

• intestines— absorb more Ca from food

what increaes osteoclast formation (signalling wise)

RANKL

Osteoprotegerin is the OPPOSITE to bind up RANK so RANKL can’t bind

good range for Ca

9-10

good range for PO4

2-4

max for Ca

55

(dont ask me man)

what can cause elevated Ca

vit D tox, malgnancies, hyperparathyroidism

other regulators of Ca?

calcitonin, thyroid, estrogen

what does calcitonin do

decreases slightly blood Ca and PO4 by inhibiting osteoclasts

what is elevated in CKD

phosphateee

what can cause decreased Ca

MAYBE CKD, malabsorption, hypoparathyroidism

what is primary hyperPTHism

• PTH high

• Ca high

• phos low

phosate is wasted from excess bone release

what is secondary hyperPTHism

• due to CKD

• PTH high

• Ca low

• Phos high

kidneys are retaining the phosphate

what happens in hypoPTH? causes?

less calcium and more phosphate

causes include neck surgery, automimmune, radiation, mg deficiency; thyroid surgery bc its in the neck and can disrupt parathyroid glands

cause of primary hyperPTH

parathryoid gland overproducing

what is cause of secondary hyperPTH

the body has chronic Ca def so body has adjusted

what does bolus of PTH do and what for

hyperPTH bc anabolic

• builds bones bc stimualtes osteoblasts more

what does continuous PTH do and what for

for hypoPTH

• constant RANKL stimulation triggers osteoclasts

how does PTH actually cause bone reabsorption

actually binds RANKL on osteoblasts to make them differentiate to osteoclasts and reabsorb bone

tetany what is it what cause

muscle cramps/twitch from low calcium

is Ca higher or lower in teh cell

lower inside the cell

what does Ca do for the body

maintain resting membrane potential (voltage wise)— nerve AND smooth muscle

maintain cardiac function

involve in coagualtion processes and cell replication

major part of bones durp!

how much Ca in ca carbonate

40% elemental

ca carbonate counseling

take with food

ca phos mg amount of Ca

25%

ca citrate amount of Ca

21%

which Ca formulation is pref when gastric pH high, in PPI pts and the elderly

ca citrate (21%)

ca lactate ca amount

13%

ca gluconate % ca

18%

what are the three IV ca formulations

Ca-gluceptate, Ca-chloride, Ca-gluconate

what is pref IV for Ca

Ca-gluconate

ADRs for Ca (po and iv)

constipation, kidney stones, hypercalcemia, headache, bone pain, coma

ddi for Ca

iron, tetracycline, bisphosphonates, fluoroquinolones, phenytoin, fluoride

how long separate chelating agents from Ca

2 hours before or two hours after

which drug can cause Ca toxicity

digoxin

what are the phosphate binding agents

ca-based: ca acetate, ca carbonate

al based: al hydroxide

polymer absed: sevelamer carbonate, sevelamer HCl

what are phosphate binding agents used for

CKD — kidneys not able to excrete as much phosohate

main causes of CKD

damage to blood vessels of kidney— esp diabetes, HTN

can also be from drug injury

MOA of phos binding agents for CKD

bind the phos in the GI tract before it gets to kidneys

• complex is excreted fecally

• prevents NEW dietary phos from getting to kidneys

important counsel point for phos binders

must be taken with food bc only prevents absorption of new phos

how phos binders dosed

titrated to acheive goal serum phos (2-4 ish)

what vit is also a hormone

vit D

adr of Ca contianing phos binders (carbonate, acetate)

constipation, nausea, abdominal pain, hypercalcemia (

adr of Al containing phos binders (hydroxide)

constipation, CNS toxicity, worsening of anemia

(due to accumulation of AL). Avoid if possible

which type of phos binding agent should be avoided if possible

aluminum

adrs of mg contain phos binders

diarrhea, abdominal cramps, hyperkalemia

hypermagnesemia

adr containing Fe phos binders

nausea, dark/discolored feces, diarrhea,

bloating, abdominal pain, constipation

REVIST PHOS AGENTS TABLE

REVIST AHHHH

examples of inorganic phosphates

Sodium phosphate, Potassium phosphate (po or iv)

what is the one that directly increaes osteoblasts

PTH as a bolus

what inorg phospates for?

phos replace in hypophos

• AUD/malnutrition

• DKA

• renal phos wasting

  • prolonged antacid use

ind for inorg phosphates

severe hypophosphatemia, hypercalcemia

adrs of inorg phos

diarrhea, hypocalcemia, hypotension, ectopic calcification (calcium in soft tissue)

besides stimulating osteoclasts and kidney to reabsorb Ca what does PTN stimulate formution of

1,25 Vit D3

what is lowest ca

ca GLUCONATE per bennett

what do cancer cells do in regard to PTN that causes hypercalcemia

release protein that looks like PTH and owkrs on those receptors

what is the PTH drug gen

Teriparatide

what is the brand for Teriparatide (PTH)

Forteo

ind for PTH drug (Forteo or Teriparatide)

postmenopausal women and men with osteoporosis

how is PTH (Forteo or Teriparatide) administered

SC; stored in fridge

adrs for (Forteo or Teriparatide)— the PTH drug

dizziness, tachycardia, leg cramps, hypercalcemia, pain at site of injection,

increase Ca, increase uric acid, increase heart rate (with 1st dose), osteosarcoma, orthostatic hypotension

what are the two NEW PTH drugs taht are not (Forteo) Teriparatide

Abaloparatide (Tymlos®)-

Palopegteriparatide (Yorvipath)

what distinguishes Palopegteriparatide (Yorvipath) and Abaloparatide (Tymlos®)- the new PTH drugs

in regard to ind

chronic hypoparathyroidism is palo; aba is just for osteoporosis

what distinguishes Palopegteriparatide (Yorvipath) and Abaloparatide (Tymlos®)- the new PTH drugs

which is the slow acting/prodrug to give continuous release

Palopegteriparatide (Yorvipath)

Palopegteriparatide (Yorvipath)- adr s

MORE osteosarcoma (bone tumor), hypercalcemia or hypo, HA

Abaloparatide (Tymlos®) adr

hypercalciuria (too much CA into the urine), increased risk of teh cancer called osteosarcoma

what are the two iron cotnaing-phos-binders

ferric citrate

sucroferric oxyhydroxide

what does Yorvipath do

Continuous PTH exposure to replace deficient PTH in hypoparathyroidism.

what is 1.25 Vitamin D3 used for

what

what is the biologically active form of vitamin D

1,25-vitamin D₃

what is another name for calcitriol (the active form of vitamin D)

1,25-vitamin D₃

what does 1,25-vitamin D₃ do when there is available ca and phos

bones mineralized, PTH suppressed

1,25-vitamin D₃ moa

prmote absorption ofCa in GI and stimualtes kdiney to reasborb Ca

1,25-vitamin D₃ where are there vit D receptors

small intestine, hematopoietic cells, epidermal cells,

lymphocytes, pancreatic islets, neurons

where does vit D synth start

in the SKIN

where does conversion of Vit D2 to D3 ocur

liver

where does D3 get activated into 1,25-vitamin D₃

kidneysss

indications per slide for 1,25-vitamin D₃

rickets (lack of Ca in children so cannot grow) , osteomalacia, hypocalecmia, CKD, secondary hyperPTH

1,25-vitamin D₃ how long half life

22 hrs but laaasts in la fat for months

1,25-vitamin D₃ eliminat

fecal