Osteoporosis Weight Problems

1. Osteoporosis Weight Problems

2. You'll hear lots of buzz about Brilinta, a new antiplatelet drug. Brilinta (ticagrelor) will compete with Plavix (clopidogrel) and Effient(prasugrel)...for acute coronary syndrome or after a stent. Plavix will still lead the pack...for a while. It was the first one approved and is used the most. But it's not perfect. Plavix has a delayed onset and variable response...because it has to be activated by cytochrome P450 enzymes in the liver. Effient is more effective than Plavix...but causes more bleeding. That's why it's not for patients with a prior stroke or TIA, or over 75. Brilinta seems to be more effective than Plavix for acute coronary syndrome...and usually doesn't cause any more major bleeding.    For every 1000 patients with acute coronary syndrome treated for a year, Brilintaprevents 11 more CV deaths, 11 more MIs, and at least 6 more stent thromboses compared to Plavix.    But these stats are affected by the dose of aspirin that is used with Brilinta.    Aspirin over 100 mg/day makes Brilinta LESS effective. Watch that patients onBrilinta take only 81 mg/day of aspirin. Brilinta has a faster onset than Plavix or Effient...because it's not a prodrug. It also wears off faster because it binds to platelets REVERSIBLY...instead of permanently like Plavix and Effient.    You'll hear this fast offset is an advantage in case a patient needs CABG or other surgery. But both Brilinta and Plavix should be stopped 5 days before surgery...andEffient at least 7 days beforehand. Brilinta's short duration may be a disadvantage in the long run because it has to be taken twice a day...instead of once like the others.    Expect to see Plavix's price drop when the generic comes out next year. If you thought that there was already a generic Plavix, good memory. There WAS. But it got withdrawn...and will soon return.    If a patient is on Brilinta, avoid using strong 3A4 inhibitors or inducers...clarithromycin, ketoconazole, rifampin, etc.    Don't exceed 40 mg/day for simvastatin or lovastatin...and monitor digoxin levels when starting or stopping Brilinta.    Keep in mind that Brilinta can cause dyspnea...especially the first week. Consider switching to Plavix or Effient if needed.

3. A.It's less effective than clopidogrel for acute coronary syndrome. B.It should be used with 81 mg/day of aspirin. C.It can be stopped just 2 days before surgery. D.It's an irreversible platelet inhibitor.

4. Answer • B. It should be used with 81 mg/day of aspirin.

5. You'll see a new ORAL anticoagulant called Xarelto (zuh-REL-toe).    It's initially approved to prevent thrombosis after hip or knee replacement surgery. It'll also likely be approved to prevent stroke in patients with atrial fibrillation. Xarelto (rivaroxaban) is the first ORAL factor Xa inhibitor.    It has a fast onset and doesn't need coagulation monitoring. Xarelto is more effective than enoxaparin 40 mg once daily after knee replacement. One more major blood clot is prevented for every 62 patients treated with Xarelto...with a similar bleeding risk. Xarelto also costs about $8 a day...compared to $25 to $50 a day for generic enoxaparin.    Patients will take Xarelto 10 mg once daily for 35 days after a hip replacement...or for 12 days after knee replacement surgery.    Watch for drug interactions when patients are on Xarelto.    Don't combine it with drugs that significantly DECREASE CYP3A4 and p-glycoprotein elimination, such as ketoconazole or ritonavir.    Also try not to combine Xarelto with drugs that INCREASE its elimination, such as phenytoin, carbamazepine, and rifampin. If the combo is unavoidable, increase the dose to Xarelto 20 mg/day.    Don't give Xarelto to patients with severe renal impairment...or moderate to severe hepatic impairment.

6.   Reps will promote Staxyn (STAX-in), a new orally disintegrating tablet version of vardenafil (Levitra).    Think of it as the same as Levitra. The new formula gives it a new marketing angle...but no significant clinical advantage.    You may hear it works faster than Levitra...but it doesn't.    Orally disintegrating tabs dissolve in the mouth...but they're still swallowed and primarily absorbed in the GI tract like oral meds. This also means that these tabs DON'T avoid the first-pass effect.    One advantage is that Staxyn costs less.    It costs about $14/tab...compared to $19 for Levitra.    Tell patients to take Staxyn an hour before sexual activity...just like with Levitra.

7.  VITAMIN B12Is it ever necessary to give vitamin B12 by injection?    Only rarely.    This is being brought up now by the recent shortage of injectable B12 (cyanocobalamin) due to manufacturing delays.    Many patients have trouble absorbing B12 from food due to reduced gastric acidity or lack of intrinsic factor.    We used to think that these patients needed B12 by injection...but in many cases supplements can be given orally instead.    About 1% of the B12 in oral supplements is absorbed passively...even in patients without gastric acid or intrinsic factor.    Feel comfortable using ORAL B12 for treating mild to moderate deficiencies...or for maintenance therapy.    The key is to give enough. Recommend 1000 to 2000 mcg/day of oral or sublingual B12 for mild to moderate deficiencies.    Steer patients away from sustained-release B12 supplements...because their absorption might not be adequate.    Consider using B12 nasal spray (Nascobal) if another option is needed...but it costs much more than oral or injectable B12.    Continue to use injectable B12 for initial treatment of more severe deficiencies...especially if there are neurologic symptoms.    Also use the injectable for patients who can't take or adhere to oral meds...or those who may not absorb it due to diarrhea, vomiting, inflammatory bowel disease, or bowel resection. 

8.  POST-TRAUMATIC STRESS DISORDERNew VA guidelines for post-traumatic stress disorder discourage using benzodiazepines and encourage treating acute pain aggressively.    PTSD is a problem for about 13% of our returning war veterans. It also affects people after assaults, rapes, disasters, and other traumas. Psychotherapy and an SSRI or SNRI antidepressant are first-line.    If two trials of an SSRI or SNRI are not helpful, try switching to mirtazapine (Remeron, etc) and then a tricyclic.    Cautiously add other drugs if needed for specific symptoms...agitation, nightmares, insomnia, pain, etc. Atypical antipsychotics (risperidone, etc) can be added to an antidepressant to decrease hyperarousal and re-experiencing symptoms. But explain they DON'T seem to help when used alone. Prazosin can help reduce nightmares associated with PTSD.    Start with prazosin 1 mg at bedtime and slowly titrate to 6 to 10 mg if needed and tolerated. Caution about possible syncope. Benzodiazepines are often used for insomnia and anxiety...but try not to use them. There's no evidence they help core PTSD symptoms...and they may worsen fear response and slow recovery from trauma. They can also be very hard to discontinue due to withdrawal symptoms.    Use trazodone or a non-benzo hypnotic (zolpidem, etc) for sleep. Anticonvulsants (topiramate, etc) overall don't seem effective either as monotherapy or when used as adjuncts to other drugs. Analgesics should be used aggressively for acute pain due to traumatic injuries. Explain that adequately treating pain may reduce the risk of developing PTSD.    But follow the usual precautions to limit opioid abuse...especially if they are used chronically. Propranolol seemed promising for lessening the memory of traumatic events. But don't count on it...the latest evidence suggests it's not effective for preventing PTSD.

9. SMOKING CESSATION   People will worry about new warnings about Chantix and an increased risk of cardiac events in patients with heart disease.    FDA says there MIGHT be a higher risk...but this is controversial. Any cardiac risk is likely to be small...if it exists at all.    Continue to prescribe Chantix (varenicline) when appropriate. Chantix is more effective than other monotherapies for smoking cessation...and FAR less dangerous than continuing to smoke.    Patients with heart disease who stop smoking lower their risk of death by 36% within 3 to 7 years.    Continue to advise Chantix patients to report serious psychiatric effects...but keep in mind that some psych problems get attributed to Chantix when they're really due to nicotine withdrawal.    Use nicotine replacement therapy or bupropion (Zyban, etc) for patients who don't tolerate Chantix.    If monotherapy isn't enough, try combining nicotine replacement therapies. Combining the patch plus gum or nasal spray can work at least as well as Chantixto help people quit smoking.    Here's a neat new opportunity for you: You can listen to a brief audio snippet of our staff discussing/debating this with our experts during one of our working sessions.

10. A.Varenicline (Chantix) is less effective than other smoking cessation therapies. B.Combining a nicotine patch and gum can work as well as varenicline. C.Nicotine replacement should never be combined with varenicline. D.Varenicline increases cardiac risk more than smoking.

11. Answer • B. Combining a nicotine patch and gum can work as well as varenicline.

12. A patient with a T score of -1.5 based on dual-energy x-ray absorptiometry (DEXA) at the spine and hip is classified as having: A) Normal bone mass B) Low bone mass C) Osteoporosis D) Severe osteoporosis

13. Answer • B) Low bone mass

14. The Fracture Risk Assessment Tool is not validated for which of the following? A) Femoral neck bone mineral density (BMD) B) Total hip BMD C) Spine BMD D) Use in patients who have never taken pharmacotherapy for osteoporosis

15. Answer •  C) Spine BMD

16. According to the American Society for Bone and Mineral Research: A) Numerous large studies show increased risk for cardiovascular events associated with calcium and vitamin D supplementation B) Calcium supplements should be taken by all patients >65 yr of age, regardless of dietary calcium intake C) Most recent osteoporosis treatment studies suggest adequate vitamin D required for efficacy of antifracture therapy D) Calcium supplements recommended only for patients with T score <-1.5

17. Answer •  C) Most recent osteoporosis treatment studies suggest adequate vitamin D required for efficacy of antifracture therapy

18. Choose the correct statement about atypical subtrochanteric and diaphyseal femoral fractures. A) Use of bisphosphonates most common cause B) Usually due to serious trauma C) No risk associated with glucocorticoids or proton pump inhibitors D) Observational data suggest risk after 9 yr of treatment similar to that of stopping treatment after 3 mo

19. Answer • D) Observational data suggest risk after 9 yr of treatment similar to that of stopping treatment after 3 mo

20. Which of the following agents used to treat osteoporosis may be associated with increased risk for serious infections of the skin, abdomen, urinary tract, or ear? A) Denosumab B) Raloxifene C) Teriparatide D) Alendronate

21. Answer •  A) Denosumab

22. Reductions in BMD on serial testing in patients on pharmacotherapy is the best predictor of fracture risk. A) True B) False

23. Answer •  B) False

24. Use of estrogen plus progestin for the treatment of menopausal symptoms is associated with increased risk for: A) Breast cancer B) Stroke C) Kidney stones D) All the above

25. Answer • D) All the above

26. A study found all the following were associated with improvements in hot flushes, except: A) Physical activity B) Weight loss C) Decrease in body mass index D) Decrease in abdominal circumference

27. Answer • A) Physical activity

28. Choose the correct statement about the treatment of vaginal dryness. A) Usually resolves over time with no treatment B) Regular use of lubricants more effective than as-needed use C) Systemic hormone therapies more effective than local hormone therapies D) Can be treated with transdermal testosterone

29. Answer •  B) Regular use of lubricants more effective than as-needed use

30. The United States Preventive Services Task Force recommends screening all adults for obesity. A) True B) False

31. Answer • A) True

32. All the following are required for a diagnosis of metabolic syndrome, except: A) Patient on medication for low high-density lipoprotein B) Waistline ≥30 in C) High blood pressure D) High fasting blood sugar

33. The IDF consensus worldwide definition of the metabolic syndrome (2006)Central obesity (defined as waist circumference# with ethnicity specific values)AND any two of the following:Raised triglycerides: > 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality.Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormalityRaised blood pressure: systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension.Raised fasting plasma glucose :(FPG)>100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes. If FPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tolerance test is strongly recommended but is not necessary to define presence of the Syndrome.# If BMI is >30 kg/m², central obesity can be assumed and waist circumference does not need to be measured

34. NCEPThe US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:[5]central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 36 inches(female)dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dl)dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)blood pressure ≥ 130/85 mmHgfasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)

35. Answer • B) Waistline ≥30 in

36. Body mass index (BMI) is often _______ in muscular patients and _______ in elderly patients. A) Underestimated; overestimated B) Overestimated; underestimated

37. Answer •  B) Overestimated; underestimated

38. Tools for enabling weight loss include: A) 24-hour dietary recall B) Increase in fiber intake to ≥25 g per day C) Exercise prescription D) All the above

39. Answer • D) All the above

40. Identify the incorrect statement about the 24-hr dietary recall. A) Done at every visit of patient being treated for hypertension, diabetes, or other weight-related problem B) Patient reports food intake from day immediately preceding visit C) Takes about 15 min D) Physician should look for patterns

41. Answer • C) Takes about 15 min

42. The prevalence of overweight adults is 10% higher in the United States than in other countries. A) True B) False

43. Answer •  B) False

44. According to the most recent National Institutes of Health guidelines (1991), obesity surgery is indicated in patients with which of the following? A) BMI >40 or BMI >35 and comorbid illness B) History of failed sustained weight loss on supervised weight-reduction program(s) C) No substance abuse, psychoses, or uncontrolled depression D) All the above

45. Answer • D) All the above

46. Which procedure produces a more rapid weight loss in the first 6 mo postprocedure? A) Gastric band B) Gastric bypass

47. Answer •  B) Gastric bypass

48. Gastric bypass has been shown to resolve diabetes in _______ of patients? A) 10% B) 25% C) 50% D) >85%

49. Answer •  D) >85%

50. Which of the following is key for successful bariatric surgery? A) Patient age <50 yr B) Absence of comorbidities C) Performance in centers with high volume of bariatric surgery D) Use of the gastric band