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Bone and Joint Disorders Discussion Essays

Module VI: Bone and Joint Disorders Discussion

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Calcium and Vitamin D supplementation are essential to bone health and the management of osteopenia and osteoporosis.  In the past few years, information regarding the potential risks of too much calcium (such as cardiovascular disease and/or events) have been emerging.

• Using an article from a medical journal, evaluate and discuss the risks and benefits of calcium supplementation for a patient with a bone disease.
• What would you recommend for is a 59-year-old postmenopausal woman with a T-score of − 2.3. Her past medical history is unremarkable and she only takes a multivitamin with additional calcium and vitamin D. Her family history is remarkable for a mother who had osteoporosis and died of breast cancer and a father who has diabetes

Gout is a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint). Although there is no cure for gout, it can be effectively treated and managed with medication and self-management strategies

• A 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner
  • Provide an evaluation of the patient including possible risk factors and treatment options, including non-pharmacologic interventions
  • Would this patient be a candidate for prophylactic therapy?

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• • Additional questions to consider for Week VI moduleSubscribe
  • Kelly Miskovsky posted Oct 12, 2020 1:28 PM
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  • Your male patient has just been diagnosed with osteoporosis. What medication would you recommend that he start as first-line therapy for his disease?If you had a patient that was taking a proton pump inhibitor for her Gastrointestinal Reflux Disease (GERD) and also required a calcium supplement, which one would you recommend and why?less0 UnreadUnread
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  • How should you counsel your patient who has been started on alendronate? How should she take it and what are some common side effects associated with the drug?
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  • Anna McMullen posted Oct 5, 2020 6:32 PM
  • Calcium and Vitamin D supplementation are essential to bone health and the management of osteopenia and osteoporosis.  In the past few years, information regarding the potential risks of too much calcium (such as cardiovascular disease and/or events) have been emerging.
    • Using an article from a medical journal, evaluate and discuss the risks and benefits of calcium supplementation for a patient with a bone disease.

    The efficacy of calcium supplementation, with and without vitamin D, has been questioned as to whether supplementation prevents or treats osteoporosis, and if any potential benefits outweigh risks such as GI upset, kidney stones, and adverse cardiovascular effects (Chiodini & Bolland, 2018). The European Society of Endocrinology (2018) published a research article titled, “Calcium Supplementation: Useful or Harmful?” where each author defended an opposing viewpoint regarding the usefulness for bone health versus potential harm of calcium supplementation. Chiodini (2018) argues that calcium with concomitant vitamin D supplementation in osteoporosis is useful and leads to an increase in bone mineral density (BMD) and a reduction of overall fractures by 15% and specifically hip fractures by 30%. Chiodini (2018) suggests that calcium and vitamin D supplementation should not be encouraged for patients with normal intake and lab values, but only for patients with low dietary intake and levels, particularly if osteoporotic and taking bone-active drugs. Chiodini (2018) states, “reported cardiovascular risk due to calcium supplementation is yet to be demonstrated and that studies that have evaluated the influence of dietary calcium intake did not show increase in the cardiovascular risk.”

    • What would you recommend for is a 59-year-old postmenopausal woman with a T-score of − 2.3. Her past medical history is unremarkable and she only takes a multivitamin with additional calcium and vitamin D. Her family history is remarkable for a mother who had osteoporosis and died of breast cancer and a father who has diabetes.

    The patient in question has a T-score of -2.3 which is indicative of low bone mass, or osteopenia (T-score between -1 and -2.5), and is quite close to the cut-off for a diagnosis of osteoporosis (T-score less than -2.5) (Bone Mass Measurement: What the Numbers Mean, 2018). It is indicated that the patient’s past medical history is unremarkable and that the only medication she is currently taking is a multivitamin with extra calcium and vitamin D. In addition to the patient’s T-score, the patient is post-menopausal and has a family history of osteoporosis, both of which are non-modifiable risk factors that increase her risk for osteoporosis. Nonpharmacologic practices that the patient should incorporate into her life to minimize her risk of bone loss include not smoking, increasing dietary calcium and vitamin D intake (can also be completed through UV exposure), partaking in weight-bearing and resistance exercises, and minimizing or eliminating alcohol use (Chisholm-burns et al., 2019). If the patient had a history of fracture after the age of 50, demonstrated historical height loss of 1.5 inches of more or prospective height loss of 0.8 inches or more, or had past or present long-term glucocorticoid use, then drug therapy such as denosumab, teriparatide, or zoledronic acid would be recommended (Chisholm-burns et al., 2019, Figures 56-2). However, with what is known about this patient, appropriate recommendations would include a bone-healthy lifestyle and calcium with vitamin D based on age and female gender (Chisholm-burns et al., 2019, Figures 56-2).

    • A 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner
      • Provide an evaluation of the patient including possible risk factors and treatment options, including non-pharmacologic interventions
      • Would this patient be a candidate for prophylactic therapy?

    This patient possesses a few risk factors for an occurrence of gout which include being of the male sex, alcohol consumption, hypertension, and use of HCTZ, which can cause hyperuricemia (Chisholm-burns et al., 2019). The patient’s symptoms are consistent with an attack of gout in the respect that it was sudden, occurred in a joint, and was accompanied by severe pain (Mayo Clinic Staff, 2019). However, although these symptoms are highly suggestive of gout, they are not totally indicative, particularly since it was the patient’s first occurrence. Serum uric acid (SUA) levels may be beneficial in diagnosis, however, though often elevated they may be normal during an attack and therefore are not enough for a diagnosis (Chisholm-burns et al., 2019). In order to prevent a recurrence of gout, the patient can adhere to certain recommendations to decrease the amount of uric acid in his body such as drinking plenty of fluids, limiting or avoiding alcohol (particularly beer), consuming only low-fat dairy products, limiting intake of meat, fish, poultry, organ meats, and high-fructose corn syrup, as well as using an alternative anti-hypertensive medication and maintaining a healthy weight (Chisholm-burns et al., 2019; Mayo Clinic Staff, 2019). Since this was the patient’s first attack, non-pharmacologic interventions should be implemented and future attacks monitored as gout is an episodic disease and frequency of attacks vary to where it may or may not become a long-term issue for this patient. According to Chisholm-burns et al. (2019), patients with recurrent attacks of gout, defined as 2 or more per year, show evidence of tophus, are diagnosis with stage 2 CKD or worse, or history of urolithiasis are candidates for prophylactic therapy to lower SUA, and therefore, this patient does not meet criteria for prophylactic therapy. However, this patient should be advised to medicate with NSAIDs (treatment of choice- naproxen, indomethacin, and sulindac FDA approved for treatment of gout), colchicine, or corticosteroids at the first sign of his next attack to reduce pain and inflammation (Chisholm-burns et al., 2019).ReferencesChiodini, I., & Bolland, M. J. (2018). Calcium supplementation in osteoporosis: Useful or harmful? European Journal of Endocrinology, 178(4), D13–D25. https://doi.org/10.1530/eje-18-0113Mayo Clinic Staff. (2019, March 1). Gout – symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897 less0 UnreadUnread

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  • View profile card for Gisselle Mustiga
  • Last post Oct 11, 2020 10:16 PM by Gisselle Mustiga
  • Chisholm-burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.
  • Bone mass measurement: What the numbers mean. (2018). NIH osteoporosis and related bone diseases national resource center. Retrieved October 5, 2020, from https://www.bones.nih.gov/health-info/bone/bone-health/bone-mass-measure
  • Gout is a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint). Although there is no cure for gout, it can be effectively treated and managed with medication and self-management strategies
  • On the contrary, Bolland (2018) indicates that the risk-benefit of calcium supplementation is not favorable for most people that the small potential benefits in preventing fractures do not outweigh the potential harm. Additionally, Bolland (2018) indicates that compliance with calcium supplementation is poor due to side-effects of constipation and dyspepsia (common). In regards to more serious side-effects, Bolland (2018) indicates that calcium supplementation with vitamin D has demonstrated increased risk of kidney stones, acute GI symptoms resulting in hospitalization, hypercalcemia, and overall relative risk of myocardial infarction (MI), stroke, and sudden death. Bolland (2018) argues that there are numerically more serious adverse events than fractures prevented; the number needed to harm to cause one vascular event (i.e. 178) is less than the number needed to treat to prevent one fracture (i.e 302), and therefore supplementation benefit is not worth the risk;  instead, high-risk individuals should be prescribed treatments proven to prevent fracture.
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  • Augusta Ibeh posted Oct 7, 2020 6:47 AM
  •              Studies showed that adequate calcium and vitamin D is vital for bone health, but the importance of calcium and vitamin D in older adults is not clear, while some showed that calcium and Vitamin D supplements help in the reduction of fractures in older people. Experts have raised concerns about a potential effect of a high intake of calcium (with or without vitamin D) from foods and supplements on cardiovascular disease (CVD) outcomes. A meta-analysis of both study- and patient-level data from randomized trials showed that calcium with or without vitamin D supplementation increased the risk for myocardial infarction and stroke Chung et al. (2016).            T-score is the results of the bone mineral density (BMD) of a healthy young adult. The 0 score means a BMD is normal. The difference between BMD of a young adult norm is measured in units called the standard deviation (SDs). The more standard deviations below 0, shows negative numbers, the lower your BMD, the higher the risk for fracture. That is to state that T-score between _1 and _2.5 or lower indicates osteoporosis, the greater the negative number, the more severe the osteoporosis National Institute of Health.gov. (n.d.).

    Normal	Bone density is within 1 SD (+1 or −1) of the young adult mean.
    Low bone mass	Bone density is between 1 and 2.5 SD below the young adult mean (−1 to −2.5 SD).
    Osteoporosis	Bone density is 2.5 SD or more below the young adult mean (−2.5 SD or lower).
    Severe (established) osteoporosis	Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.

    The factors that affect serum uric acid (SUA) levels are age and gender, after puberty, SUA levels increases to reach normal level. In men, levels are higher than women, but at menopause, women SUA levels increase to reach men’s level Ragab et al. (2017). Therefore, gout is in the increase on middle aged men, older men and menopausal women.            Alcohol is well known factor for gout, depending on the amount consumed and the type of alcohol.  Beer is worst in increasing the risk of gout compared to liquor and the lowest risk is wine Ragab et al. (2017).              Management of gout includes the use of colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids, they can be taken together in severe symptoms. Colchicine when taken 12 hours of the flare up of gout shows to be more effective but the toxicity must be monitored such gastrointestinal intolerance, diarrhea, nausea or vomiting, neutropenia and multi-organ failure. Chung, M., University, F. T., Tang, A. M., Fu, Z., Wang, D. D., Newberry, S. J., . . . Margolis,    K. L. (2016). Calcium Intake and Cardiovascular Disease Risk. Retrieved from             https://www.acpjournals.org/doi/10.7326/M16-1165Föger-Samwald, U., Dovjak, P., Azizi-Semrad, U., Kerschan-Schindl, K., & Pietschmann, P.       (2020). Osteoporosis: Pathophysiology and therapeutic options. EXCLI journal, 19,           1017–1037. https://doi.org/10.17179/excli2020-2591less0 UnreadUnread

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  • View profile card for Augusta Ibeh
  • Last post Oct 11, 2020 5:58 PM by Augusta Ibeh
  • Ragab, G., Elshahaly, M., & Bardin, T. (2017). Gout: An old disease in new perspective – A             review. Journal of advanced research, 8(5), 495–511.          https://doi.org/10.1016/j.jare.2017.04.008
  • Bone Mass Measurement: What the Numbers Mean. (n.d.). Retrieved from             https://www.bones.nih.gov/health-info/bone/bone-health/bone-mass-measure#:~:text=A   T-score between −1, the more severe the osteoporosis.
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  •             Patient’s education on lifestyle changes, weight loss, avoiding beer consumption, restriction of seafoods, meat and non-alcoholic beverages such as spirit, sugar sodas and diet modifications, increase intake of skimmed-milk products, physical activities Ragab et al. (2017). The first line of drug for the treatment of gout is xanthine oxidase inhibitors, and the leading agents are allopurinol, probenecid. The proposed dosages are 50 to 100 mg/day to increase to a maximum of 800 mg/day. Patient will be monitored for adverse side effects such as diarrhea, nausea, vomiting, increased liver enzymes, skin reactions and hypersensitivity syndrome Ragab et al. (2017).
  •             Diagnosis of gout includes: SUA levels between 7 and 7.9 mg/dl but Hyperuricemia is a weak marker for gout diagnosis and the disease might still be diagnosed even with normal serum levels. The gold standard of diagnosis is the identification of Monosodium urate crystal (MSU) in synovial fluid aspirate using polarized light microscopy Ragab et al. (2017).  Other diagnostic procedures are Ultrasound to detect joint effusion and synovitis, bone erosions etc.
  •             The deficiency of enzymes that metabolize purine is the cause of overproduction of uric acid, example in Lesch-Nyhan syndrome in newborn and is called, hypoxanthine–guanine phosphoribosyltransferase which an X-linked dominant inherited disorder Ragab et al. (2017).  Foods high in purines such as cooked or processed food from animals and seafood, vegetables like beans, lentils, mushrooms, peas, legumes, and diary products do not have the risk for hyperuricemia and gout. Plant oils such as olive oil, sunflower, foods rich in vitamin C and soy do not have risk for hyperuricemia and gout. Vitamin C helps in the excretion of uric acid and as such can be used as supplement for gout management.
  •             Gout is a systemic disease that results from the deposition of monosodium urate crystals (MSU) in tissues. Increased serum uric acid (SUA) above a specific threshold is a requirement for the formation of uric acid crystals Ragab et al. (2017). Uric acid is a weak acid is a weak acid with pH of 5.8, the urate crystals deposition in the tissues from serum uric acid level is high above the normal blood level. The pathological threshold of hyperuricemia is defined as 6.8 mg/dl Ragab et al. (2017).
  •             59-year-old and postmenopausal woman with T-score of -2.3 has a low bone mass and if treated with supplemental calcium plus D and encourage her to eat foods that are rich in calcium (dairy products, leafy vegetables etc.) will be at risk for osteoporosis. Osteoporosis is a multifactorial disease with a complex interplay of genetic, intrinsic, exogenous, and lifestyle factors contributing to an individual’s risk of the disease Föger-Samwald et al. (2020).
  •             The chart below shows the level of T-score and the definition or extent of osteoporosis from the National Institute of Health.gov.
  •             In this article, randomized, controlled trials were used to examine the effects of calcium plus Vitamin D supplements to determine if Calcium with or without Vitamin D causes cardiovascular disease or stroke. Two studies looked at the effects of calcium plus vitamin D supplementation, while three studies evaluated the effects of calcium supplementation alone. The conclusion of the research stated that calcium intake within tolerable upper intake levels (2000 to 2500 mg/d) is not associated with cardiovascular risk in health adults Chung et al. (2016).
  •             Calcium is a nutrient for the maintenance of bone health and in the regulation of vascular contraction, vasodilation, muscle function, nerve transmission, intracellular signaling and hormonal secretion. Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations, enabling normal bone mineralization and preventing hypokalemic tetany Chung et al. (2016).
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  • Jessica Faltinowski posted Oct 5, 2020 9:16 PM
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  • Module 6:  Bone and Joint DisordersDiagnosis of osteoporosis vs osteopenia is based upon bone mineral density (BMD) at the spine and hip, which is best achieved through dual-energy X-ray absorptiometry (DXA).  Then a “T score” is assigned.  Kling defines a T- score as “the difference in number of standard deviations (SDs) from the mean BMD of a normally distributed, healthy adult reference population (2014, para.3).  A score of less than -2.5 indicates a diagnosis of osteoporosis, while a score between -1 to -2.5 indicates osteopenia (Ibrahim et al., 2019).  Osteopenia, if left untreated will likely become osteoporosis.  Our 59-year-old post-menopausal patient has a T-score of -2.3, which puts her within the upper limits of a diagnosis of osteopenia, but indicates intervention is needed, as she has a is likely to develop osteoporosis within 1 year (Kling et al., 2014) without treatment.Benefits to calcium supplementation outweigh risks as the patient has a family history of diabetes, osteoporosis, and breast cancer.  However, before beginning therapy, it would be beneficial for our patient to have a fracture risk assessment tool (FRAX) completed.  The FDA and National Osteoporosis Foundation have approved and recommend therapy for patients with osteopenia, such as our patients, if the FRAX study shows a 10-year risk of hip fracture of at least 3% or the risk of hip or other osteoporotic fracture at 20% or higher  (Kling et al., 2014).  If the patients FRAX score demonstrates a 10-year risk, then she should first be started on a bisphosphonate such as alendronate, risedronate, or zoledronic acid.  Another possibility would be raloxifene, as this decreases bone resorption, decreases overall bone turnover, and decreases breast cancer risk in high risk postmenopausal women (Kling et al., 2014).   If the test did not indicate a 10-year risk, then the patient should be started on 1200 mg calcium along with cholecalciferol.  The patient would be encouraged to add in regular weight bearing exercises in addition to making dietary modifications, and to be screened yearly for BMD.Our patient has given us a history to indicate that his severe joint pain came on rapidly, as is common with acute episodes of gout.  Ingestion of alcohol was a precipitating factor as well.  Our patient has also endorsed a personal history of hypertension, which is a common comorbidity with gout.  Additionally, our patient is taking hydrochlorothiazide, a diuretic, which is also a risk factor for hyperuricemia (Dalbeth et al., 2016).  As diuretics are a risk factor for hyperuricemia, the patient would likely be a better candidate for losartan as it has been shown to increase uric acid excretion in some patients (Abhishek et al., 2017).At this time, the patient will be instructed in dietary modifications including reducing alcohol consumption, decreasing consumption of high fructose corn syrup, red meat, and other foods high in purines.  Long term urate lowering therapy such as xanthine oxidase inhibitors (allopurinol and febuxostat) or urate lowering therap,y such as probenecid is not recommended, unless the patient is having frequent flares or trophi, as there is an association with low serum urate and neurological disorders (Dalbeth et al., 2016).   Currently, our patient is not a candidate for prophylactic therapy.  However, he will be monitored every 6 months and recommendations reevaluated if he continues to have flares.ReferencesDalbeth, N., Merriman, T. R., & Stamp, L. K. (2016). Gout. The Lancet, 388(10055), 2039–2052. https://doi.org/10.1016/s0140-6736(16)00346-9Kling, J. M., Clarke, B. L., & Sandhu, N. P. (2014). Osteoporosis prevention, screening, and treatment: A review. Journal of Women’s Health, 23(7), 563–572. https://doi.org/10.1089/jwh.2013.4611 less1 UnreadUnread10 ViewsViews
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  • View profile card for Shante Hunt
  • Last post Oct 11, 2020 4:32 PM by Shante Hunt
  • National Academy of Medicine. (2010, November 30). IOM report sets new dietary intake levels for calcium and vitamin d to maintain health and avoid risks associated with excess. Retrieved October 4, 2020, from http://www.nationalacademies.org/news/2010/11/iom-report-sets-new-dietary-intake-levels-for-calcium-and-vitamin-d-to-maintain-health-and-avoid-risks-associate-with-excess#:~:text=The%20upper%20intake%20levels%20for%20calcium%20are%202%2c500%20milligrams%20per,for%20all%20other%20age%20groups
  • Ibrahim, N., Nabil, N., & Ghaleb, S. (2019). Pathophysiology of the risk factors associated with osteoporosis and their correlation to the t-score value in patients with osteopenia and osteoporosis in the united arab emirates. Journal of Pharmacy And Bioallied Sciences, 11(4), 364. https://doi.org/10.4103/jpbs.jpbs_4_19
  • Abhishek, A., Roddy, E., & Doherty, M. (2017). Gout – a guide for the general and acute physicians. Clinical Medicine, 17(1), 54–59. https://doi.org/10.7861/clinmedicine.17-1-54

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  • Last post Oct 11, 2020 11:53 AM by Candace Whitman-Workman
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  • Kathryn Mosholder posted Oct 7, 2020 11:28 PM
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  • Calcium and Vitamin D SupplementationFor a fifty-nine-year-old woman who is postmenopausal and has a T-score of 2.3 with no significant medical history who takes calcium and vitamin D supplements and has a family history of osteoporosis, cancer, and diabetes, I would recommend assessment first (Chisholm-Burns et al., 2019). The review of BMD, imaging, labs, and biochemical markers for bone turnover (Chisholm-Burns et al., 2019). Treatment for this patient would be to prevent activities that increase her risk for fractures, maintain a high BMD, and prevent bone loss as much as possible (Chisholm-Burns et al., 2019). I would recommend trying Denosuma since it is recommended for postmenopausal osteoporosis. Along with Vitamin D and Calcium supplementation (Chisholm-Burns et al., 2019).The case scenario is as follows: a 45-year-old white man presents to your office complaining of left knee pain that started last night. He says that the problem started suddenly after dinner and was severe within 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He is most likely suffering from gout. He has a history of hypertension, for which he takes hydrochlorothiazide (HCTZ (Chisholm-Burns et al., 2019)). He admits to consuming a significant amount of wine last night with dinner.                                        ReferencesBillington, E. O., Bristow, S. M., Gamble, G. D., Kwant, J. A. D., Stewart, A., Mihov, B. V., … Reid, I. R. (2016). Acute effects of calcium supplements on blood pressure: randomized, crossover trial in postmenopausal women. Osteoporosis International, 28(1), 119–125. https://doi.org/10.1007/s00198-016-3744-yDalbeth, N., Merriman, T. R., & Stamp, L. K. (2016). Gout. The Lancet, 388(10055), 2039-2052. http://dx.doi.org.wilkes.idm.oclc.org/10.1016/S0140-6736(16)00346-9less1 UnreadUnread11 ViewsViews
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  • View profile card for Pawn Johnson-Hunter
  • Last post Oct 10, 2020 11:46 PM by Pawn Johnson-Hunter
  • Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Bookstaver, P. B., & Lee, K. C. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education.
  • Abrahamsen, B. (2017). The calcium and vitamin D controversy. Therapeutic Advances in Musculoskeletal Disease, 9(5), 107–114. https://doi.org/10.1177/1759720×16685547
  • Additionally, alcohol consumption is contraindicated when a patient has gout because it raises uric acid, making gout even worse (Chisholm-Burns et al., 2019). Hydrochlorothiazide can also exacerbate and increase uric acid levels and the prevalence of gout occurrences (Chisholm-Burns et al., 2019). So a change to another medication is recommended if this patient keeps having gout (Chisholm-Burns et al., 2019). NSAIDs, colchicine, and corticosteroids are the recommended first-line treatment for gout(Chisholm-Burns et al., 2019). For this patient, I would do prescribe NSAIDs and colchicine. If the patient did not respond favorably and is still having a lot of pain after 24 hrs, I would prescribe prednisone (Chisholm-Burns et al., 2019). This patient is a candidate for prophylactic therapy(Chisholm-Burns et al., 2019). I would recommend starting Allopurinol with the colchicine making sure a prophylactic colchicine dose is given 12 hrs after the last initial acute treatment dose(Chisholm-Burns et al., 2019). Long term treatment will reduce the serum urate to less than 360 μmol/L. By lowering the serum urate crystals, dissolve, and gout flares occur less often (Dalbeth et al., 2016). Unfortunately, continued long-term gout treatment is rare, and many patients experience flares due to undermanagement of long-term regiments (Dalbeth et al., 2016).
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  •              There are many benefits and risks related to starting a patient on calcium supplementation, especially if they have a bone disease.  One negative side effect of calcium supplementation is that with calcium supplementation in women, blood pressures tend to be between 6-9 mmHg higher than those who did not take calcium supplementation (Billington et al., 2016). Women with already high blood pressure and are on medication will still show higher blood pressure readings six hours after taking their calcium supplement (Billington et al., 2016). Some clinical trials have also suggested that the combination of calcium and vitamin D is related to fewer fractures and reduced morbidity (Andersson et al., 2017). Additionally, some clinical trials feel no significant benefit in calcium and Vit D supplementation for the average healthy patient. It only my benefit a nutritionally deficient patient (Andersson et al., 2017).  In summary, these two articles indicate that some supplementation may cause a risk to blood pressure and cardiac health; however, for a deficient patient, the benefits could outweigh the risks. When deciding to supplement calcium and vitamin D, the provider should consider each patients’ medical condition.
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  • Pawn Johnson-Hunter posted Oct 7, 2020 11:55 PM
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  • The most widely used over the counter medications are vitamin supplementation. The use of vitamin supplementation can have adverse effects if not used with caution to overuse and interact with prescribed medication therapies. The most common unwanted effects of calcium; overuse may include cardiovascular, musculoskeletal, gastrointestinal disturbances, and renal problems. Hypercalcemia is due to the impact of a high level of calcium in the blood, resulting in acute kidney injury (AKI) and arterial hypertension (Bormann, 2019). However, the supplement is often recommended for a patient with bone mineral density (BMD), such as elderly and menopausal women. Calcium supplementation should have transient effects on BMD, and the effects may well be limited to persons with inadequate intake or absorption of calcium (Abrahamsen, 2017).HRT (estrogen alone or combined with progestogen or another agent [such as bazedoxifene]) is used to prevent and treat osteoporosis in postmenopausal women with the goal of inhibiting bone resorption and reducing the risk of osteoporotic fractures (DynaMed, 2018).The 45-year-old male patient who has presenting symptoms of knee painNon-pharmacologic methods include immobilization of the affected extremity, applying ice packs to the joint, and reduction/avoidance of foods that will aggravate gouty arthritis. According to Chisholm-Burns 2019, prophylactic therapy is recommended for patients who have two or more episodes per year, chronic kidney disease, or past urolithiasis are candidates for uricosuric agents.ReferencesHormonal Replacement Therapy (HRT) and Osteoporosis. (2018, October 2). https://www.dynamed.com/management/hormonal-replacement-therapy-hrt-and-osteoporosis.Von Bormann, S., Suksompong, S., & von Bormann, B. (2019). A rare case of acute kidney injury and anemia induced by hypercalcemia. Clinics and Practice, 9(2), 1117. doi:10.4081/cp.2019.1117less1 UnreadUnread8 ViewsViews
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  • Last post Oct 10, 2020 6:32 PM by Augusta Ibeh
  • Sheu, W. H. (2020). Lowering the risk of gout: another benefits from the use of sodium-glucose cotransporter 2 inhibitors. Journal of Diabetes Investigation, 11(5), 1115-1116. doi:10.1111/jdi.13254
  • Abrahamsen, B. (2017). The calcium and vitamin D controversy. London, England: SAGE Publications. doi:10.1177/1759720X16685547
  • The risk of gout exists with his hypertension diagnosis, increased drinking wine, and his prescription drug hydrochlorothiazide (HCTZ). Elevated circulating uric acid concentrations are associated with an increased risk of hypertension, cardiovascular disease, and chronic kidney disease (Sheu, 2020). Treatment options may include corticosteroids; it appears that he may be having an acute attack. Corticosteroids are considered the first-line therapy for acute gouty episodes followed by management with NSAID on the first sign of a flare. The recommended dosing for prednisone of 0.5mg/kg daily for five to ten days, followed by abrupt discontinuation (Chisholm-Burns, 2019).
  • Other options include treatment with bisphosphonate medications. Nonpharmacologic therapies would be aimed at increasing dietary and nutrition to high vitamin D concentrated foods, exercise, and the reduction/prevention of falls.
  • The 59-year-old postmenopausal woman with a T-score of – 2.3 indicates a lower bone density. With her family history of osteoporosis and current postmenopausal state, she is at high risk of developing osteoporosis even though she is currently taking supplementation. In this case, it would be beneficial for her to continue with vitamin D and calcium, also take estrogen supplementation…
  • Karen Halter
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  • Karen Halter posted Oct 5, 2020 6:37 PM
  • Pharm Module 6Regarding our young 59-year-old female, her T-score indicates that she is suffering from osteopenia and that she would benefit from proper calcium intake. I would educate her on calcium rich foods, weight bearing exercises, and assure that between diet and supplements that her daily calcium intake was meeting the recommended 1200 mg per day. I would have her do a food diary and supplement her calcium requirement to meet this goal.  ReferencesHandler, J. (2010). Managing hypertensive patients with gout who take thiazide. The Journal of Clinical Hypertension, 12(9), 731–735. https://doi.org/10.1111/j.1751-7176.2010.00346.xless0 UnreadUnread
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  • The risks and benefits of calcium supplementation. (2015). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384676/
  • Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). Mcgraw-hill Education / Medical.
  • Moving on to our unfortunate gentleman, it sounds as if he is having an episode of gout in his knee. Non-pharmacy modalities can play an adjunctive role in the treatment of gout and I would recommend ice to decrease pain and immobilization of the joint.(Chisholm-burns et al., 2019, p. 917) Precipitating factors to his gout can be contributed to his HCTZ use and increase in alcohol consumption both which can block uric acid secretion in the kidneys.(Chisholm-burns et al., 2019, p. 915) Handler does not recommend changing antihypertensive therapy for 0-1 episodes of gout per year, but rather treat with lifestyle modifications and possibly treat with NSAIDS for 48 hours. (Handler, 2010)Prior to recommending any NSAID therapy I would evaluate kidney function and provide education on diet and alcohol consumption.
  • Osteoporosis is a common skeletal disorder that causes reduction in the quality of life and increased mortality and morbidity. (Chisholm-burns et al., 2019, p. 875) The risks and benefits of calcium supplementation has been discussed due to emerging data regarding cardiovascular disease. Although some studies point to a correlation of calcium supplements and heart disease, many scholars feel that the data does not support the adverse effects.(The Risks and Benefits of Calcium Supplementation, 2015) The Auckland Calcium Study reported an increase in cardiovascular effects with calcium supplements, but a large consensus feels as if the skeletal benefits outweigh the risk factors. It was also noted that the studies were conducted in countries that had available dietary calcium and perhaps the participants of the study had an excess of calcium. (The Risks and Benefits of Calcium Supplementation, 2015) Due to the high mortality/morbidity that fractures in the elderly cause from osteoporosis, I feel a proper dose of calcium and vitamin D supplements in populations at risk for osteoporosis is warranted.
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  • Carlita Lockett posted Oct 6, 2020 10:21 PM
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  •              It is surprising that an individual who requires calcium supplementation could be causing harm to themselves by doing so.  There are some positive benefits associated with calcium supplementation.  Adequate calcium intake is essential for the maintenance of bone health during growing phases and the preservation of bone mineral density in elderly individuals (Kim & Shin, 2015).   It is important to replace loss calcium for women and elderly patients to reduce bone loss and enhance bone density to prevent a fracture during a fall.    A number of adverse events are possibly influenced by calcium supplementation; these include myocardial infarction, constipation, colorectal neoplasms, and kidney stone (Chen et al., 2018).           The passage discussing the 45-year-old patient has a few factors that could be an issue for him regarding gout.  The first factors would be the patient’s age and sex.  Generally, gout affects men who are between 30-50 years old.  Another factor would be his large consumption of wine.  Wine would be a factor because of its high purine content, which can cause an acute attack.  Alcohol is a well-known risk factor for gout.  Studies show that alcohol consumption is related to the amount consumed (Bardin et al., 2017).  I would classify his episode as an acute gouty attack.  Acute gouty attack is usually monoarthritic that peaks within hours to severely inflamed joint with cardinal signs of inflammation including redness, hotness, tenderness, swelling, and loss of function.  In large joints, such as knees and ankles, skin signs are infrequent, but swelling and pain can be intense (Bardin et al. 2017).  The history of the patient taking hydrochlorothiazide (HCTZ) for hypertension, may cause an increase in uric acid levels which could exacerbate an attack.  Diuretics are one of the most important causes of secondary hyperuricaemia.  Drugs raise serum uric acid level by an increase of uric acid reabsorption and/or decrease in uric acid secretion (Fathallah et al., 2017).                                                                                                                     References:review.  Journal of Advanced Research, 8(5), 495-511. Fathallah, N., Hmouda, H., Salem, C.B., & Slim, R. (2017).  Drug-induced hyperuriaemia andhttps://doi.org/10.1093/rheumatology/kew293Endocrinology and Metabolism, 30(1), 27-34. Chen, Y-C., Deng, H-W., Deng, J., Guo, Y-F., Li, D-Y., Li, K., Lin, X., Liu, X-G., Shen, J.,supplementation: A review of calcium intake on human health.  Clinical Interventions inhttps://doi.org/10.2147/CIA.S157523
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  • Aging, 13, 2443-2452.
  • Zhao, L-J., & Zhou, R. (2018).  The good, the bad, and the ugly of calcium
  • https://doi.org/10.3803/EnM.2015.30.1.27
  • Kim, K.M. & Shin, C.S. (2015).  The risks and benefits of calcium supplementation.
  • gout.  Rheumatology, 56(5), 679-688.
  • https://doi.org/10.1016/j.jare.2017.04.008
  • Bardin, T., Elshahaly, M., & Ragab, G. (2017).  Gout: An old disease in new perspective – a
  •            Some non-pharmacologic options would be to reduce his consumption of alcohol reduce the likeliness of attacks.  Although it is unclear, the patient should lose weight if he is obese because this is also a factor.  Some pharmacologic interventions would be to begin him on a uric acid reducer. I would start him on a prophylactic therapy of Losartan and non-steroidal anti-inflammatory drugs (NSAID`s).  I would discontinue his order for HCTZ because he needs a diuretic that is a uricosuric diuretic to keep his blood pressure normalized and his uric acid levels low.
  •           I would recommend the 59-year-old female to begin taking a 1200mg calcium supplement with 800 IU vitamin D PO daily, in addition to her multi-vitamin.  Due to her family history and being post-menopausal,  calcium supplementation would be beneficial.  Thus, calcium supplementation may inhibit the increase in PT (parathyroid) levels and prevent bone loss in individuals with a high bone turnover status, such as postmenopausal females and elderly individuals (Kim & Shin, 2015).  Neither her current history nor family history is remarkable enough to cause concern for her to take a calcium supplementation.  Although the patient’s father has diabetes, it requires long-term compliance for the possibility of diabetes to develop.  In this case, I believe the benefits outweigh the risks.
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  • Robin Morgan posted Oct 7, 2020 7:56 PM
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  • Calcium is an important electrolyte for good health. Calcium keeps our bones strong and helps decrease the incidents of fractures. Calcium is utilized for sending nerve signals, releasing hormones and regulating how muscles and blood vessels contract and dilate. Its very apparent that calcium is important to our bodies especially as we age. Calcium may also come with some risks but the evidence is conflicting. Regardless of the potential risks, when treating a patient with osteoporosis its important to maintain their calcium level to prevent further bone weakening.According to an article on Helahtline.com(Jennings, MS, RD, 2016) some evidence today suggests that Calcium supplementation may cause health risks, but the evidence is conflicting. Over the past several years researchers have published opposing findings about calcium supplement causing an increased risk in heart disease, high levels of prostate disease among male users, increased risk of kidney stones and high levels of calcium in your blood. The link between calcium supplementation and the link with these risks is unclear. What we do know for sure is high levels of calcium from any source may have negative health effects,In making recommendations for a 53-year-old postmenopausal woman with a T-score of -2.3 indicating a diagnosis of Osteoporosis. I would recommend Calcium supplementation. The recommended dosage of calcium for woman over 50 is 1200mg per day. I would switch this patient to a multivitamin without calcium and order a daily calcium supplement of 1200mg to ensure an adequate dose without potential for her to consume to much calcium.ReferencesJennings, MS, RD, K.-A. (2016). Calcium Supplements: Should You Take Them? Healthline.less1 UnreadUnread12 ViewsViews
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• Gout. (2019). JAMA, 282(6), 592. https://doi.org/10.1001/jama.282.6.592-jbk0811-3-1
• After obtaining a health history and examining a 45-year=old male patient it has been determined that he is suffering from gout. Gout is caused by toot much uric acid in the body. The pain usually comes on suddenly and is intense. There is usually swelling, redness and heat in the joint. Alcohol increases the uric acid levels, thus increasing the risk for gout. The patent is male and between 30 and 50 years of age making him more likely to develop first episodes of Gou(“Gout,” 2019)t. My patient consumed a large amount of wine he should be counseled on decreasing alcohol intake. Diuretics such as Hydrochlorothiazide can increase one’s risk of developing gout. I would change this patient to a different antihypertensive such as Norvasc. I would council this patient on the triggers for Gout in order to prevent future flairs.  I would start him on prophylactic medication to prevent attacks of Gout in the future such as Colchicine 0.5mg once or twice a day or NSAIDS such as naproxen 250mg twice per day. .
• The benefits of calcium supplementation for a patient with a diagnosed bone disease outweighs any unproven links between calcium and an increased in heart disease or kidney stones. With any patient we are consulting on calcium supplementation, we need to get the correct dosage for therapeutic level without unnecessary high dosages of calcium that may cause health problems
• The importance of Calcium in the body is evident. Calcium down not only help keep bones strong, nerves performing optimally, but it also helps s with fat floss, lowers risk of colon cancer and improves some metabolic markers. We need vitamin D in order to use calcium. As we age our skin absorbs four times less vitamin D from the sun as when we were younger. As we get older our dietary intake often decreases, so we take in less calcium. Calcium supplementation is an important electrolyte to add to health regimens to maintain healthy body function.
• Module 6 – Candace Whitman-Workman
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• Candace Whitman-Workman posted Oct 8, 2020 12:11 AM
•  Osteoporosis/OsteopeniaHiemstra, et al 2019, wrote about vitamin D deficiency.  Vitamin D deficiency can lead to cardiovascular disease, however, research does not support routine vitamin D dosing to prevent cardiovascular disease.  Abrahamsen 2017, however, suggests that high calcium levels with inadequate vitamin D levels have a propensity to lead to both osteoporosis and cardiovascular disease.  Abrahamsen 2017, states that studies are inconclusive, however, they suggest increasing vitamin D and avoiding calcium supplements.This 45 year old man is most likely suffering from an episode of gout.  Men more so than women are affected by gout.  It is unknown what this patient ate for dinner, but I would question him to determine the type of protein consumed.  Most likely the high alcohol consumption coupled with his medication of hydrochlorothiazide (HCTZ) lead to this gout exacerbation. At this time, I would not consider prophylactic treatment, but rather trial the changes outlined above for improvement.  However, if this patient continued to have gout flares, I would consider adding allopurinol.Abrahamsen, B. (2017). The calcium and vitamin D controversy. London, England: SAGE Publications. doi:10.1177/1759720X16685547Hiemstra, T. F., Lim, K., Thadhani, R., & Manson, J. E. (2019). Vitamin D and atherosclerotic cardiovascular disease. The Journal of Clinical Endocrinology and Metabolism, 104(9), 4033-4050. doi:10.1210/jc.2019-00194less0 UnreadUnread
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• Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.
• References
• Nonpharmacological interventions I would suggest would be to apply ice to the affected area.  To prevent future exacerbations, I would educate him to avoid organ meats, high fructose corn syrup, alcohol, and aspirin.  I would consider changing his treatment for HTN to a non-thiazide medication such as a potassium sparing diuretic, amiloride or triamterene (Chisolm-Burns, et al., 2019).
• Gout
• The 59 year old postmenopausal women in the first scenario is suffering from osteopenia.  Chisolm-Burns et al 2019 defines osteopenia as having a T score between -2.5 and -1.  However, osteopenia can develop into osteoporosis and should she have had a T score of -2.5, I would say she had osteoporosis.  Given her familial history of maternal osteoporosis and no known cardiac disease, would lead me to believe this patient to be a good candidate for prophylactic therapy.  In this patient’s case, given the fact she already has osteopenia and a family history of osteoporosis, I would educate on the benefits of sound nutrition, exercise, smoking cessation if she’s a smoker, and limiting alcohol ingestion.  I would keep her on her multivitamin as it has both calcium and vitamin D.  I would complete a Fracture Risk Assessment (FRAX) to determine the score which would lead in my decision regarding prophylactic therapy.  I do not have all the assessment data needed to complete a FRAX, but in my opinion, she would benefit from prophylactic pharmacologic therapy.  After assessing renal function, I would start this patient on a biphoshonate such as Fosamax.  There is minimal risk factors with the use of Fosamax as long as the patient has the ability to remain in an upright seated position for 30 minutes post dosing (Chisolm-Burns, et al., 2019).  I would not consider an estrogen therapy secondary to the breast cancer risk.
• Module VI: Bone & Joint Discussion Post
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• Gisselle Mustiga posted Oct 7, 2020 9:59 PM
• Calcium supplementation presents essential benefits to patients with a bone disease. Two benefits are involved during mitigation of bone disease with adequate calcium intake. They include preservation of the density of bone mineral and maintenance of growing bone health (Li et al., 2018). Parathyroid hormone is involved in the regulation of serum calcium levels and a decrease in the calcium levels causes compensatory increase in the hormone levels. An increase in the hormone levels will cause bone reabsorption which is harmful for bone health during the growing phases and can be mediated by calcium supplementation. Calcium supplementation for populations with low calcium intake has also been shown to slow down losses in lumbar spine bone thus showing its role in preserving bone density. However, in recent years, several studies have posted relations between increased cardiovascular events and calcium supplementation (Shin & Kim, 2015). These studies involve analyses of calcium studies where the relation to cardiovascular mortality is established. The 59-year-old post-menopausal woman has a T-Score of 2.4 which puts her on the Ostopenia range. The goal here is prevention of Osteoporosis. To begin with, I would conduct a thorough physical, medication regimen, medical history, and lifestyle assessment. The patient would benefit from calcium 750 mg BID along with Vitamin D3 4,000IU  QD supplementation that would aid in increasing her bone mineral density and preventing further losses in bone mass that would lead to osteoporosis. In addition, I would counsel the patient on making the right food choices and how to implement a bone-healthy diet.” A weight bearing exercise regimen would be discussed as well.ReferencesLi, K., Wang, X. F., Li, D. Y., Chen, Y. C., Zhao, L. J., Liu, X. G., … & Zhou, R. (2018). The good, the bad, and the ugly of calcium supplementation: a review of calcium intake on human health. Clinical Interventions in Aging, 13, 2443. https://doi.org/10.2147/CIA.S157523Shin, C. S., & Kim, K. M. (2015). The risks and benefits of calcium supplementation. Endocrinology and Metabolism, 30(1), 27-34.  https://doi.org/10.3803/EnM.2015.30.1.27
• Roddy, E., & Doherty, M. (2010). Gout. Epidemiology of gout. Arthritis research & therapy, 12(6), 223. https://link.springer.com/article/10.1186/ar3199
• Busso, N., & So, A. (2010). Gout. Mechanisms of inflammation in gout. Arthritis research & therapy, 12(2), 206. https://link.springer.com/article/10.1186/ar2952
• The 45-year-old white man presents symptoms characteristic of gout. They include swelling and pain in the joints and the sudden occurrence of the attack especially during the night. Gout is normally caused by the crystallization of uric acids in the joints (Busso & So, 2010). The process occurs when the kidney fails to efficiently eliminate uric acid. Efficiency of the kidney in eliminating such substances can be affected by ingestion of some food and drinks including too much alcohol. The 45-year-old white man is documented to have ingested a great amount of wine during dinner, this plus the use of hydrochlorothiazide drugs (HCTZ) for his HTN places him at greater risk. Treatment for the gout attack entails Naproxen Sodium 750 mg PO Once followed by 250 mg Q8 and the use of anti-inflammatory drugs such as Prednisone PO 30-60mg QD for 3-5 days and taper to discontinue  in 5mg increments during 10-14 days. This combination will help in reducing the pain and swelling (Roddy & Doherty, 2010). In order to place him in a prophylactic regimen, I would have to run some labs, and other Dx tests, and ask patient about the frequency and severity of his symptoms. The patient can benefit from prophylactic therapy that would help in preventing future similar occurrences. The therapy would involve change in eating habits, such as adopting the DASH diet, regular physical exercise and cessation of alcohol intake. If these methods don’t bring any relief, the next step would be to place him on PPx therapy. First, I would switch his HTN medication to Calcium-Channel Blocker and provide him with a prescription for Allopurinol and/or Febuxostat as first-line treatments.