Pharm Bone Mineral Homeostasis

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  • 1/20 Questions

    A 55-year-old woman complained to her physician of a persistent back pain of 3 days duration. A dual-energy x-ray absorptiometry showed diffuse osteoporosis of the spine and hips. The physician ordered calcium and vit D supplementation and alendronate, 10 mg daily. Which of the following actions most likely mediated the therapeutic effect of alendronate in this patient?

    • Stimulation of osteoblast activity
    • Stimulation of intestinal calcium absorption
    • Inhibition of renal calcium excretion
    • Inhibition of osteoclast activity
    • Inhibition of renal synthesis of calcitriol
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About This Quiz

Pharmacology students, welcome to today’s quiz on yet another important element of your studies, where we will be discussing pharmaceuticals regarding bone mineral homeostasis. Do you know how these particular drugs work in the body? Answer the questions below and we’ll find out for sure! Good luck!

Pharm Bone Mineral Homeostasis - Quiz

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  • 2. 

    DIRECTIONS 1-5 Match each drug affecting bone mineral homeostasis with the appropriate description (each lettered option can be selected only once): This drug is a recombinant PTH 1-34

    • Alendronate

    • Calcipotriene

    • Calcitonin

    • Calcitriol

    • Calcium

    • Cholecalciferol

    • Cinacalcet

    • Fluoride

    • Paricalcitol

    • Teriparatide

    Correct Answer
    A. Teriparatide
    Explanation
    Teriparatide is a recombinant PTH 1-34, meaning it is a synthetic form of parathyroid hormone that contains the first 34 amino acids of the PTH molecule. It is used to treat osteoporosis by stimulating bone formation and increasing bone mineral density.

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  • 3. 

    DIRECTIONS 1-5 Match each drug affecting bone mineral homeostasis with the appropriate description (each lettered option can be selected only once): This drug can induce osteoclast apoptosis

    • Alendronate

    • Calcipotriene

    • Calcitonin

    • Calcitriol

    • Calcium

    • Cholecalciferol

    • Cinacalcet

    • Fluoride

    • Paricalcitol

    • Teriparatide

    Correct Answer
    A. Alendronate
    Explanation
    Alendronate is a drug that can induce osteoclast apoptosis. This means that it can cause the death of osteoclasts, which are cells responsible for breaking down bone tissue. By inducing osteoclast apoptosis, alendronate helps to slow down bone resorption and maintain bone mineral homeostasis.

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  • 4. 

    A 63-year-old woman, suffering from osteoporosis, had been receiving alendronate, and calcium and vit D supplementation for two years, but a recent dual-energy x-ray absorptiometry showed a significant decrease in bone density. The patient history was significant for a femur fracture 8 months ago and a rib fracture one months ago. The physician decided to add teriparatide to the current therapy. Which of the following actions most likely mediated the therapeutic effect of the drug in this patient?

    • Stimulation of osteoblast activity

    • Stimulation of renal calcium excretion

    • Inhibition of renal phosphate excretion

    • Inhibition of osteoclast activity

    • Inhibition of renal synthesis of calcitriol

    Correct Answer
    A. Stimulation of osteoblast activity
    Explanation
    Answer: A
    Teriparatide is a recombinant PTH 1-34. Eve if PTH can increase both osteoblast and
    osteoclast activity, the net effect of excess of PTH is an increase in bone resorption (bone
    calcium, phosphate, collagen and proteins decrease). However low and intermittent doses of
    PTH increases bone formation (by increasing osteoblast activity) without stimulating bone
    resorption. This has lead to the recent approval of teriparatide for the treatment of osteoporosis.
    The drug should be reserved should be reserved for those patients with a high risk of fracture,
    like in the present case.
    B, C) Actually PTH does the opposite.
    D) PTH stimulates, not inhibits, osteoclast activity, but this does not occur when therapeutic
    doses of teriparatide are given.
    E) PTH stimulates, not inhibits, the renal synthesis of calcitriol.

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  • 5. 

    DIRECTIONS 1-5 Match each drug affecting bone mineral homeostasis with the appropriate description (each lettered option can be selected only once): This drug is secreted by the parafollicular cells of the thyroid gland

    • Alendronate

    • Calcipotriene

    • Calcitonin

    • Calcitriol

    • Calcium

    • Cholecalciferol

    • Cinacalcet

    • Fluoride

    • Paricalcitol

    • Teriparatide

    Correct Answer
    A. Calcitonin
    Explanation
    Calcitonin is the drug that is secreted by the parafollicular cells of the thyroid gland.

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  • 6. 

    Which of the following actions most likely mediates the therapeutic efficacy of calcitriol in rickets?

    • Stimulation of liver hydroxylation of cholecalciferol

    • Stimulation of renal alpha1-hydroxylase

    • Decreases intestinal phosphate absorption

    • Increased intestinal calcium absorption

    • Decreased renal phosphate reabsorption

    Correct Answer
    A. Increased intestinal calcium absorption
    Explanation
    Intestinal calcium absorption is potently augmented by calcitriol and this seems the main action
    that mediates the therapeutic efficacy of calciferols in rickets and in osteomalacia. There is little
    evidence that calcitriol directly promotes bone mineralization. Rather is the increased serum
    calcium levels that indirectly promotes bone mineralization by decreasing PTH-mediated bone
    resorption.
    A, B, C, E) (See explanation above)

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  • 7. 

    A 49-year-old woman complained to her physician of occasional, severe back pain. Medical history of the patient was significant for mastectomy for breast cancer four years ago, and for an episode of severe angioedema which occurred six month ago after a prophylactic treatment with hepatitis A immune globulin. An x-ray showed diffuse osteoporosis. Which of the following drugs would be most appropriate for this patient?

    • Ethynil estradiol

    • Calcitonin

    • Alendronate

    • Sodium fluoride

    • Cinacalcet

    • Sodium phosphate

    Correct Answer
    A. Alendronate
    Explanation
    Answer: C
    The current options for the pharmacological therapy of osteoporosis are bisphosphonates,
    SERMs, calcitonin, PTH (teriparatide) and estrogens. Bisphosphonates are first line therapy
    since they preserve bone mass, can decrease vertebral and hip fractures by > 50% and have
    low toxicity. Moreover in this patient:
    A) Estrogens are contraindicated because of previous breast cancer.
    B) Calcitonin is contraindicated because of a previous severe allergic reaction to a protein.
    D) Fluoride is not approved for osteoporosis since the results of this treatment are still
    controversial.
    E, F) These drugs are contraindicated since they decrease serum calcium levels.

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  • 8. 

    A 70-year-old woman suffering from osteoporosis and hypertension, has been treated for the last three years with raloxifene and calcium carbonate (1.5 g daily) for osteoporosis and with hydrochlorothiazide for hypertension. In spite of the therapy, a recent bone mineral density showed a significant decrease in bone mass. Which of the following would be an appropriate change in the treatment plan of this patient?

    • To substitute hydrochlorothiazide with propranolol

    • To substitute raloxifene with ethinyl-estradiol

    • To add calcitonin to the present regimen

    • To increase the daily dose of calcium carbonate

    • To add prednisone to the present regimen

    • To add alendronate to the present regimen

    Correct Answer
    A. To add alendronate to the present regimen
    Explanation
    Answer: F
    Bisphosphonates are first line therapy for osteoporosis, so adding alendronate to the present
    regimen is a rational choice, since the therapy failed to prevent the decrease in bone mass.
    A) This option is irrational. Hydrochlorotiazide is useful in osteoporosis since it decreases the
    renal excretion of calcium.
    B) SERMs are today preferred over estrogens for the therapy of osteoporosis since they do not
    increase the risk of breast and endometrial cancer.
    C) Calcitonin is less effective than bisphosphonates in the therapy of osteoporosis.
    D) The dose of calcium taken by the patient is the standard dose for calcium supplementation in
    postmenopausal women. It is quite unlikely that a larger dose may add additional benefit.
    E) Glucocorticoid are contraindicated in osteoporosis since they increased bone reabsorption.

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  • 9. 

    A 56-year-old woman complained to her physician of frequent heartburn and pain in the substernal region. The woman, recently diagnosed with postmenopausal osteoporosis, started an appropriate therapy two weeks previously. Which of the following drugs most likely caused the patient’s symptoms?

    • Prednisone

    • Calcitonin

    • Raloxifene

    • Teriparatide

    • Alendronate

    Correct Answer
    A. Alendronate
    Explanation
    Answer: E
    When administered by oral route bisphosphonates (mainly alendronate)can cause frequently
    esophageal and gastric irritation. Because of this patients are often instructed to take the
    medication early in the morning on an empty stomach with a large glass of water and then to
    stay upright for 30 minutes in order to reduce the chance of esophageal irritation.
    A) Glucocorticoids can cause gastric irritation but they are contraindicated in osteoporosis.
    B, C, D) These drugs are used in case of osteoporosis but their risk of esophageal and gastric irritation is very low.

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  • 10. 

    DIRECTIONS 1-5 Match each drug affecting bone mineral homeostasis with the appropriate description (each lettered option can be selected only once): This drug activates a calcium-sensing receptor on the parathyroid glands

    • Alendronate

    • Calcipotriene

    • Calcitonin

    • Calcitriol

    • Calcium

    • Cholecalciferol

    • Cinacalcet

    • Fluoride

    • Paricalcitol

    • Teriparatide

    Correct Answer
    A. Cinacalcet
    Explanation
    Cinacalcet activates a calcium-sensing receptor on the parathyroid glands.

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  • 11. 

    A 46-year-old man presented to the hospital with complains of muscle weakness, fatigue, constipation, nausea and polyuria. Past medical history was unremarkable. Pertinent laboratory values on admission were: calcium of 14.5 mg/dL, phosphate 2.1 mg/dL and immunoreactive parathyroid hormone level of 142 pg/mL (normal 11-54). Which of the following drugs was most likely included in the therapeutic management of the patient?

    • Calcitriol

    • Hydrochlorothiazide

    • Sodium fluoride

    • Mannitol

    • Calcitonin

    Correct Answer
    A. Calcitonin
    Explanation
    Answer: E
    The symptoms of the patient, together with the high calcium level, the low phosphorus level and
    the high parathyroid hormone level are consistent with the diagnosis of primary
    hyperparathyroidism. In fact PTH values are elevated in >90% of parathyroid-related causes of
    hypercalcemia, undetectable or low in malignancy-related hypercalcemia, and undetectable or
    normal in high-bone-turnover causes of hypercalcemia. The approach to medical treatment of
    hypercalcemia varies with its severity. Mild hypercalcemia (< 12 mg/dL), can be managed by
    hydration. More severe hypercalcemia (13 to 15 mg/dL) must be managed aggressively
    because above that level hypercalcemia can be life-threatening and requires emergency
    measures. Therefore the more severe the hypercalcemia, the greater the number of combined
    therapies that should be used.
    The mainstay of treatment, in patients with normal renal function, is to increase renal calcium
    excretion with IV saline and furosemide, which inhibits calcium reabsorption in the thick
    ascending limb of Henle. Bisphosphonates, which are long-lasting inhibitors of bone resorption,
    have become drugs of choice for the antiresorptive treatment of hypercalcemia In addition
    calcitonin could be given for its rapid albeit short-lived, blockade of bone resorption. An effect
    on serum calcium is observed within 4-6 hours and last 6-10 hours).
    A) Calcitriol is contraindicated in this case since it tends to increase serum calcium level. .
    B, C) Thiazides are contraindicated since they enhance calcium reabsorption in the distal
    convolute tubule. Fluoride stimulate bone formation, but the doses that cause hypocalcemia are
    toxic and the drug is not used for this purpose.
    D) Potassium sparing diuretics have low efficacy and are contraindicated in this case since they
    tend to enhance calcium reabsorption in the distal convolute tubule are

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  • 12. 

    A 52-year-old woman was admitted to the hospital because of tetanic muscle spasms and paresthesias following a recent thyroidectomy. Which of the following drugs given IV could rapidly reverse the patient’s symptoms?

    • Vitamin D

    • Calcitonin

    • Sodium phosphate

    • Calcium gluconate

    • Hydrocortisone

    • Alendronate

    Correct Answer
    A. Calcium gluconate
    Explanation
    Answer: D
    The symptoms and the history of the patient indicate that she is suffering from severe
    hypocalcemia secondary to hypoparathyroidism, likely due to accidental damage of parathyroid
    glands during thyroidectomy. The treatment of severe hypocalcemia can be best accomplished
    with slow infusion of calcium gluconate (the preferred calcium salt for Iv therapy because it is
    less irritating for veins.
    A) Vitamin D can increase calcium levels but its onsets of action is too slow for an emergency
    therapy
    B, C, E, F) All these drug are actually contraindicated since they decrease serum calcium
    levels.

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  • 13. 

    A 62-year-old man was admitted to the hospital because of increasing pain in the back and left upper thigh over the past month. The patient also complained that recently he felt drowsy and tired most of the time and urinated very frequently. Past history of the patient was significant for radical prostatectomy for prostate cancer six months ago. Physical examination showed a dehydrated man less alert than normal and slow in his responses. Pertinent laboratory values on admission were: calcium 13.5 mg/L, alkaline phosphatase 204 U/L. An appropriate therapy was started which included an IV infusion of a drug. Which of the following drugs was most likely infused IV?

    • Sodium phosphate

    • Hydrochlorothiazide

    • Pamidronate

    • Mannitol

    • Calcitriol

    • Fludrocortisone

    Correct Answer
    A. Pamidronate
    Explanation
    Answer: C
    The symptoms and signs of the patient and the elevated alkaline phosphatase indicated that he
    was most likely suffering for hypercalcemia due to bone metastases of prostate cancer.
    Rehydration with saline and diuresis with furosemide are the first step of the treatment of severe
    hypercalcemia. Bisphosphonates like pamidronate, infused over at least 15 minutes, have been
    approved for the acute treatment of hypercalcemia of malignancy.
    A) IV sodium phosphate is probably the fastest way to lower serum calcium level, but it is an
    hazardous procedure because of the risk involved (sudden hypocalcemia, ectopic calcification,
    hypotension, acute renal failure). In light of satisfactory responses to other agents, IV sodium
    phosphate cannot be recommended as a mean to treat hypercalcemia Therefore IV phosphate
    should be used only after other method of treatment have failed to control hypercalcemia.
    B, D, E, F) These drug s are ineffective of contraindicated in case of hypercalcemia.

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  • 14. 

    Which of the following drugs appears to facilitate new bone formation if concomitant calcium supplementation is adequate?

    • Phenytoin

    • Fluoride

    • Thyroxine

    • Leuprolide

    • Prednisone

    Correct Answer
    A. Fluoride
    Explanation
    Answer: B
    If calcium supplementation is adequate, fluoride can increase bone formation and trabecular
    bone volume. However the new bone appear to be structurally abnormal and is associated with
    an increased incidence of fractures. For these reasons the use of fluoride in the therapy of
    osteoporosis remains controversial.
    A, C, D, E) All these drugs tend to decrease, not to increase, new bone formation.

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  • 15. 

    A 50-year-old man presented to the hospital because of increasingly severe bone pain, which is accentuated at night, headache, fatigue and decreasing auditory acuity. Pasts history of the patient was significant for gastroesophageal reflux disease presently treated with omeprazole. Physical examination revealed skull enlargement, a hobbing gait and anterolateral bowing of the legs with warmth and periosteal tenderness. A X-ray exam showed increased bone density, cortical thickening and bony enlargement. Laboratory results showed alkaline phosphatase of 230 I.U./L (normal 20-90). Which of the following drugs would be appropriate for this patient?

    • Calcitonin

    • Alendronate

    • Calcium carbonate

    • Sodium fluoride

    • Raloxifene

    • Calcitriol

    Correct Answer
    A. Calcitonin
    Explanation
    Answer: A
    The symptoms and signs of the patient indicate that he is most likely affected by Paget’s
    disease of bone, a chronic disorder of the adult skeleton in which bone turnover is accelerated
    in localized areas. Bisphosphonates are first line agents for this disease. Calcitonin an
    alternative to bisphosphonates whin this drugs are contraindicated, as in the present case (see
    below).
    B) Bisphosphonates are relatively contraindicated in patients with gastrointestinal reflux
    disease, esophagitis, gastritis and peptic ulcer.
    C, D, E, F) These drugs are useless in Paget’s disease.

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  • 16. 

    A 4-year-old black boy was brought to the emergency room after he fell while playing in the yard. Physical examination revealed only minor skin scratches but an x-ray exam showed 2 rib fractures, a clearly demineralized bone and widening and cupping of metaphyses with exaggerated normal concavity and irregular calcification. Pertinent laboratory values were: calcium 8.3 mg/dL, phosphate 3.2 mg/dL, and a two fold increase in alkaline phosphatase. Which of the following would be an appropriate treatment for this boy?

    • Cholecalciferol

    • Calcitonin

    • Fluoride

    • Teriparatide

    • Alendronate

    Correct Answer
    A. Cholecalciferol
    Explanation
    Answer: A
    The symptoms and signs of the patient together with the lab results suggest that he is suffering
    from rickets, a disease that can affect children, more often the black ones, since skin
    pigmentation makes ultraviolet irradiation more difficult. Rickets is due to vitamin D deficiency
    which in turn causes deficient mineralization of epiphyseal cartilages and osteoid matrix.
    Vitamin D deficiency tend to cause hypocalcemia. When this occurs PTH production is
    increased. Thus the serum level of calcium is restored to nearly normal by hypophosphatemia
    persists and so mineralization of bone is impaired. Cholecalciferol (Vit D3) supplementation with
    adequate calcium and phosphate intake is the standard therapy for rickets.
    B, C, D , E) (see explanation above)

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  • 17. 

    A 52-year-old homeless man with a 15 year history of alcoholism was brought to the hospital by the police who found him laying on the street. Physical examination showed a disheveled, confused and cachectic man with prominent veins on a very tense abdomen. Pertinent laboratory values on admission were: calcium 5.5 mg/L, ALT 300 U/L (normal 8- 35), AST 255 U/L (normal 8-35). An x-ray disclosed diffuse demineralization of bones. An appropriate therapy was ordered. Which of the following drugs was most likely included in the therapeutic management of this patient?

    • Teriparatide

    • Cholecalciferol

    • Sodium fluoride

    • Calcitriol

    • Calcipotriene

    Correct Answer
    A. Calcitriol
    Explanation
    Answer: D
    The symptoms, the lab results and the history of the patient indicate that he was most likely
    suffering from alcoholic cirrhosis. The bone demineralization and the low calcium levels suggest
    that the diffuse liver disease caused an impaired synthesis of 25(OH)D with the final outcome of
    osteomalacia. Calcitriol is the most effective agent for hypocalcemia in a patient with impaired
    liver function since it bypass the impaired synthesis of the agent.
    A) Patients with hypocalcemia have already an increased production of PTH, so teriparatide can
    add very little to the therapy.
    B) Vit D3 is not effective because the liver cannot provide the 25 hydroxylation.
    C, E )(see explanation above)

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  • 18. 

    A 42-year-old man with 25-year history of type 1 diabetes presented for a control visit. His laboratory values were: glucose 190 mg/dL, calcium 11.2 mg/dL, phosphate 5.3 mg/dL, creatinine 4.9 mg/dL. An x-ray exam revealed density changes in the bones that were consistent with renal osteodystrophy. Which of the following drugs should be included in the treatment plan for this patient?

    • Alendronate

    • Calcitonin

    • Paricalcitol

    • Sodium fluoride

    • Sodium phosphate

    Correct Answer
    A. Paricalcitol
    Explanation
    Answer: C
    The high creatinine levels of the patient point out that the patient was most likely suffering from
    chronic renal failure, presumably due to diabetic nephropathy (the most common cause of renal
    failure in the U.S.). Chronic renal failure can cause renal osteodystrophy, a term used to
    describe collectively all the skeletal changes in chronic renal disease. Renal osteodystrophy is
    due to several factors which include loss of calcitriol production because the damaged kidney
    cannot activate the renal alpha1-hydroxylase which converts 25(OH) D3 into calcitriol. This
    contributes to secondary hyperparathyroidism (remember that calcitriol suppresses PTH gene
    expression and secretion) which in turn can cause increased bone resorption. In chronic renal
    failure calcitriol should be initiated as long as serum phosphate is not significantly elevated.
    Paricalcitol, synthetic analog of calcitriol, is preferred when the secondary hyperparathyroidism
    is pronounced, like in the present case (see the high serum calcium levels) because it may
    lower PTH levels without significantly increasing serum calcium levels.
    A, B, D, E) (see explanation above)

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  • 19. 

    DIRECTIONS 1-5 Match each drug affecting bone mineral homeostasis with the appropriate description (each lettered option can be selected only once): This drug can inhibit the gene expression of PTH

    • Alendronate

    • Calcipotriene

    • Calcitonin

    • Calcitriol

    • Calcium

    • Cholecalciferol

    • Cinacalcet

    • Fluoride

    • Paricalcitol

    • Teriparatide

    Correct Answer
    A. Calcitriol
    Explanation
    Calcitriol is the correct answer because it can inhibit the gene expression of PTH.

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  • 20. 

    A 47-year-old man presented to his physician complaining of recurring skin lesions most prominent over the scalp, extensor surfaces of elbows and knees, buttock an penis. The man also complained of increasing pain in his left hand and left hip. Physical examination showed oval erythematous plaques covered with thick, silvery, shiny scales. The distal interphalangeal joints of digits two and three of the left hand were swollen and tender. The physician told the patient the diagnosis and ordered a topical drug treatment. Which of the following drugs was most likely prescribed?

    • Fludrocortisone

    • Calcitonin

    • Calcipotriene

    • Erythromycin

    • Alendronate

    Correct Answer
    A. Calcipotriene
    Explanation
    Answer: C
    The symptoms and signs of the patient indicate that he was most likely affected by plaque
    psoriasis, a common skin disorder that affects 1-5% of the population worldwide. The disease is
    diagnosed most often by clinical appearance and distribution of lesions. Arthritis develops in up
    to 30% of patients, like in the present case (see the swollen and tender joints). Calcipotriene is
    a topical vit D 3 analog which induces normal keratinocyte proliferation and differentiation.
    Improvement of psoriasis is generally noted following two weeks of therapy, with continued
    improvement for up to 8 weeks of treatment.
    A) Glucocorticoids, not mineralocorticoids, are used for psoriasis.
    B, D, E) (see explanation above)

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