Osteoporosis monitoring

One chronic adverse effect that is of concern is osteoporosis.32,33 Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, and valproate have all been shown to decrease bone mineral density, even after only 6 months of treatment. Data on the relationship between other AEDs and osteoporosis are not currently available. Multiple studies have shown the risk of osteoporosis due to chronic AED use to be similar to the risk with chronic use of corticosteroids. Patients taking carbamazepine, phenytoin, phenobarbital, or valproate for longer than 6 months should take supplemental calcium and vitamin D. Additionally routine monitoring for osteoporosis should be performed every 2 years, and patients should be instructed on ways to protect themselves from fractures. 

The growth and spread of thyroid carcinoma is stimulated hy TSH. An important component of thyroid carcinoma management is the use ofLT4 to suppress TSH secretion. Early in therapy, patients receive the lowest LT4 dose sufficient to fully suppress TSH to undetectable levels. Controlled trials show that suppressive LT4 therapy reduces tumor growth and improves survival. These patients are purposefully overtreated with LT4 and rendered subclinically hyperthyroid. Postmenopausal women should receive aggressive osteoporosis therapy to prevent LT4-induced bone loss. Other thyrotoxic complications, such as atrial fibrillation, should be monitored and managed appropriately. 

Recommend an appropriate treatment regimen for a patient with osteoporosis, and develop a monitoring plan for the selected regimen. 

Guidelines for managing corticosteroid-induced osteoporosis recommend measuring BMD at the beginning of chronic therapy (prednisone 5 mg or more daily or equivalent for at least 6 months) and followup monitoring with DXA in 6 to 12 months. BMD should be measured in patients taking chronic therapy whose baseline values were not obtained. 

Side effects of inhaled corticosteroids are relatively mild and include hoarseness, sore throat, oral candidiasis, and skin bruising. Severe side effects such as adrenal suppression, osteoporosis, and cataract formation are reported less frequently than with systemic corticosteroids, but clinicians should monitor patients receiving high-dose chronic inhaled therapy. 

Increased concentrations in plasma of markers such as P1NP or cross-linked C-terminal telopeptides (CTx), or urinary excretion of DPD, indicate increased bone turnover but are generally not useful for initial diagnosis of osteoporosis. Changes in plasma concentrations or urinary excretion of bone markers may be useful for monitoring patients response to therapy. 

Ca, leg cramps EMS May cause cardiac conduction abnormalities d/t T monitor ECG not used to prevent osteoporosis osteosarcoma has been rqwrted in animals OD May cause NA, HA, and h5 percalcemia and associated cardiac conduction problems s5rmptomatic and supportive... 

Uses Chronic asthma Actions Topical steroid Dose Two inhalations tid-qid or 4 inhal bid Caution [C, ] Contra Component aU gy Disp Met-dose inhaler SE Cough, oral candidiasis Interactions T Risk of GI bleed W/ ASA, NSAIDs T effects W/ sakneterol, troleandomycin -1- effects W/barbiturates, hydantoins, pheny-toin, rifampin T effects OF diuretics, insulin, oral hypoglycemics, K supl, salicylates, somatrem, live virus vaccines EMS May affect glucose(hyperglycemia) monitor ECG for hypokalemia (flattened T waves) concurrent ASA/NSAID use may t risk of GI bleeding OD Acute OD unlikely to cause life-threatening Sxs, chronic OD may lead to S/Sxs of muscle weakness, and osteoporosis symptomatic and supportive... 

The toxicity of thyroxine is directly related to the hormone level. In children, restlessness, insomnia, and accelerated bone maturation and growth may be signs of thyroxine toxicity. In adults, increased nervousness, heat intolerance, episodes of palpitation and tachycardia, or unexplained weight loss may be the presenting symptoms. If these symptoms are present, it is important to monitor serum TSH (Table 38-2), which will determine whether the symptoms are due to excess thyroxine blood levels. Chronic overtreatment with T4, particularly in elderly patients, can increase the risk of atrial fibrillation and accelerated osteoporosis. 

Patients receiving glucocorticoids must be monitored carefully for the development of hyperglycemia, glycosuria, sodium retention with edema or hypertension, hypokalemia, peptic ulcer, osteoporosis, and hidden infections. 

Gastrointestinal complaints (eg, nausea, diarrhea, vomiting, flatulence) are the most common adverse effects but rarely require discontinuation of therapy. Other potential adverse effects include headache and asthenia. Tenofbvir-associated proximal renal tubulopathy causes excessive renal phosphate and calcium losses and 1-hydroxylation defects of vitamin D, and preclinical studies in several animal species have demonstrated bone toxicity (eg, osteomalacia). Monitoring of bone mineral density should be considered with long-term use in those with risk factors for or with known osteoporosis, as well as in children. Reduction of renal function over time, as well as cases of acute renal failure and Fanconi s syndrome, have been reported in patients receiving tenofovir alone or in combination with emtricitabine. For this reason, tenofovir should be used with caution in patients at risk for renal dysfunction. Tenofovir may compete with other drugs that are actively secreted by the kidneys, such as cidofovir, acyclovir, and ganciclovir. 

How would you adapt Dr. Brouchard s strategies for compensation for a different type of service, such as asthma education and monitoring, weight-loss, or osteoporosis counseling ... 

---