Treatment of Osteoporosis

TREATMENT OF OSTEOPOROSIS

Q. 1

Decreased vitamin 0 [PGI May 00] 5. A 48 years old female suffering from severe men­orrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X – ray shows osteoporosis. The treatment of choice is 

 A

Progesterone

 B

Estrogen and progesterone

 C

Estrogen

 D

None

Q. 1

Decreased vitamin 0 [PGI May 00] 5. A 48 years old female suffering from severe men­orrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X – ray shows osteoporosis. The treatment of choice is 

 A

Progesterone

 B

Estrogen and progesterone

 C

Estrogen

 D

None

Ans. C

Explanation:

Ans. is c i.e Estrogen

Hormone Replacement Therapy for a oo.st – menopausal female can be in the form of

Estrogen Alone          Progesterone       Tibolone         Selective               Androgens Estrogen

Oestrogen                                       Receptor               Estrogens Modulator 

1. Estrogen Alone :

MC estrogen used : Conjugated equine oestrogen

Advantages           It decreases hot flushes°

  • Prevents osteoporosis°
  • Useful in senile vaginitis°
  • Useful in dyspareunia and urethral syndrome°

Disadvantage : Besides the risk of Coronary heart disease°. (as discussed earlier) it can cause Vaginal bleeding°, Endometrial hyperplasia° and Endometrial carcinoma° so, estrogens are combined with progestins in HRT so as to decrease the risk of Endometrial hyperplasia with Endometrial carcinoma.

Indications For the use of Estrogen Alone                                                                      

In woman who have undergone hysterectomy (other than that for Endometrial cancer)

Remember : All women who have intact uterus or even those who underwent hysterectomy for endometrial Cancer (Stage I), endometroid ovarian tumors or endometriosis or those with Severe osteoporosis should receive combined estrogen – progesterone therapy or be considered for selective estrogen receptor modulator therapy.

2. Estrogen + Progesterone

When HRT is to be given for a period more than 2-3 months, in woman with intact uterus progesterone should be given along with estrogen as progesterone is protective against Endometrial cancer.

In Perimenopausal females : low dose OCP should be given.

In Postmenopausal females : OCP’s Should not be used, as the amount of estrogen is higher in them than required.

In such cases oestrogen should be supplemented by progesterone for last 10-12 days of treatment. Most treatment regimes are on a cyclical 3 weeks out of 4 weeks.

Progesterones used in HRT :

  • Medroxy progesterone acetate°                                           • Dydrogesterone°
  • Norethisterone°                                                                 • Desogesterel°
  • Micronized progesterone°

Disadvantages of progesterones :

 

Weight gain                                                                             • Breast tenderness

Bloated feeling                                                                        • Depression

 

Note : Progesterone should not be added in hysterectomised patients because of patients intolerance to them and for the fear of their adverse effects on lipid profile and the breast.      

 

3. Tibolone : Is a synthetic derivative of 19 nortestosterone°. It is metabolized into isomers with three major metabolic (oestrogenic, progestogenic and androgenic) effects.

 

At a standard dose of 2.5 mg :

 

Tibolone has beneficial effects on

Bone                              Vasomotor symptoms i.e.         Genital tract i.e.             Libido                           Mood

prevents osteoporosis       hot flushes                                   vaginal atrophy               increase libido

 

  • Total HDL, LDL are not altered
  • Triglycerides are decreased
  • Endometrium atrophy occurs
  • Inhibits breast cell proliferation. Major advantages :
  • Low incidence of vaginal bleeding°
  • Can be used in women with leiomyomas and endometriosis in whom conventional HRT may cause aggravation of symptoms.°

estrogen Receptor Modulator – (SERM)

  • Drug used : Raloxifene
    • It prevents osteoporosis by increasing Bone mineral density (is useful for patients who are reluctant to use HRT or have H/O endometriosis or high risk of Breast cancer)

It also has favourable effect on lipoprotein A, LDL, homocysteine and fibrinogen

It has no effect on atherosclerosis°, HDL° levels and may even increase hot flushes and Leg cramps. ° Side effects : Hot flushes, Cramps°, Venous thrombosis° and Retinopathy°.

Contraindication : • Venous Thrombosis (should not be given with estrogen)

  • Hepatic dysfunction
  • It should be stopped 72 hours before Surgery.
  1. Androgens (Testosterone) : The only indication for the use of androgens in HRT is loss of libido.
  2. Recent Advances : Phytoestrogens
  • These are substances found in plants like Soya and are strongly oestrogenic but-non steroidal thereby reducing the potential risk of breast cancer, liver disease and other side effects of estrogen.
  • Their daily intake reduces hot flushes by 45% within 12 weeks.
  • They improve plasma lipid profile and therefore inhibit the development of coronary atherosclerosis.

Estrillshould no be used in women with any of the following conditions :

1. Undiagnosed abnormal genital bleeding.

2. Known, suspected, or history of breast cancer.

3. Known or suspected estrogen-dependent neoplasia.

4. Active deep vein thrombosis, pulmonary embolism, or history of these conditions.

5. Active or recent (e.g., within the past year) arterial thromboembolic disease (e.g., stroke or myocardial infarction).

6. Liver dysfunction or disease.

7. Known hypersensitivity to the ingredients of the estrogen preparation.

8. Known or suspected pregnancy. There is no indication for estrogen in pregnancy. There appears to be little or no increased risk of birth defects in children born to women who have used estrogens and progestins from oral contraceptives inadvertently during early pregnancy

Estrogen should be used with caution In women with the following conditions :

1.

Dementia

2.

Gallblader disease

3.

Hypertriglyceridemia

4.

Prior cholestatic jaundice

5.

Hypothyroidism

6.

Fluid retention plus cardiac or renal dysfunction

7.

Severe hypocalcemia

8.

Prior endometriosis

9.

Hepatic hemangiomas

 

 

Extra Edge Warnings and Precautions with Estrogen administration :

 

Q. 2

Non hormonal drug to prevent post menopausal osteoporosis is :

 A

Alendronate

 B

Estrogen

 C

Raloxifene

 D

Parathyroid

Q. 2

Non hormonal drug to prevent post menopausal osteoporosis is :

 A

Alendronate

 B

Estrogen

 C

Raloxifene

 D

Parathyroid

Ans. A

Explanation:

Ans. is a i.e. Alendronate

Alenderonate, Etidronate, Pamidronate, Ibandronate are bisphosphonates which inhibit bone resorption, and are very effective for both osteoporosis prevention and treatment.

Uses : • Postmenopausal osteoporosis

  • Paget’s disease
  • Osteolytic bone metastasis.

Caution : Patient should be instructed to take these drugs on an empty stomach with a large glass of water
and then to remain upright for atleast 30 minutes as its major side effect is GI upset.

Route of administration : Oral or I.V. infusion of Alendronate and risedronate can be given once weekly, whereas ibandronate is given once in a month.

Now lets have a look at other options :

  • Raioxitene : is a selective Estrogen receptor modulator which is also useful in management of osteoporosis.
  • Parathyroid horrnope . is a novel therapy for osteoporosis. Unlike most of the treatments for osteoporosis that inhibit bone resorption, parathyroid hormone stimulates new bone formation.
  • Parathyroid hormone is given by daily subcutaneous injection.

Also know : Other non hormonal drugs used for treatment of osteoporosis :

  1. Calcium
  2. Vitamin D
  3. Calcitonin
  4. Slow releasing sodium fluoride.

Q. 3

Raloxifene can cause :

 A

Endometrial carcinoma

 B

Ovarian carcinoma

 C

Breast carcinoma

 D

Cervical carcinoma

Q. 3

Raloxifene can cause :

 A

Endometrial carcinoma

 B

Ovarian carcinoma

 C

Breast carcinoma

 D

Cervical carcinoma

Ans. A

Explanation:

Cervical carcinoma

Quiz In Between


Q. 4

Drugs used for post menopausal symptoms include the following except :

 A

Conjugated estrogens

 B

Tibolone

 C

Alendronate

 D

Danazol

Q. 4

Drugs used for post menopausal symptoms include the following except :

 A

Conjugated estrogens

 B

Tibolone

 C

Alendronate

 D

Danazol

Ans. D

Explanation:

Danazol


Q. 5

SERM drug used in treatment of osteoporosis ‑

 A

Raloxifene

 B

Estrogen

 C

Strontium

 D

Alendroate

Q. 5

SERM drug used in treatment of osteoporosis ‑

 A

Raloxifene

 B

Estrogen

 C

Strontium

 D

Alendroate

Ans. A

Explanation:

Raloxifene [Ref: K.D.T. 6/e 305; Harrison 17/c 2405; Katzung 11/e 716]

  • Traditionally hormone replacement therapy with estrogen was being used to prevent/treat osteoporosis in postmenopausal worsen.
  • HRT has been shown to reduce the risk of osteoporosis in women.
  • But long term use of estrogen leads to range of adverse effect including cardiovascular disease, stroke, pulmonary emboli and invasive breast cancer.
  • These serious adverse effect made to look for other options.

Selective estrogen receptor modulators

  • These are class of compounds that act on estrogen receptors.
  • Their characteristic feature is that they do not have pure agonist or antagonistic action on estrogen receptors. – Their selective action distinguishes these substances .from pure receptor agonist or antagonist.

SERMS are “selective” that means SERMS block estrogen in some tissues and activate estrogen action in  others.

– All the SERMS bind to the estrogen receptor but each agent produces a unique receptor drug conformation.

– As a result specific coactivator or co-oppressor proteins are bound to the receptor resulting in differential effects. Two SERMS are currently being used

  • Raloxifens        For the t/t and prevention of osteoporosis
  • Tamoxifen —> For the t/t and prevention of Breast Ca
  • The .first SERM to reach the market was Tamoxifen which blocks the stimulative effect of estrogen on breast tissue and is used in breast cancer.
  • Raloxifene is the second SERM to be approved by the FDA.
  • Raloxifens has been approved for the tit and prevention of osteoporosis in postmenopausal women.
  • Raloxifens acts like estrogen on bone and helps to build and maintain bone density.

– Raloxifen has been shown in clinical trials to increase bone density in the spine and hip and to reduce the risk of spinal fractures in women with osteoporosis.

  • While it acts like estrogen on bone, it blocks the action of estrogen on breast and uterus.

– This profile makes it very useful for the t/t of osteoporosis because Raloxifene provides the bone benefits of estrogen without increasing the risk for estrogen related breast and uterine cancers.

Raloxifene in Breast cancer

  • Due to its antiestrogenic effect on breast, Raloxifene has been shown to reduce the risk of invasive breast cancer in women who are taking it for osteoporosis.
  • Raloxifene reduces the risk of breast cancer by 50-70% in both low risk and high risk postmenopausal women.
  • The national cancer institute U.S.A. funded the STUDY OF TAMOXIFEN AND RALOXIFEN (STAR) a clinical trial comparing raloxtfens with tamoxifen in preventing breast cancer, in postmenopausal women who are at increased risk of developing the disease.
  • The study found that tamoxifen and Raloxifen are equally effective in reducing invasive breast cancer risk in postmenopausal women who are at increased risk of the disease.
  • The study also .found out that women who took raloxifen had fewer uterine cancer and.fewer blood clots than women who took tamoxifen. However, Raloxifen did not decrease the risk of noninvasive breast Ca.
  • On September 14 2007, the US. food and drug administration announced approval of raloxifens for reducing the risk of invasive breast cancer in postmenopausal women with osteoporosis and in postmenopausal women at high risk for invasive cancer.

Q. 6

Which of the following drugs is both antiresoptiveand bone formative?

 A

Strontium ranelate

 B

Calcitonin

 C

Ibadronate

 D

Teriperatide

Q. 6

Which of the following drugs is both antiresoptiveand bone formative?

 A

Strontium ranelate

 B

Calcitonin

 C

Ibadronate

 D

Teriperatide

Ans. A

Explanation:

Strontium Ranelate [Ref Harrison 17 th/e p. 2407]

  • Osteoporosis is an abnormal decrease in amount orbone, but whatever left, is of normal quality. It results from bone loss due to age related changes in bone remodelling.
  • In adult bones, remodelling is the principal metabolic skeletal process.

– During remodelling the bone is ,first resorbed by osteoclasts and is then replaced by an equal amount of bone tissue due to action of osteoblasts.

– This process of bone resorption and formation goes on throughout the adult life, and it serves two purposes. – To repair the microdamage within the skeleton.

– To supply calcium. from the skeleton to maintain serum calcium.

  • In young adult the resorbed bone is replaced by an equal amount of new bone tissue. Thus the mass of skeleton remains constant after peak bone mass in achieved in adulthood.
  • However after the age of 35-40 the resorption and formation processes becomes imbalanced and resorption exceeds formation.

– Excessive bone loss can be due to an increase in osteoclastic activity and or decrease in osteoblastic activity. Mechanism of action of Strontium Ranelate in the tit of osteoporosis.

  • Strontium Ranelate increases bone mass throughout the skeleton. It appears to be modestly antiresorptive while at the same time not causing much decrease in bone fonnation.

–  Strontium is incorporated into hydroxyappatite replacing calcium, a feature that might explain some of its .fracture benefit.

  • It is approved in several European countries for the t/ t of osteoporosis.
  • Pharmacological agents used to manage osteoporosis either act by

– Decreasing the rate of bone resorption (antiresorptive therapy.)

– Promoting bone formation (anabolic therapy).

  • Since bone remodelling is a coupled process, antiresorptive drugs ultimately decrease the rate of bone .formation and therefore do not promote substantial gains in BMD.

“Thus, Strontium renelate is unique because it decreases osteoclastosis as well as promote bone formation.”

More on tit of osteoporosis

  • Pharmacological treatment of osteoporosis is generally aimed at restoring bone strength and preventing .fractures.
  • The long standing centrepiece of this approach has been antiresorptive drugs such as: ?

–  Biphosphonate

– Estrogen

– Selective estrogen receptor modulator, Raloxifene

– Calcitonin

  • Until recently, antiresorptive drugs were the only drugs approved in the United States ,for treating osteoporosis.
  • This situation changed in 2002 when FDA approved Teriparatide (the biologically active PTH fragment). Teriparatide acts by increasing the bone mass

–  Because teriparatide stimulates bone formation whereas biphosphonates reduce bone resorption, it was predicted that therapy combining the two would enhance the effect on bone marrow density more than treatment with either one alone.

– However addition of teriparatide to alendronate provided no additional bebefit for bone mass density.

  • Before the advent of strontium Ranelate there was’nt any drug which combined the two processes i.e., increasing bone formation and at the same time, decreasing bone resorption.

Strontium Ranelate has a novel mechanism of action for an osteoporotic drug as it acts on bone resorption to  reduce the rate of hone growth but also acts on bone formation promoting the growth of new bone.

More on antiresorptive therapies for osteoporosis:

Biphosphonates

Alendronate,Pamidronctte

  • Most effective drugs currently approved for prevention and t/t of osteoporosis.
  • They suppress bone resorption at doses that do not inhibit mineralization.

Thiazide diuretics

  • They are not strictly antiresorptive but they reduce urinary Cat` excretion and constrain bone loss in patients with hypercalciurea.

Estrogen

  • There is an unambiguous relationship between estrogen deficiency and osteoporosis. Post menopausal status or estrogen deficiency at any stage significantly increases patient’s risk.for osteoporosis.

Selective Estrogen receptor modulator (SERM)

  • These are estrogenic compounds with tissue selective activities.
  • Raloxifene (SERM) acts as an estrogen agonist on bone and liver and is inactive on the uterus.

Calcitonin

  • Calcitonin inhibits oteoclastic bone resorption.

Quiz In Between


Q. 7

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation ?

 A

Teriparatide

 B

Ibadronate

 C Strontium ranelate
 D Calcitonin
Q. 7

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation ?

 A

Teriparatide

 B

Ibadronate

 C Strontium ranelate
 D Calcitonin
Ans. C

Explanation:

Hyperkalemia [Ref: Harrison 16th/e p. 1375] Repeat from May 2009


Q. 8 Bisphosphonates are not used in:
 A Hypercalcemia
 B Osteoporosis
 C Cancer induced osteolysis
 D Vitamin D intoxication
Q. 8 Bisphosphonates are not used in:
 A Hypercalcemia
 B Osteoporosis
 C Cancer induced osteolysis
 D Vitamin D intoxication
Ans. D

Explanation:

Vitamin D intoxication


Q. 9

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation?

 A

Teriparatide

 B

Ibandronate

 C

Strontium ranelate

 D

Calcitonin

Q. 9

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation?

 A

Teriparatide

 B

Ibandronate

 C

Strontium ranelate

 D

Calcitonin

Ans. C

Explanation:

Strontium ranelate appears to block differentiation of osteoclasts while promoting their apoptosis, thus inhibiting bone resorption. At the same time, strontium ranelate appears to promote bone formation. Unlike bisphosphonates, denosumab, or teriparatide, this drug increases bone formation markers while inhibiting bone resorption markers.

Calcitonin inhibits osteoclastic bone resorption. Although bone formation is not impaired at first after calcitonin administration, with time both formation and resorption of bone are reduced.

Ref: Bikle D.D. (2012). Chapter 42. Agents that Affect Bone Mineral Homeostasis. In B.G. Katzung, S.B. Masters, A.J. Trevor (Eds), Basic & Clinical Pharmacology, 12e.

Quiz In Between


Q. 10

A 52 year old woman presents to her physician for a check-up. She is recovering from a wrist fracture after a fall. Dual energy x-ray absorptiometry of the hip had shown her to have osteoporosis. She became menopausal at age 50 and did not begin hormone replacement therapy because of a strong family history of breast cancer. She now fears a future hip fracture and would like to begin a bone loss prevention regime.Which of the following pharmaceutical agents is most appropriate for this patient?

 A

Calcitonin nasal spray

 B

Oral conjugated estrogen

 C

Raloxifene

 D

Tamoxifen

Q. 10

A 52 year old woman presents to her physician for a check-up. She is recovering from a wrist fracture after a fall. Dual energy x-ray absorptiometry of the hip had shown her to have osteoporosis. She became menopausal at age 50 and did not begin hormone replacement therapy because of a strong family history of breast cancer. She now fears a future hip fracture and would like to begin a bone loss prevention regime.Which of the following pharmaceutical agents is most appropriate for this patient?

 A

Calcitonin nasal spray

 B

Oral conjugated estrogen

 C

Raloxifene

 D

Tamoxifen

Ans. C

Explanation:

Raloxifene is a selective estrogen receptor modulator that helps prevent osteoporosis by lessening bone resorption and reducing bone turnover. It lowers risk for vertebral fractures by 40% to 50%.
It is a bone-preserving alternative for women who prefer to avoid estrogen.
Raloxifene does not cause breast pain and may lessen the risk for breast cancer in menopausal women.
There is also a favorable effect on LDL and cholesterol.
 
Calcitonin nasal spray is an osteoclastic bone resorption inhibitor that modestly increases bone mineral density and reduces the incidence of vertebral fracture. Although it is an estrogen alternative for bone preservation, its impact on hip fracture is not known. It is also lacks the anti-breast cancer properties of raloxifene.
 
Oral conjugated estrogen and transdermal estradiolare not the best choices, as this patient wants to avoid estrogen because of a strong family history of breast cancer. The route of administration of estrogen has been shown to have similar effects on bone preservation, even though the transdermal dosage is generally half that of the oral dosage. Breast cancer risk, however, is slightly increased with the unopposed higher dosage oral estrogen replacement.
 
Tamoxifen , while indicated in the long-term care of breast cancer patients, is not alone useful for treatment or prevention of osteoporosis. Tamoxifen is an anti-estrogen agent that competes with estrogen for binding sites.
 
Ref: Shoback D. (2013). Chapter 58. Osteoporosis & Glucocorticoid-Induced Osteoporosis. In J.B. Imboden, D.B. Hellmann, J.H. Stone (Eds), CURRENT Diagnosis & Treatment: Rheumatology, 3e.

Q. 11

Intranasal calcitonin is given for a 65 year old post-menopausal lady. What is the likely indication?

 A

Paget’s disease

 B

Osteoporosis

 C

Hypercalcemia

 D

Osteopetrosis

Q. 11

Intranasal calcitonin is given for a 65 year old post-menopausal lady. What is the likely indication?

 A

Paget’s disease

 B

Osteoporosis

 C

Hypercalcemia

 D

Osteopetrosis

Ans. B

Explanation:

Calcitonin-salmon is a hormone that decreases osteoclast activity, thereby impeding postmenopausal bone loss.

It is indicated for the treatment of women who are more than 5 years post menopause and have low bone mass relative to healthy premenopausal women.

It is available as an injection and as an intranasal spray.

The intranasal spray is delivered as a single daily spray that provides 200 IU of the drug.


Q. 12

A female is on hormone replacement therapy for her menopausal symptoms. She is worried about her bone strength because her mom and sister had osteoporosis after the age of 50. All are given for prevention of osteoporosis along with hormonal replacement therapy, EXCEPT:

 A

Calcium

 B

Vit.D

 C

Vitamin-E

 D

None of the above

Q. 12

A female is on hormone replacement therapy for her menopausal symptoms. She is worried about her bone strength because her mom and sister had osteoporosis after the age of 50. All are given for prevention of osteoporosis along with hormonal replacement therapy, EXCEPT:

 A

Calcium

 B

Vit.D

 C

Vitamin-E

 D

None of the above

Ans. C

Explanation:

Women most at risk for osteoporotic fractures should consider bisphosphonates, raloxifene, along with hormone replacement therapy. Elemental calcium should be taken as a daily supplement at the time of the menopause and thereafter; calcium supplements should be taken with meals to increase their absorption. Vitamin D, sunlight, or supplements, is necessary to enhance calcium absorption and maintain bone mass.

Ref: MacKay H., Woo J. (2013). Chapter 18. Gynecologic Disorders. In M.A. Papadakis, S.J. McPhee, M.W. Rabow, T.G. Berger (Eds), CURRENT Medical Diagnosis & Treatment 2014.

Quiz In Between


Q. 13

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Q. 13

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Ans. C

Explanation:

Osteoporosis in this patient is due to estrogen deficiency. Estrogens are efficacious when administered orally or transdermally.

Various types of estrogens (conjugated equine estrogens, estradiol, estrone, esterified estrogens, ethinyl estradiol, and mestranol) reduce bone turnover, prevent bone loss, and induce small increases in bone mass of the spine, hip, and total body.

The effects of estrogen are seen in women with natural or surgical menopause and in late postmenopausal women with or without established osteoporosis.

Ref: Lindsay R., Cosman F. (2012). Chapter 354. Osteoporosis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.


Q. 14

All of the following appear to decrease hot flushes in menopausal women except:

 A

Androgens

 B

Raloxifene

 C

Isoflavones

 D

Tibolone

Q. 14

All of the following appear to decrease hot flushes in menopausal women except:

 A

Androgens

 B

Raloxifene

 C

Isoflavones

 D

Tibolone

Ans. B

Explanation:

Raloxifene increases the occurrence of hot flushes. Ref: International Position Paper on Women’s Health and Menopause : A Comprehensive Approach By Giovanni Lorenzini, 2002, Page 56; Harrison’s Internal Medicine, 17th Edition, Page 2405; Shaw’s Gynaecology, 13th Edition, Pages 63-64


Q. 15

The success of estrogen and estrogen-like drugs in combating osteoporosis in postmenopausal women may indicate that estrogen:

 A

Stimulates osteoclastic activity

 B

Inhibits osteoclastic activity

 C

Inhibits osteoblastic activity

 D

Inhibits recalcification during bone turnover

Q. 15

The success of estrogen and estrogen-like drugs in combating osteoporosis in postmenopausal women may indicate that estrogen:

 A

Stimulates osteoclastic activity

 B

Inhibits osteoclastic activity

 C

Inhibits osteoblastic activity

 D

Inhibits recalcification during bone turnover

Ans. B

Explanation:

Estrogens directly regulate osteoblasts and increase the synthesis of type I collagen, osteocalcin, osteopontin, osteonectin, alkaline phosphatase, and other markers of differentiated osteoblasts.

Estrogens also increase osteocyte survival by inhibiting apoptosis.

However, the major effect of estrogens is to decrease the number and activity of osteoclasts.

Much of the action of estrogens on osteoclasts appears to be mediated by altering cytokine (both paracrine and autocrine) signals from osteoblasts.

Estrogens decrease osteoblast and stromal cell production of the osteoclast-stimulating cytokines interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)- and increase the production of IGF-1, bone morphogenic protein (BMP)-6, and transforming growth factor (TGF) Beta which are antiresorptive.

Ref: Levin E.R., Hammes S.R. (2011). Chapter 40. Estrogens and Progestins. In L.L. Brunton, B.A. Chabner, B.C. Knollmann (Eds), Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12e.

Quiz In Between


Q. 16

A patient with diabetic nephropathy developed secondary hyperparathyroidism. Hyperparathyroidism is seen in all of the following conditions, EXCEPT:

 A

Osteoporosis

 B

Osteomalacia

 C

Rickets

 D

Chronic renal failure

Q. 16

A patient with diabetic nephropathy developed secondary hyperparathyroidism. Hyperparathyroidism is seen in all of the following conditions, EXCEPT:

 A

Osteoporosis

 B

Osteomalacia

 C

Rickets

 D

Chronic renal failure

Ans. A

Explanation:

In chronic kidney disease, hyperphosphatemia and decreased renal production of 1,25-dihydroxycholecalciferol (1,25[OH]2D3) initially produce a decrease in ionized calcium. The parathyroid glands are stimulated (secondary hyperparathyroidism) and may enlarge, becoming autonomous (tertiary hyperparathyroidism).
In osteomalacia and rickets, hypocalcemia acts as stimulus to secondary hyperparathyroidism.

Ref: Shoback D., Sellmeyer D. (2011). Chapter 8. Metabolic Bone Disease. In D.G. Gardner, D. Shoback (Eds), Greenspan’s Basic & Clinical Endocrinology, 9e.

Quiz In Between


Q. 17

Strontium ranelate is approved for treatment of:

 A

Asthma

 B

Cystic fibrosis

 C

UTI

 D

Osteoporosis

Q. 17

Strontium ranelate is approved for treatment of:

 A

Asthma

 B

Cystic fibrosis

 C

UTI

 D

Osteoporosis

Ans. D

Explanation:

Strontium ranelate is approved in several European countries for the treatment of osteoporosis. It increases bone mass throughout the skeleton; in clinical trials, the drug reduced the risk of vertebral fractures by 37% and nonvertebral fractures by 14%. It appears to be modestly antiresorptive, while at the same time not causing as much of a decrease in bone formation (measured biochemically). 
 
Ref: Harrison’s principle of internal medicine 17th edition, chapter 338.

Q. 18

All of the following are side effects of Amiodarone except –

 A

Pulmonary fibrosis

 B

Corneal microdeposits

 C

Thyroid dysfunction

 D

Osteoporosis

Q. 18

All of the following are side effects of Amiodarone except –

 A

Pulmonary fibrosis

 B

Corneal microdeposits

 C

Thyroid dysfunction

 D

Osteoporosis

Ans. D

Explanation:

Ans. is ‘d’ i.e., Osteoporosis

Adverse effects of Amiodarone
o Thyroid dysfunction                                o Peripheral neuropathy                         o Corneal microdeposits
(Hypothyroidism or hyperthyroidism)         o Myocardial depression                          o Photosensitivity
o Bluish discoloration of exposed skin.       o Pulmonary fibrosis                                o Hepatitis

Quiz In Between


Q. 19

All of the following appears to decrease hot flushes in menopausal women except –

 A

Androgens

 B

Raloxifene

 C

Isoflavones

 D

Tibolone

Q. 19

All of the following appears to decrease hot flushes in menopausal women except –

 A

Androgens

 B

Raloxifene

 C

Isoflavones

 D

Tibolone

Ans. B

Explanation:

Ans. is ‘b’ i.e., Raloxifen

  • “Raloxifene does not relieve vasomotor symptoms of menopause, rather hot flushes may be induced in some women.             
  • Hot fluses and other vasomotor symptoms respond to estrogen.
  • Tibolone has both estrogenic and progestational properties .
  • Tibolone suppresses menopausal symptoms and lowers the the raised gonadotropin levels –
  • Isoflavones (genistein) have estrogenic effect (Goodman & Gillman 
  • So they can suppress vasomotor symptoms.
  • Estrogen can be produced from androgen by the action of aromatase. Selected women may be treated with low dose methyltestosterone, which is available in combination with conjugated estrogen.

Q. 20

SERM used in Rx of osteoporosis in menopausal female?

 A

Raloxifene

 B

Estrogen

 C

Cyproterone

 D

Clomiphene

Q. 20

SERM used in Rx of osteoporosis in menopausal female?

 A

Raloxifene

 B

Estrogen

 C

Cyproterone

 D

Clomiphene

Ans. A

Explanation:

Ans. is ‘a’ i.e., Raloxifen

Raloxifene is a selective estrogen receptor modulator (SERM).

o It is used as first line drug for prevention and treatment of osteoporosis.


Q. 21

Raloxifene is used in

 A

Osteoporosis

 B

Cervical cancer

 C

Osteopetrosis

 D

Fibroadenoma

Q. 21

Raloxifene is used in

 A

Osteoporosis

 B

Cervical cancer

 C

Osteopetrosis

 D

Fibroadenoma

Ans. A

Explanation:

Ans. is ‘a’ i.e., Osteoporosis

Quiz In Between


Q. 22

All of the following statements about Selective Estrogen Receptor Downregulator (SERD), Fulvestrant are true, Except

 A

It is a selective estrogen antagonist

 B

Used in the treatment of breast cancer

 C

Slower acting, safer and less effective than SERM

 D

May be administered as ‘once a month’ dose

Q. 22

All of the following statements about Selective Estrogen Receptor Downregulator (SERD), Fulvestrant are true, Except

 A

It is a selective estrogen antagonist

 B

Used in the treatment of breast cancer

 C

Slower acting, safer and less effective than SERM

 D

May be administered as ‘once a month’ dose

Ans. C

Explanation:

Ans is ‘c’ i.e. Slower acting, safer and less effective than SERM

Fulvestrant

  • It is a selective estrogen receptor downregulator (SERD) or pure antiestrogen/pure estrogen antagonist. o Fulverstrant is thought to have an improved safety profile, faster onset and longer duration of action than the SERMs due to its pure ER antagonistic activity.

o Fulvestrant is used to treat post menopausal women with metastatic breast cancer that expresses the estrogen receptor (hormone receptor positive) and is used when first line treatments (e.g. tamoxifen or an aromatase inhibitor) have failed.

Therapeutic uses

o Fulverstrant typically is administered as a 250-gm intramuscular injection of monthly intervals.

o It is used in post-menopausal women as antiestrogen theraphy of hormone receptor — positive metastatic breast cancer after progression on first – line antiestrogen theraphy such as tamoxifen or aromatase inhibitors.


Q. 23

Intranasal calcitonin is given in ?

 A

Pagets’s disease

 B

MEN syndrome

 C

Hypercalcemia

 D

Post menopausal osteoporosis

Q. 23

Intranasal calcitonin is given in ?

 A

Pagets’s disease

 B

MEN syndrome

 C

Hypercalcemia

 D

Post menopausal osteoporosis

Ans. D

Explanation:

Ans. is ‘d’ i.e., Post menopausal osteoporosis

o Salmon calcitonin is approved for clinical use. The latter product also is available as a nasal spray, introduced for

once-daily treatment of postmenopausal osteoporosis.

o For Paget c disease, calcitonin generally is administered by subcutaneous injection  because intranasal delivery is relatively ineffective owing to limited bioavailability.


Q. 24

Which of the following is recombinant PTH‑

 A

Teriparatide

 B

Cinacalcet

 C

Carisoprodol

 D

Oxethazaine

Q. 24

Which of the following is recombinant PTH‑

 A

Teriparatide

 B

Cinacalcet

 C

Carisoprodol

 D

Oxethazaine

Ans. A

Explanation:

Ans. is ‘a’ i.e., Teriparatide

o Teriparatide is a recombinant preparation of 1 – 34 residues of amino terminal of human PTH, introduced for treatment of osteoporosis.

Quiz In Between


Q. 25

rPTH used in osteoporosis is –

 A

Teriparatide

 B

Denosumab

 C

Calcitriol

 D

Calcipotriol

Q. 25

rPTH used in osteoporosis is –

 A

Teriparatide

 B

Denosumab

 C

Calcitriol

 D

Calcipotriol

Ans. A

Explanation:

Ans. is ‘a’ i.e., Teriparatide


Q. 26

Bisphosphonates are used in all of the following conditions except –

 A

Post-menopausal osteoporosis

 B

Steroid induced osteoporosis

 C

Hypervitaminosis D

 D

Malignancy associated hypercalcemia

Q. 26

Bisphosphonates are used in all of the following conditions except –

 A

Post-menopausal osteoporosis

 B

Steroid induced osteoporosis

 C

Hypervitaminosis D

 D

Malignancy associated hypercalcemia

Ans. C

Explanation:

Ans. is ‘c’ i.e., Hypervitaminosis D

Uses of Bisphosphonates

  1. Osteoporosis (Postmenopausal, idiopathic and steroid induced).
  2. Paget’s disease
  3. Hypercalcemia of malignancy
  4. Osteolytic bone metastasis

Q. 27

Bisphosphonates are not used in?

 A

Hypercalcemia

 B

Osteoporosis

 C

Cancer induced osteolysis

 D

Vitamin D intoxication

Q. 27

Bisphosphonates are not used in?

 A

Hypercalcemia

 B

Osteoporosis

 C

Cancer induced osteolysis

 D

Vitamin D intoxication

Ans. D

Explanation:

Ans. is `d’ Vitamin D intoxication

Quiz In Between


Q. 28

Bisphosphonate-induced osteomalacia is commonly seen with –

 A

Alendronate

 B

Pamidronate

 C

Zolendronate

 D

Etidronate

Q. 28

Bisphosphonate-induced osteomalacia is commonly seen with –

 A

Alendronate

 B

Pamidronate

 C

Zolendronate

 D

Etidronate

Ans. D

Explanation:

Ans. is ‘d’ i.e., Etidronate

o First genertion BNPs (etidronate, tiludronate, medronate) can cause osteomalacia.


Q. 29

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation?

 A

Teriparatide

 B

Ibadronate

 C

Strontium ranelate

 D

Calcitonin

Q. 29

Which of the following drugs used in osteoporosis acts both by decreasing the resorption of bone as well as inducing new bone formation?

 A

Teriparatide

 B

Ibadronate

 C

Strontium ranelate

 D

Calcitonin

Ans. C

Explanation:

Ans. is ‘c’ i.e., Strontium Ranelate

Drug used in osteoporosis

1.   Inhibit resorption : -Bisphosphonates, donesumab, cinacalcet, calcitonin, estrogen, SERMS, gallium nitrate.

2.   Stimulate formation : -Teriparatide, calcium, calcitrial, fluorides,.

3.   Both actions : – Strontium renelate.


Q. 30

Which of the following is not a treatment of osteoporosis ?

 A

Calcitriol

 B

Androgen

 C

Estrogen

 D

Vitamin D

Q. 30

Which of the following is not a treatment of osteoporosis ?

 A

Calcitriol

 B

Androgen

 C

Estrogen

 D

Vitamin D

Ans. B

Explanation:

Ans. is ‘b’ i.e., Androgen

Quiz In Between


Q. 31

Parathormone is useful in which of the following?

 A

Hyperparathyroidism

 B

Paget’s disease

 C

Osteoporosis

 D

Osteomalacia

Q. 31

Parathormone is useful in which of the following?

 A

Hyperparathyroidism

 B

Paget’s disease

 C

Osteoporosis

 D

Osteomalacia

Ans. C

Explanation:

Ans. is ‘c’ i.e., Osteoporosis

o Several clinical trials have been performed using an exogenous PTH analogue (1-34hPTH; teriparatide) that has been approved for the treatment of established osteoporosis in both men and women.

o Exogenously administered PTH appears to have direct actions on osteoblast activity, with biochemical and histomorphometric evidence of de novo bone formation early in response to PTH, before activation of bone resorption.

o Subsequently, PTH activates bone remodeling but still appears to favor bone formation over bone resorption.


Q. 32

DENOSUMAB a monoclonal antibody against RANKL receptor is used in the treatment of

 A

Rheumtoid arthritis

 B

Osteoporosis

 C

Osteoarthritis

 D

SLE

Q. 32

DENOSUMAB a monoclonal antibody against RANKL receptor is used in the treatment of

 A

Rheumtoid arthritis

 B

Osteoporosis

 C

Osteoarthritis

 D

SLE

Ans. B

Explanation:

Ans. is ‘b i.e., Osteoporosis

Donesumab

o Osteoclast is a cell responsible for bone resorption.

o Osteoclasts express RANK receptors on its surface (RANK —> receptor activator for nuclear factor).

o When RANK receptor combine with their ligands (RANKL) osteoclastogenesis is initiated and bone resorption occurs.

o Donesumab is a monoclonal antibody against RANK ligand. o It prevents the activation of the osteoclasts by these ligand.

Note :

o Osteoporosis is a disease characterized by decrease in the bone mass.

o In osteoporosis there is increase in the osteoclast activity and there is increased expression of RANK and RANKL.


Q. 33

Secondary Hyperparathyroidism is seen in all of the following, Except

 A

Rickets

 B

Osteomalacia

 C

Osteoporosis

 D

Renal failure

Q. 33

Secondary Hyperparathyroidism is seen in all of the following, Except

 A

Rickets

 B

Osteomalacia

 C

Osteoporosis

 D

Renal failure

Ans. C

Explanation:

Answer is C (Osteoporosis):

Osteoporosis is neither associated with hypocalcaemia nor with secondary Hyperparathyroidism

Quiz In Between


Q. 34

Treatment of Hypercalcemia

 A

Calcitonin

 B

Gallium nitrate

 C

Orthophosphate

 D

a and b

Q. 34

Treatment of Hypercalcemia

 A

Calcitonin

 B

Gallium nitrate

 C

Orthophosphate

 D

a and b

Ans. D

Explanation:

Answer is A and B (Calcitonin and Gallium Nitrate):

Calcitonin and Gallium Nitrate may be used in treatment of hypercalcemia.


Q. 35

All of the following may be used to treat Acute Hypercalcemia Except:

 A

Hydration with saline

 B

Calcitonin

 C

Biphosphonates

 D

Gallium Nitrate

Q. 35

All of the following may be used to treat Acute Hypercalcemia Except:

 A

Hydration with saline

 B

Calcitonin

 C

Biphosphonates

 D

Gallium Nitrate

Ans. D

Explanation:

Answer is D (Gallium Nitrate)

Gallium Nitrate exerts s hypocalcemic effect by inhibiting calcium resorption from bone. Maximum hypocakemic

effect of gallium nitrate may take 3-4 days to appear and it is not often used now because of availability of superior alternatives.

Gallium nitrate is the single best answer of exclusion.

Treatment of Hypercalcemia

Onset of Action

Hydration with Saline

Hours

Forced diuresis (saline + loop diuretic)

Hours

Calcitonin

Hours

Intravenous phosphate

Hours

Pheomycin / Mithromycin

Hours

Dialysis

Hours

Biphosphonates

Days (1 to 2 days)

Glucocorticoids

Days

Gallium Nitrate

Days (3-4 days)


Q. 36

All of the following agents may be used in the management of Chronic Hypocalcemia, except:

 A

Etidronate

 B

Thiazides

 C

Elemental calcium

 D

Vitamin D analogs

Q. 36

All of the following agents may be used in the management of Chronic Hypocalcemia, except:

 A

Etidronate

 B

Thiazides

 C

Elemental calcium

 D

Vitamin D analogs

Ans. A

Explanation:

Answer is A (Etidronate):

Etidronate is a first generation bisphosphonate, used for the management of Hypercalcemia (not used fir Hypocalcemia).

`Treatment of Hypocalcemia includes Calcium replacement with Vitamin D analogs along with Thiazide diuretics to prevent excess calcium excretion besides replenishing any decreases in magnesium and phosphate restriction’.

Quiz In Between


Q. 37

All of the following drugs cause osteoporosis except:

September 2011

 A

Steroid

 B

Alendronate

 C

Thyroxine

 D

Heparin

Q. 37

All of the following drugs cause osteoporosis except:

September 2011

 A

Steroid

 B

Alendronate

 C

Thyroxine

 D

Heparin

Ans. B

Explanation:

Ans. B: Alendronate

Biphosphonates are the first drug of choice for treating post-menopausal osteoporosis

PLEASE NOTE: A biphosphonate (pamidronate or zolendronic acid) inhibits osteoclastic bone resorption and is particularly useful in hypercalcemia of malignancy as well

Osteoporosis

  • In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered.
  • Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density that is 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by DXA; the term “established osteoporosis” includes the presence of a fragility fracture.
  • The disease may be classified as primary type 1, primary type 2, or secondary.
  • The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis.
  • Primary type 2 osteoporosis or senile osteoporosis occurs after age 75 and is seen in both females and males at a ratio of 2:1.
  • Finally, secondary osteoporosis may arise at any age and affects men and women equally.
  • This form of osteoporosis results from chronic predisposing medical problems or disease, or prolonged use of medications such as glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP).

Certain medications have been associated with an increase in osteoporosis risk; only steroids and anticonvulsants are classically associated

Steroid-induced osteoporosis (SIOP) arises due to use of glucocorticoids – analogous to Cushing’s syndrome and involving mainly the axial skeleton.

The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake.

Barbiturates, phenytoin and some other enzyme-inducing antiepileptics – These probably accelerate the metabolism of vitamin D.

L-Thyroxine over-replacement may contribute to osteoporosis, in a similar fashion as thyrotoxicosis does. Anticoagulants – Long-term use of heparin is associated with a decrease in bone density, and warfarin (and related coumarins) have been linked with an increased risk in osteoporotic fracture in long-term use.

Proton pump inhibitors – These drugs inhibit the production of stomach acid; it is thought that this interferes with calcium absorption.

  • Chronic phosphate binding may also occur with aluminium-containing antacids.
  • Thiazolidinediones (used for diabetes) – Rosiglitazone and possibly pioglitazone, inhibitors of PPAR-gamma, have been linked with an increased risk of osteoporosis and fracture.
  • Chronic lithium therapy has been associated with osteoporosis
  • The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density (BMD).
  • The most popular method of measuring BMD is dual energy x-ray absorptiometry (DXA or DEXA).
  • There are several medications used to treat osteoporosis, depending on gender.
  • Medications themselves can be classified as antiresorptive or bone anabolic agents.
  • Antiresorptive agents work primarily by reducing bone resorption, while bone anabolic agents build bone rather than inhibit resorption.
  • Bisphosphonates are the main pharmacological measures for treatment.
  • However, newer drugs have appeared in the 1990s, such as teriparatide and strontium ranelate.
  • In confirmed osteoporosis, bisphosphonate drugs are the first-line treatment in women.
  • The most often prescribed bisphosphonates are presently sodium alendronate, risedronate or ibandronate.
  • Oral bisphosphonates are relatively poorly absorbed, and must therefore be taken on an empty stomach, with no food or drink to follow for the next 30 minutes.
  • They are associated with inflammation of the esophagus (esophagitis)
  • Estrogen replacement therapy remains a good treatment for prevention of osteoporosis.
  • Selective Estrogen Receptor Modulators (SERMs) are a class of medications that act on the estrogen receptors throughout the body in a selective manner.
  • Normally, bone mineral density (BMD) is tightly regulated by a balance between osteoblast and osteoclast activity in the trabecular bone.
  • Estrogen has a major role in regulation of the bone formation-resorption equilibrium, as it stimulates osteoblast activity.
  • Some SERMs such as raloxifene, act on the bone by slowing bone resorption by the osteoclasts.
  • Raloxifene has the added advantage of reducing the risk of invasive breast cancer.
  • Calcitonin works by directly inhibiting osteoclast activity via the calcitonin receptor.
  • Teriparatide (recombinant parathyroid hormone residues 1-34) has been shown to be effective in osteoporosis.
  • It acts like parathyroid hormone and stimulates osteoblasts, thus increasing their activity.
  • It is used mostly for patients with established osteoporosis (who have already fractured), have particularly low BMD or several risk factors for fracture or cannot tolerate the oral bisphosphonates.
  • Calcium salts come as water insoluble and soluble formulations.
  • Calcium carbonate is the primary water insoluble drug, while calcium citrate, lactate, and gluconate are water soluble.
  • Sodium fluoride treatment in patients with osteoporosis has been shown to cause skeletal changes such as pronounced bone density with increased number and thickness of trabeculae, cortical thickening, and partial obliteration of the medullary space.
  • Denosumab is a fully human monoclonal antibody that mimics the activity of osteoprotegerin.
  • It binds to RANKL, thereby preventing RANKL from interacting with RANK and reducing its bone resorption.
  • Oral strontium ranelate is an alternative oral treatment, belonging to a class of drugs called “dual action bone agents” (DABAs).
  • Strontium ranelate has side effect benefits over the bisphosphonates, as it does not cause any form of upper GI side effect, which is the most common cause for medication withdrawal in osteoporosis.
  • Calcium is required to support bone growth, bone healing and maintain bone strength and is one aspect of treatment for osteoporosis.
  • A high intake of vitamin D reduces fractures in the elderly
  • It did increase formation of kidney stones by 17%.
  • Calcium and vitamin D are currently recommended for the primary prevention of osteoporosis and the primary and secondary prevention of osteoporotic fractures.

Q. 38

Following is true about alendronate except‑

 A

It is a second generation amino – BNP

 B

It is used in prevention and treatment of osteoporosis

 C

Oral bioavailability is 10%

 D

Iron interferes with alendronate absorption

Q. 38

Following is true about alendronate except‑

 A

It is a second generation amino – BNP

 B

It is used in prevention and treatment of osteoporosis

 C

Oral bioavailability is 10%

 D

Iron interferes with alendronate absorption

Ans. C

Explanation:

Ans. is ‘c’ i.e., Oral bioavailability is 10%

Alendronate

  • Potent orally effective second generation amino – BNP.
  • It is used primarily in the prevention and treatment of osteoporosis as well as for paget’s disease.
  • It is to be taken empty stomach with one glass of water and patient should not lie supine for half an hour to prevent esophagitis.
  • Calcium, iron, antacids, mineral water, tea, coffee, fruit juice interfere with alendronate absorption.
  • Oral bioavailability of alendronate is 1%.
  • Adverse effects are: esophagitis, gastric erosion, retrosternal pain, flatulence, headache and bodyache.
  • Terminal elimination T1/2 of alendronate has been measured as 10.5 years.

Q. 39

Bisphosphonates are used for all except ‑

 A

Osteolytic bone metastases

 B

Osteoporosis

 C

Osteosclerosis

 D

Pagets disease

Q. 39

Bisphosphonates are used for all except ‑

 A

Osteolytic bone metastases

 B

Osteoporosis

 C

Osteosclerosis

 D

Pagets disease

Ans. C

Explanation:

Ans. is ‘c’ i.e., Osteosclerosis

Uses of Bisphosphonates

  1. Osteoporosis (Postmenopausal, idiopathic and steroid induced).
  2. Paget’s disease
  3. Hypercalcemia of malignancy
  4. Osteolytic bone metastasis

Quiz In Between


Q. 40

In osteoporosis, bone formation is increased by which drug –

 A

Bisphosphonates

 B

Estrogen

 C

Calcitonin

 D

Teriparatide

Q. 40

In osteoporosis, bone formation is increased by which drug –

 A

Bisphosphonates

 B

Estrogen

 C

Calcitonin

 D

Teriparatide

Ans. D

Explanation:

Ans. is ‘opl’ i.e

Teriparatide

  • Drug used in osteoporosis
  1. Inhibit resorption Bisphosphonates, donesumab, cinacalcet, calcitonin, estrogen, SERMS, gallium nitrate.
  2. Stimulate formation :-Teriparatide, calcium, calcitriol, fluorides.
  3. Both actions Strontium renelate.

Q. 41

Hormone replacement herapy is contraindicated in

 A

Atherosclerosis

 B

Thromboembolism

 C

Osteoporosis

 D

Gall stones

Q. 41

Hormone replacement herapy is contraindicated in

 A

Atherosclerosis

 B

Thromboembolism

 C

Osteoporosis

 D

Gall stones

Ans. B

Explanation:

Ans. is ‘b’ i.e., Thromboembolism 

Contraincations of hormone replacement therapy

  • Pregnancy and breast feeding.
  • Undiagnose vaginal bleeding.
  • Recent angina or MI.
  • Venous thromboembolic disease. 
  • Breast cancer.
  • Active liver disease.
  • Endometrial cancer.
  • Uncontrolled hypertension.

Q. 42

Which of the following is recombinant PTH ‑

 A

Teriparatide

 B

Cinacalcet

 C

Carisoprodol

 D

Oxethazaine

Q. 42

Which of the following is recombinant PTH ‑

 A

Teriparatide

 B

Cinacalcet

 C

Carisoprodol

 D

Oxethazaine

Ans. A

Explanation:

Ans. is ‘a’ i.e., Teriparatide 

  • Teriparatide – recombinant preparation of 1 – 34 residues of amino terminal of human PTH, introduced for treatment of osteoporosis.
  • Injected s.c. 20mcg once daily. Increase bone mineral density and stimulate bone formation. Reduces risk of vertebral as well as non – vertebral fractures in osteoporotic women.

Q. 43

Raloxifene is used in ‑

 A

Osteoporosis

 B

Cervical cancer

 C

Osteopetrosis

 D

Fibroadenoma

Q. 43

Raloxifene is used in ‑

 A

Osteoporosis

 B

Cervical cancer

 C

Osteopetrosis

 D

Fibroadenoma

Ans. A

Explanation:

Ans. is ‘a’ i.e., Osteoporosis 

Quiz In Between



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